Sports Medicine Division | Expert's Corner

The Female Athlete Triad is comprised of three components—low energy availability with or without disordered eating, menstrual dysfunction and low bone mineral density. Patients may present with one or more of the components.

Clinicians and sports medicine physicians have differed in their approaches to management, says Kathryn Ackerman, MD, MPH, co-director of the Female Athlete Program at Boston Children’s Hospital. “We lacked standardized criteria to determine which patients need a more in-depth workup and who needs to be restricted from activities,” says Ackerman.

The Female Athlete Triad Coalition, in February 2014, published a consensus statement detailing a 12-point scale that takes into account various aspects of the triad—low energy availability, low body mass index, delayed menarche, menstrual irregularities, low bone density and history of fractures—to help physicians make more systematic decisions.

According to the consensus statement, patients scoring zero or one point can be fully cleared for sports participation, and those with six or more points should be restricted from training. However, provisional or limited clearance is recommended for patients scoring between two and five points.

“Patients scoring from two to five points represent a bit of a gray area,” says Ackerman. “The approach to sports participation and training is going to vary. Depending on individual needs, the sports medicine physician might recommend limited sports participation and follow-up with a nutritionist, physician, sport psychologist and/or other health professional.”

After initial evaluation and risk assessment, primary care providers can manage low-risk patients. However, moderate- and high-risk athletes should be referred to a sports medicine physician who can provide the expertise and multidisciplinary resources to manage more complex cases. 

Meanwhile, some colleges and universities have started to implement a related model. The International Olympic Committee (IOC) has suggested replacing the term Female Athlete Triad with Relative Energy Deficiency in Sport (RED-S). RED-S is a more inclusive term which recognizes that men and Paralympic athletes can have similar health sequalae stemming from low energy intake.

While the IOC and Female Athlete Triad Coalition refine terms and patient populations, Ackerman and colleagues at Boston Children’s and elsewhere plan to study the impact of the triad guidelines. Their primary objective is to define ways to make them more user-friendly and applicable in clinical practice, particularly for moderate-risk patients.