Information for Physicians

Female Athlete Triad Screening Tool:

Female athletes at risk for the Triad can be identified via a screening questionnaire. This document outlines the questions that are sensitive for identifying the athlete at risk who requires further investigation.

In addition, this document outlines for physicians the next level of history questions, physical examination and laboratory investigations recommended to be completed on the female athlete at risk for the Triad.

>>Pre Participation Evaluation (PDF)

ACSM Position Stand Slideshow:

>>ACSM Position Stand Slideshow (PDF)

Helpful References:

Beals, K.A. Disordered Eating Among Athletes. A Comprehensive Guide for Health Professionals. Champaign, IL: Human Kinetics, 2004.

Beals, K.A., and M.M. Manore. Subclinical eating disorders in physically active women. Topics Clin. Nutrition 14(3):14-29, 1999.

Beals, K.A., and M.M. Manore. Disorders of the female athlete triad among collegiate athletes. Int. J. Sport Nutr. Exerc. Metab. 12(3):281-294, 2002.

Brooks-Gunn, J., C. Burrow, M.P. Warren. Attitudes toward eating and body weight in different groups of female adolescent athletes. Int. J. Eat. Disord. 7:749-757, 1988.

Calabrese LH, Kirkendall DT: Nutritional and medical considerations in dancers. Clin Sports Med 1983; 2 (#): 539-47.

Cobb KL, Bachrach LK, Greendale G, et al. Disordered eating, menstrual irregularity, and bone mineral density in female runners. Med. Sci. Sports Exerc. 35(5):711-719, 2003.

De Souza, MJ, S West, S. Jamal, G Hawker, C Gundberg, and NI Williams. The Presence of Both an Energy Deficiency and Estrogen Deficiency Exacerbate Alterations of Bone Metabolism in Exercising Women. Bone. 2008 Apr 8. [Epub ahead of print]

De Souza MJ, Williams NI. Beyond hypoestrogenism in amenorrheic athletes: energy deficiency as a contributing factor for bone loss. Curr Sports Med Rep 2005;4: 38–44.

De Souza MJ, Hontscharuk R, Olmsted MP, Kerr G, Williams NI. Drive for thinness score is a proxy indicator of energy deficiency in exercising women. Appetite 2007; 48(3):359–67.

De Souza MJ, Williams NI. Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women. Hum Reprod Update 2004;10: 433–48.

Drinkwater, B.L., B. Bruemner, and C.H. Chesnut 3rd. Menstrual history as a determinant of current bone density in young athletes. JAMA 263, 545-548, 1990.

Drinkwater, B.L., K. Nilson, C.H.I. Chesnut, W.J. Bremner, S. Shainholtz, and M.B. Southworth. Bone mineral content of amenorrheic and eumenorrheic athletes. N. Engl. J. Med. 311:277-281, 1984.

Drinkwater, B.L., K. Nilson, S. Ott, and C.H. Chesnut. Bone mineral density after resumption of menses in amenorrheic athletes. JAMA 256:380-382, 1986.

Dueck C.A., M.M. Manore, and K.S. Matt. Role of energy balance in athletic menstrual dysfunction. Int. J. Sport Nutr. 6:90-116, 1996.

Dueck C.A., K.S. Matt, M.M. Manore and J.S. Skinner. Treatment of athletic amenorrhea with a diet and training intervention program. Int. J. Sport Nutr. 6:24-40, 1996.

Ellison, P.T., and C. Lager. Moderate recreational running is associated with lowered salivary progesterone profiles in women. Am. J. Obstet. Gynecol. 154: 1000-1003, 1986.

Ferin M: The menstral cycle: An integrative veiw. LN: Adashi KY, Rock JA, Rosenwaks Z, eds: Reproductive endocrinology Surgery, and Technology. Philadelphia; Penn. Lippincott-Rven; 1996; 103-22.

Grinspoon S, Miller K, Coyle C, Krempin J, Armstrong C, Pitts S, Herzog D, Klibanski A. Severity of osteopenia in estrogen-deficient women with anorexia nervosa and hypothalamic amenorrhea. J Clin Endocrinol Metab 1999;84: 2049–55.

Hergenroeder AC, Smith EO, Shypailo R, Jones LA, Klish WJ, Ellis K. Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone, or placebo over 12 months. Am J Obstet Gynecol 1997;176: 1017–25.

Hobart JA, Smucker DR, The female athlete triad. Am Fam Phys 2000; 61:3357-3364.

Hoch, A.Z., R.L. Dempsey, G.F. Carrera, C.R. Wilson, E.H. Chen, V.M. Barnabei, P.R. Sandford, T.A. Ryan, and D.D. Guterman. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med. Sci. Sports Exerc. 35:377-383, 2003.

Ihle R, Loucks AB. Dose-response relationships between energy availability and bone turnover in young exercising women. J Bone Miner Res 2004;19: 1231-40. Epub 2004 Apr 19.

International Society for Clinical Densitometry Position Development Conference. The diagnosis of osteoporosis in men, premenopausal women, and children. J. Clin. Densitom. 7:17-26, 2004.

Jonnavithula S, Warren MP, Fox RP, Lazaro MI. Bone density is compromised in amenorrheic women despite return of menses: a 2-year study. Obstet Gynecol 1993;81: 669–74.

Johnson, A.W., C. Weiss, D.L. Wheeler. Stress fractures of the femoral shaft in athletes — more common than expected: a new clinical test. Am. J. Sports Med. 22:248-256, 1994.

Johnson C, P.S. Powers, and R. Dick. Athletes and eating disorders: The National Collegiate Athletics Association Study. Int. J. Eat. Disord. 26:179-188, 1999.

Johnson MD. Disordered eating in active and athletic women. Clin Sports Med 1994; 13(2); 355-69.

Kanis, J.A. Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929-1936, 2002.

Kanis, J.A., L.J. Melton, C. Christiansen, C.C. Johnston, and N. Khaltaev. The diagnosis of osteoporosis. J. Bone Miner. Res. 9:1137-1141, 1994.

Keen AD, Drinkwater BL. Irreversible bone loss in former amenorrheic athletes. Osteoporos Int 1997;7: 311–5.

Klibanski A, Biller BM, Schoenfeld DA, Herzog DB, Saxe VC. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. J Clin Endocrinol Metab 1995;80: 898–904.

Kopp-Woodroffe S.A., M.M. Manore, C.A. Dueck, J.S. Skinner, and K.S. Matt. Energy and nutrient status of amenorrheic athletes participating in a diet and exercise training intervention program. Int. J. Sport Nutr. 9:70-88, 1999.

Laughlin, G.A., C.E. Dominguez, and S.S. Yen. Nutritional and endocrine-metabolic aberrations in women with functional hypothalamic amenorrhea. J. Clin. Endocrinol. Metab. 83:25-32, 1998.

Laughlin, G.A., and S.S.C. Yen. Nutritional and endocrine-metabolic aberrations in amenorrheic athletes. J. Clin. Endocrinol. Metab. 81:4301-4309, 1996.

Leib, E.S., E. M. Lewiecki, N. Binkley, R.C. Hamdy. Official positions of the International Society for Clincal Densitometry. J. Clin. Densitom. 7:1-6, 2004.

Loucks, A.B., J.F. Mortola, L. Girton, and S.S.C. Yen. Alterations in the hypothalamic-pituitary-ovarian and hypothalamic-pituitary-adrenal axes in athletic women. J. Clin. Endocrinol. Metab. 68, 402-411, 1989.

Loucks A.B., and J.R. Thuma. Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women. J. Clin. Endocrinol. Metab. 88(1):297-311, 2003.

Loucks, A.B., M. Verdun, M. and E.M. Heath. Low energy availability, not the stress of exercise, alters LH pulsatility in exercising women. J. Appl. Physiol. 84, 37-46, 1998.

Loucks, A.B., and R. Callister. Induction and prevention of low-T3 syndrome in exercising women. Am. J. Physiol. 264:R924-R930, 1993.

Manore M M. Nutritional needs of the female athlete. Clin. Sports Med. 18(3):549-563. 1999.

Manore MM: Nutritional needs of the female athlete. Clin Sports Med 1999;18 (3): 549-57.

Manore M.M. Dietary recommendations and athletic menstrual dysfunction. Sports Med. 32(14):887-901, 2002.

Marcus, R. C.E. Cann, P. Madvig, J. Minkoff, M. Goddard, M. Bayer, M.C. Martin, L. Gaudiani, W. Haskell, H.K. Genant. Menstrual function and bone mass in elite women distance runners. Ann. Intern. Med. 102:158-163, 1985.

Marcus, M.D., T.L. Loucks, and S.L. Berga. Psychological correlates of functional hypothalamic amenorrhea. Fertil. Steril 2001; 76: 310-316.

Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP. American College of Sports Medicine position stand. The Female Athlete Triad. Med Sci Sports Exerc, 2007, Oct;39(10):1867–82.

Nattiv A. Stress fractures and bone health in track and field athletes. J. Sci. Med. Sport. 3(3):268-279, 2000.

Nattiv A., R. Agostini, B.L. Drinkwater, K.K. Yeager. The female athlete triad: the inter-relatedness of disordered eating, amenorrhea and osteoporosis. Clin. Sports Med. 13(2):405-418, 1994

Nichols, D.L., and C.F. Sanborn. Female Athletes and Bone. In: Nutrition for Sport & Exercise. Berning, J.R., and S.N. Steen (Eds.) Gaithersburg, MD: Aspen Publications, 1998, pp. 205-215.

Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The Female Athlete Triad. Med Sci Sports Exerc 1997, 29:i–ix.

Otis CL, Drinkwater BL, Johnson M, et al: ACSM Position stand on the female athlete triad. Med Sci Sports Exerc 1997; 29(5):i-ix.

Renchken ML, Chesnut CH, Drinkwater BL: Bone Density at multiple skeletal sites in amenorrheic athletes. J Am Med Assoc 1996; 276 (3):238-40.

Sanborn, C.F., B.H. Albrecht, and W.W. Wagner, Jr. Athletic amenorrhea: lack of association with body fat. Med. Sci. Sports Exerc. 19(3):207-212, 1987.

Sundgot-Borgen, J. Nutrient intakes of elite female athletes suffering from eating disorders. Int. J. Sport Nutr. 3:431-442, 1993.

Sundgot-Borgen, J. Risk and trigger factors for the development of eating disorders in female elite athletes. Med. Sci. Sports Exerc. 26:414-419, 1994.

Sundgot-Borgen, J. Weight and eating disorders in elite athletes. Scand. J. Med. Sci Sports 12(5):259-260, 2002.

Vescovi, J., S Jamal, MJ De Souza. Strategies to Reverse Bone Loss in Women with Functional Hypothalamic Amenorrhea: A Systematic Review of the Literature. Osteoporosis International. 2008 Apr;19(4):465–478. Epub 2008 Jan 8.

Vescovi, J., JL VanHeest, MJ De Souza. Short term response of bone turnover to low dose oral contraceptives in exercising women with hypothalamic amenorrhea. Contraception. 2008 Feb;77(2):97–104. Epub 2007 Dec 21.

Warren, M.P. The effects of exercise on pubertal progression and reproductive function in girls. J. Clin. Endocrinol. Metab. 51:1150-1157, 1980.

Warren, M.P., J. Brooks-Gunn, R.P. Fox, C.C. Holderness, E.P. Hyle, W.G. Hamilton. Osteopenia in exercise-associated amenorrhea using ballet dancers as a model: a longitudinal study. J. Clin. Endocrinol. Metab. 87(7):3162-3168, 2002.

Warren, M.P., J. Brooks-Gunn, L.H. Hamilton, L F. Warren, and W.G. Hamilton. Scoliosis and fractures in young ballet dancers. Relation to delayed menarche and secondary amenorrhea. N. Engl. J. Med. 314:1348-1353, 1986.

Warren, M.P., R.P. Fox, C.C. Holderness, A.J. DeRogatis, W.G. Hamilton, L. Hamilton. Persistent osteopenia in women with amenorrhea and delayed menarche despite hormone replacement therapy: A longitudinal study. Fertility and Sterility. 80(2):398-404, 2003.

Warren, M.P., F. Voussoughian, E.B. Geer, E.P. Hyle, C.L. Adberg, and R.H. Ramos. Functional hypothalamic amenorrhea: hypoleptinemia and disordered eating. J. Clin. Endocrinol. Metab. 84:873-877, 1999.

Williams NI, Helmreich DL, Parfitt DB, Caston-Balderrama A, Cameron JL. Evidence for a causal role of low energy availability in the induction of menstrual cycle disturbances during strenuous exercise training. J Clin Endocrinol Metab 2001;86: 5184–93.

Williams NI, Caston-Balderrama AL, Helmreich DL, Parfitt DB, Nosbisch C, Cameron JL. Longitudinal changes in reproductive hormones and menstrual cyclicity in cynomolgus monkeys during strenuous exercise training: abrupt transition to exercise-induced amenorrhea. Endocrinology 2001;142: 2381–9.

Yeager KK, Agostini R. Nattiv A et al. The female athlete triad. Med Sci Sport Exerc 1993; 25:775-777.

Zanker, C.L., and I.L. Swaine. Bone turnover in amenorrhoeic and eumenorrhoeic women distance runners. Scand. J. Med. Sci. Sports 8:20-26, 1998.

Zanker, C.L., and I.L. Swaine. Relation between bone turnover, oestradiol, and energy balance in women distance runners. Br. J. Sports Med. 32:167-171, 1998.

Zipfel S, Seibel MJ, Lowe B, Beumont PJ, Kasperk C, Herzog W. Osteoporosis in eating disorders: a follow-up study of patients with anorexia and bulimia nervosa. J Clin Endocrinol Metab 2001;86: 5227–33.