Skip to main content
SpringerLink
Log in

The Female Athlete Triad and Abnormal Pubertal Development

  • Chapter
  • First Online:
Book cover Abnormal Female Puberty

  • 725 Accesses

Abstract

The female athlete triad is a medical condition that occurs in exercising adolescent females and consists of three factors: energy availability, menstrual function, and bone health. These interrelated factors exist on spectrums from optimal health to dysfunction. Underlying the triad is low energy availability which can be the result of inadvertent undereating, purposeful undereating, or an eating disorder. The resulting low energy availability directly impacts bone health as well as menstrual function. Menstrual irregularity or amenorrhea also has a direct impact on bone health and should not be viewed as a normal consequence of exercise, but instead a pathologic response to low energy availability. In combination, the female athlete triad can lead to long-term health consequences such as poor bone health, infertility, and endothelial dysfunction as well as more immediate health consequences such as stress fractures and musculoskeletal injury. Awareness of the components and health consequences of the female athlete triad is low among athletes and coaches and education may improve early identification of adolescents at risk for the condition and its associated health consequences. A non-pharmacologic approach to restoration of optimal energy availability is the key to treatment of the female athlete triad and a multidisciplinary team including the athlete, coach, dietician, health care provider, and mental health professional, if needed, should be utilized in any treatment plan.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 54.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Abbreviations

ACSM:

American College of Sports Medicine

BMD:

Bone mineral density

BMI:

Body mass index

COC:

Combination oral contraceptive

DHEA-S:

Dehydroepiandrosterone sulfate

DSM-5:

Diagnostic and Statistical Manual of Mental Disorders: 5th edn

DXA:

Dual-energy X-ray absorptiometry

FFM:

Fat free mass

FSH:

Follicle-stimulating hormone

GnRH:

Gonadotropin releasing hormone

HCG:

Human chorionic gonadotropin

IGF-1:

Insulin-like growth factor 1

LH:

Luteinizing hormone

NCAA:

National Collegiate Athletic Association

PPE:

Pre-participation physical examination

T3:

Triiodothyronine

T4:

Thyroxine

Triad:

Female athlete triad

TSH:

Thyroid stimulating hormone

References

  1. Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The eating attitudes test: psychometric features and clinical correlates. Psychol Med. 1982;12:871–8.

    Article  CAS  PubMed  Google Scholar 

  2. U.S. Department of Health and Human Services. Physical activity guidelines advisory committee report. Washington, DC: USDHHS; 2008.

    Google Scholar 

  3. Zach KN, Smith Machin AL, Hoch AZ. Advances in management of the female athlete triad and eating disorders. Clin Sports Med. 2011;30:551–73.

    Article  PubMed  Google Scholar 

  4. Yeager KK, Agostini R, Nattiv A, Drinkwater B. The female athlete triad: disordered eating, amenorrhea, osteoporosis. Med Sci Sports Exerc. 1993;25:775–7.

    Article  CAS  PubMed  Google Scholar 

  5. Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin. Sports Med. 1994;13:405–18.

    CAS  Google Scholar 

  6. 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.

    Article  CAS  PubMed  Google Scholar 

  7. 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;39:1867–82.

    Article  PubMed  Google Scholar 

  8. Loucks AB, Kiens B, Wright HH. Energy availability in athletes. J Sports Sci. 2011;29 Suppl 1:S7–15.

    Article  PubMed  Google Scholar 

  9. Loucks AB, Thuma JR. Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women. J Clin Endocrinol Metab. 2003;88:297–311.

    Article  CAS  PubMed  Google Scholar 

  10. Reed JL, De Souza MJ, Kindler JM, Williams NI. Nutritional practices associated with low energy availability in Division I female soccer players. J Sports Sci. 2014;32:1499–509.

    Article  PubMed  Google Scholar 

  11. Myerson M, Gutin B, Warren MP, May MT, Contento I, Lee M, et al. Resting metabolic rate and energy balance in amenorrheic and eumenorrheic runners. Med Sci Sports Exerc. 1991;23:15–22.

    Article  CAS  PubMed  Google Scholar 

  12. De Souza MJ, Lee DK, VanHeest JL, Scheid JL, West SL, Williams NI. Severity of energy-related menstrual disturbances increases in proportion to indices of energy conservation in exercising women. Fertil Steril. 2007;88:971–5.

    Article  PubMed  Google Scholar 

  13. O’Donnell E, Harvey PJ, De Souza MJ. Relationships between vascular resistance and energy deficiency, nutritional status and oxidative stress in oestrogen deficient physically active women. Clin Endocrinol (Oxf). 2009;70:294–302.

    Article  Google Scholar 

  14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

    Google Scholar 

  15. Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45:985–96.

    Article  PubMed  Google Scholar 

  16. Holm-Denoma JM, Scaringi V, Gordon KH, Van Orden KA, Joiner TE. Eating disorder symptoms among undergraduate varsity athletes, club athletes, independent exercisers, and nonexercisers. Int J Eat Disord. 2009;42:47–53.

    Article  PubMed  Google Scholar 

  17. Martinsen M, Sundgot-Borgen J. Higher prevalence of eating disorders among adolescent elite athletes than controls. Med Sci Sports Exerc. 2013;45:1188–97.

    Article  PubMed  Google Scholar 

  18. Byrne S, McLean N. Elite athletes: effects of the pressure to be thin. J Sci Med Sport. 2002;5:80–94.

    Article  CAS  PubMed  Google Scholar 

  19. Sawaya AL, Tucker K, Tsay R, Willett W, Saltzman E, Dallal GE, et al. Evaluation of four methods for determining energy intake in young and older women: comparison with doubly labeled water measurements of total energy expenditure. Am J Clin Nutr. 1996;63:491–9.

    CAS  PubMed  Google Scholar 

  20. Joy E, De Souza MJ, Nattiv A, Misra M, Williams NI, Mallinson RJ, et al. 2014 Female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. Curr Sports Med Rep. 2014;13:219–32.

    Article  PubMed  Google Scholar 

  21. Rodriguez NR, Di Marco NM, Langley S. American College of Sports Medicine position stand. Nutrition and athletic performance. Med Sci Sports Exerc. 2009;41:709–31.

    Article  PubMed  Google Scholar 

  22. Georgopoulos N, Markou K, Theodoropoulou A, Paraskevopoulou P, Varaki L, Kazantzi Z, et al. Growth and pubertal development in elite female rhythmic gymnasts. J Clin Endocrinol Metab. 1999;84:4525–30.

    Article  CAS  PubMed  Google Scholar 

  23. Valentino R, Savastano S, Tommaselli AP, D’Amore G, Dorato M, Lombardi G. The influence of intense ballet training on trabecular bone mass, hormone status, and gonadotropin structure in young women. J Clin Endocrinol Metab. 2001;86:4674–8.

    Article  CAS  PubMed  Google Scholar 

  24. Maïmoun L, Coste O, Mura T, Philibert P, Galtier F, Mariano-Goulart D, et al. Specific bone mass acquisition in elite female athletes. J Clin Endocrinol Metab. 2013;98:2844–53.

    Article  PubMed  Google Scholar 

  25. Warren MP, Brooks-Gunn J, Fox RP, Holderness CC, Hyle EP, Hamilton WG, et al. Persistent osteopenia in ballet dancers with amenorrhea and delayed menarche despite hormone therapy: a longitudinal study. Fertil Steril. 2003;80:398–404.

    Article  PubMed  Google Scholar 

  26. Beals KA, Manore MM. Disorders of the female athlete triad among collegiate athletes. Int J Sport Nutr Exerc Metab. 2002;12:281–93.

    PubMed  Google Scholar 

  27. Chumlea WC, Schubert CM, Roche AF, Kulin HE, Lee PA, Himes JH, et al. Age at menarche and racial comparisons in US girls. Pediatrics. 2003;111:110–3.

    Article  PubMed  Google Scholar 

  28. De Souza MJ, Toombs RJ, Scheid JL, O’Donnell E, West SL, Williams NI. High prevalence of subtle and severe menstrual disturbances in exercising women: confirmation using daily hormone measures. Hum Reprod. 2010;25:491–503.

    Article  PubMed  Google Scholar 

  29. Loucks AB, Verdun M, Heath EM. Low energy availability, not stress of exercise, alters LH pulsatility in exercising women. J Appl Physiol. 1998;84:37–46.

    CAS  PubMed  Google Scholar 

  30. De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, et al. 2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013. Clin J Sport Med. 2014;24:96–119.

    PubMed  Google Scholar 

  31. Friedman JM, Halaas JL. Leptin and the regulation of body weight in mammals. Nature. 1998;395:763–70.

    Article  CAS  PubMed  Google Scholar 

  32. Maïmoun L, Georgopoulos NA, Sultan C. Endocrine disorders in adolescent and young female athletes: impact on growth, menstrual cycles, and bone mass acquisition. J Clin Endocrinol Metab. 2014;99:4037–50.

    Article  PubMed  Google Scholar 

  33. Corr M, De Souza MJ, Toombs RJ, Williams NI. Circulating leptin concentrations do not distinguish menstrual status in exercising women. Hum Reprod. 2011;26:685–94.

    Article  CAS  PubMed  Google Scholar 

  34. Osteoporosis prevention, diagnosis, and therapy. NIH Consens Statement. 17:1–45.

    Google Scholar 

  35. Bachrach LK. Acquisition of optimal bone mass in childhood and adolescence. Trends Endocrinol Metab. 2001;12:22–8.

    Article  CAS  PubMed  Google Scholar 

  36. Golden NH, Abrams SA. Optimizing bone health in children and adolescents. Pediatrics. 2014;134:e1229–43.

    Article  PubMed  Google Scholar 

  37. Hind K, Burrows M. Weight-bearing exercise and bone mineral accrual in children and adolescents: a review of controlled trials. Bone. 2007;40:14–27.

    Article  CAS  PubMed  Google Scholar 

  38. Fehling PC, Alekel L, Clasey J, Rector A, Stillman RJ. A comparison of bone mineral densities among female athletes in impact loading and active loading sports. Bone. 1995;17:205–10.

    Article  CAS  PubMed  Google Scholar 

  39. Risser WL, Lee EJ, LeBlanc A, Poindexter HB, Risser JM, Schneider V. Bone density in eumenorrheic female college athletes. Med Sci Sports Exerc. 1990;22:570–4.

    Article  CAS  PubMed  Google Scholar 

  40. Christo K, Prabhakaran R, Lamparello B, Cord J, Miller KK, Goldstein MA, et al. Bone metabolism in adolescent athletes with amenorrhea, athletes with eumenorrhea, and control subjects. Pediatrics. 2008;121:1127–36.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Tenforde AS, Fredericson M. Influence of sports participation on bone health in the young athlete: a review of the literature. PM R. 2011;3:861–7.

    Article  PubMed  Google Scholar 

  42. Khosla S, Oursler MJ, Monroe DG. Estrogen and the skeleton. Trends Endocrinol Metab. 2012;23:576–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Jackowski SA, Erlandson MC, Mirwald RL, Faulkner RA, Bailey DA, Kontulainen SA, et al. Effect of maturational timing on bone mineral content accrual from childhood to adulthood: evidence from 15 years of longitudinal data. Bone. 2011;48:1178–85.

    Article  PubMed  Google Scholar 

  44. Gilsanz V, Chalfant J, Kalkwarf H, Zemel B, Lappe J, Oberfield S, et al. Age at onset of puberty predicts bone mass in young adulthood. J Pediatr. 2011;158:100–5, 105.e1–2.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 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.

    Article  PubMed  Google Scholar 

  46. Barrack MT, Rauh MJ, Nichols JF. Cross-sectional evidence of suppressed bone mineral accrual among female adolescent runners. J Bone Miner Res. 2010;25:1850–7.

    Article  PubMed  Google Scholar 

  47. Gibbs JC, Nattiv A, Barrack MT, Williams NI, Rauh MJ, Nichols JF, et al. Low bone density risk is higher in exercising women with multiple triad risk factors. Med Sci Sports Exerc. 2014;46:167–76.

    Article  PubMed  Google Scholar 

  48. Barrack MT, Ackerman KE, Gibbs JC. Update on the female athlete triad. Curr Rev Musculoskelet Med. 2013;6:195–204.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Misra M, Prabhakaran R, Miller KK, Goldstein MA, Mickley D, Clauss L, et al. Weight gain and restoration of menses as predictors of bone mineral density change in adolescent girls with anorexia nervosa-1. J Clin Endocrinol Metab. 2008;93:1231–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Kelsey JL, Bachrach LK, Procter-Gray E, Nieves J, Greendale GA, Sowers M, et al. Risk factors for stress fracture among young female cross-country runners. Med Sci Sports Exerc. 2007;39:1457–63.

    Article  PubMed  Google Scholar 

  51. Bennell KL, Malcolm SA, Thomas SA, Reid SJ, Brukner PD, Ebeling PR, et al. Risk factors for stress fractures in track and field athletes. A twelve-month prospective study. Am J Sports Med. 1996;24:810–8.

    Article  CAS  PubMed  Google Scholar 

  52. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes. Am J Sports Med. 2001;29:304–10.

    CAS  PubMed  Google Scholar 

  53. Rauh MJ, Nichols JF, Barrack MT. Relationships among injury and disordered eating, menstrual dysfunction, and low bone mineral density in high school athletes: a prospective study. J Athl Train. 2010;45:243–52.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Rauh MJ, Barrack M, Nichols JF. Associations between the female athlete triad and injury among high school runners. Int J Sports Phys Ther. 2014;9:948–58.

    PubMed  PubMed Central  Google Scholar 

  55. Nattiv A, Kennedy G, Barrack MT, Abdelkerim A, Goolsby MA, Arends JC, et al. Correlation of MRI grading of bone stress injuries with clinical risk factors and return to play: a 5-year prospective study in collegiate track and field athletes. Am J Sports Med. 2013;41:1930–41.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Thijssen DHJ, Black MA, Pyke KE, Padilla J, Atkinson G, Harris RA, et al. Assessment of flow-mediated dilation in humans: a methodological and physiological guideline. Am J Physiol Heart Circ Physiol. 2011;300:H2–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. O’Donnell E, Goodman JM, Harvey PJ. Clinical review: Cardiovascular consequences of ovarian disruption: a focus on functional hypothalamic amenorrhea in physically active women. J Clin Endocrinol Metab. 2011;96:3638–48.

    Article  PubMed  Google Scholar 

  58. Temme KE, Hoch AZ. Recognition and rehabilitation of the female athlete triad/tetrad: a multidisciplinary approach. Curr Sports Med Rep. 2013;12:190–9.

    Article  PubMed  Google Scholar 

  59. Zeni Hoch A, Dempsey RL, Carrera GF, Wilson CR, Chen EH, Barnabei VM, et al. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med Sci Sports Exerc. 2003;35:377–83.

    Article  PubMed  Google Scholar 

  60. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. J Clin Endocrinol Metab. 2005;90:1354–9.

    Article  CAS  PubMed  Google Scholar 

  61. Hoch AZ, Papanek P, Szabo A, Widlansky ME, Schimke JE, Gutterman DD. Association between the female athlete triad and endothelial dysfunction in dancers. Clin J Sport Med. 2011;21:119–25.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Herzog DB, Keller MB, Sacks NR, Yeh CJ, Lavori PW. Psychiatric comorbidity in treatment-seeking anorexics and bulimics. J Am Acad Child Adolesc Psychiatry. 1992;31:810–8.

    Article  CAS  PubMed  Google Scholar 

  63. Preti A, Rocchi MBL, Sisti D, Camboni MV, Miotto P. A comprehensive meta-analysis of the risk of suicide in eating disorders. Acta Psychiatr Scand. 2011;124:6–17.

    Article  CAS  PubMed  Google Scholar 

  64. Keel PK, Dorer DJ, Eddy KT, Franko D, Charatan DL, Herzog DB. Predictors of mortality in eating disorders. Arch Gen Psychiatry. 2003;60:179–83.

    Article  PubMed  Google Scholar 

  65. Steinhausen H-C. Outcome of eating disorders. Child Adolesc Psychiatr Clin N Am. 2009;18:225–42.

    Article  PubMed  Google Scholar 

  66. Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch. Gen. Psychiatry. 2011;68:724–31.

    Google Scholar 

  67. Gulliver A, Griffiths KM. Mackinnon A. Stanimirovic R. The mental health of Australian elite athletes. J. Sci. Med. Sport: Batterham PJ; 2014.

    Google Scholar 

  68. Rosen DS. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126:1240–53.

    Article  PubMed  Google Scholar 

  69. Practice Committee of American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril. 2008;90:S219–25.

    Google Scholar 

  70. House S, Loud K, Shubkin C. Female athlete triad for the primary care pediatrician. Curr Opin Pediatr. 2013;25:755–61.

    Article  PubMed  Google Scholar 

  71. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994;16:363–70.

    CAS  PubMed  Google Scholar 

  72. Damilakis J, Adams JE, Guglielmi G, Link TM. Radiation exposure in X-ray-based imaging techniques used in osteoporosis. Eur Radiol. 2010;20:2707–14.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Lewiecki EM, Gordon CM, Baim S, Leonard MB, Bishop NJ, Bianchi M-L, et al. International Society for Clinical Densitometry 2007 Adult and Pediatric Official Positions. Bone. 2008;43:1115–21.

    Article  PubMed  Google Scholar 

  74. Bishop N, Arundel P, Clark E, Dimitri P, Farr J, Jones G, et al. Fracture prediction and the definition of osteoporosis in children and adolescents: the ISCD 2013 Pediatric Official Positions. J Clin Densitom. 2013;17:275–80.

    Article  Google Scholar 

  75. Gordon CM, Bachrach LK, Carpenter TO, Crabtree N, El-Hajj Fuleihan G, Kutilek S, et al. Dual energy X-ray absorptiometry interpretation and reporting in children and adolescents: the 2007 ISCD Pediatric Official Positions. J Clin Densitom. 2007;11:43–58.

    Article  Google Scholar 

  76. Institute of Medicine. 2011 Dietary reference intakes for calcium and vitamin D. Washington DC: National Academies Press; 2011.

    Google Scholar 

  77. Bailey RL, Dodd KW, Goldman JA, Gahche JJ, Dwyer JT, Moshfegh AJ, et al. Estimation of total usual calcium and vitamin D intakes in the United States. J Nutr. 2010;140:817–22.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  78. Society for Adolescent Health and Medicine. Recommended vitamin D intake and management of low vitamin D status in adolescents: a position statement of the society for adolescent health and medicine. J Adolesc Health. 2013;52:801–3.

    Article  Google Scholar 

  79. Hagman J, Gralla J, Sigel E, Ellert S, Dodge M, Gardner R, et al. A double-blind, placebo-controlled study of risperidone for the treatment of adolescents and young adults with anorexia nervosa: a pilot study. J Am Acad Child Adolesc Psychiatry. 2011;50:915–24.

    Article  PubMed  PubMed Central  Google Scholar 

  80. Holtkamp K, Konrad K, Kaiser N, Ploenes Y, Heussen N, Grzella I, et al. A retrospective study of SSRI treatment in adolescent anorexia nervosa: insufficient evidence for efficacy. J Psychiatr Res. 2005;39:303–10.

    Article  CAS  PubMed  Google Scholar 

  81. Kafantaris V, Leigh E, Hertz S, Berest A, Schebendach J, Sterling WM, et al. A placebo-controlled pilot study of adjunctive olanzapine for adolescents with anorexia nervosa. J Child Adolesc Psychopharmacol. 2011;21:207–12.

    Article  CAS  PubMed  Google Scholar 

  82. Swanson SA, Crow SJ, Le Grange D, Swendsen J, Merikangas KR. Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Arch. Gen. Psychiatry. 2011;68:714–23.

    Google Scholar 

  83. Touchette E, Henegar A, Godart NT, Pryor L, Falissard B, Tremblay RE, et al. Subclinical eating disorders and their comorbidity with mood and anxiety disorders in adolescent girls. Psychiatry Res. 2011;185:185–92.

    Article  PubMed  Google Scholar 

  84. Mattar L, Thiébaud M-R, Huas C, Cebula C, Godart N. Depression, anxiety and obsessive-compulsive symptoms in relation to nutritional status and outcome in severe anorexia nervosa. Psychiatry Res. 2012;200:513–7.

    Article  PubMed  Google Scholar 

  85. Aigner M, Treasure J, Kaye W, Kasper S. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders. World J Biol Psychiatry. 2011;12:400–43.

    Article  PubMed  Google Scholar 

  86. Golden NH, Lanzkowsky L, Schebendach J, Palestro CJ, Jacobson MS, Shenker IR. The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa. J Pediatr Adolesc Gynecol. 2002;15:135–43.

    Article  PubMed  Google Scholar 

  87. Strokosch GR, Friedman AJ, Wu S-C, Kamin M. Effects of an oral contraceptive (norgestimate/ethinyl estradiol) on bone mineral density in adolescent females with anorexia nervosa: a double-blind, placebo-controlled study. J Adolesc Health. 2006;39:819–27.

    Article  PubMed  Google Scholar 

  88. Sim LA, McGovern L, Elamin MB, Swiglo BA, Erwin PJ, Montori VM. Effect on bone health of estrogen preparations in premenopausal women with anorexia nervosa: a systematic review and meta-analyses. Int J Eat Disord. 2010;43:218–25.

    PubMed  Google Scholar 

  89. Cobb KL, Bachrach LK, Sowers M, Nieves J, Greendale GA, Kent KK, et al. The effect of oral contraceptives on bone mass and stress fractures in female runners. Med Sci Sports Exerc. 2007;39:1464–73.

    Article  CAS  PubMed  Google Scholar 

  90. Misra M, Katzman D, Miller KK, Mendes N, Snelgrove D, Russell M, et al. Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa. J Bone Miner Res. 2011;26:2430–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  91. Golden NH, Iglesias EA, Jacobson MS, Carey D, Meyer W, Schebendach J, et al. Alendronate for the treatment of osteopenia in anorexia nervosa: a randomized, double-blind, placebo-controlled trial. J Clin Endocrinol Metab. 2005;90:3179–85.

    Article  CAS  PubMed  Google Scholar 

  92. Ducher G, Turner AI, Kukuljan S, Pantano KJ, Carlson JL, Williams NI, et al. Obstacles in the optimization of bone health outcomes in the female athlete triad. Sports Med. 2011;41:587–607.

    Article  PubMed  Google Scholar 

  93. Fazeli PK, Wang IS, Miller KK, Herzog DB, Misra M, Lee H, et al. Teriparatide increases bone formation and bone mineral density in adult women with anorexia nervosa. J Clin Endocrinol Metab. 2014;99:1322–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  94. Brown KN, Wengreen HJ, Beals KA. Knowledge of the female athlete Triad, and prevalence of Triad risk factors among female high school athletes and their coaches. J Pediatr Adolesc Gynecol. 2014;27:278–82.

    Article  PubMed  Google Scholar 

  95. Feldmann JM, Belsha JP, Eissa MA, Middleman AB. Female adolescent athletes’ awareness of the connection between menstrual status and bone health. J Pediatr Adolesc Gynecol. 2011;24:311–4.

    Article  PubMed  Google Scholar 

  96. American Academy of Pediatrics. In: Bernhardt DT, Roberts WO, editors. Preparticipation physical evaluation. 4th ed. Washington, DC: American Academy of Pediatrics; 2010.

    Google Scholar 

  97. Mencias T, Noon M, Hoch AZ. Female athlete triad screening in National Collegiate Athletic Association Division I athletes: is the preparticipation evaluation form effective? Clin J Sport Med. 2012;22:122–5.

    Article  PubMed  Google Scholar 

  98. Madsen NL, Drezner JA, Salerno JC. The preparticipation physical evaluation: an analysis of clinical practice. Clin J Sport Med. 2014;24:142–9.

    Article  PubMed  Google Scholar 

  99. Melin A, Tornberg AB, Skouby S, Faber J, Ritz C, Sjödin A, et al. The LEAF questionnaire: a screening tool for the identification of female athletes at risk for the female athlete triad. Br J Sports Med. 2014;48:540–5.

    Article  PubMed  Google Scholar 

  100. Elliot DL, Goldberg L, Moe EL, Defrancesco CA, Durham MB, McGinnis W, et al. Long-term Outcomes of the ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) Program for Female High School Athletes. J Alcohol Drug Educ. 2008;52:73–92.

    PubMed  PubMed Central  Google Scholar 

  101. Becker CB, McDaniel L, Bull S, Powell M, McIntyre K. Can we reduce eating disorder risk factors in female college athletes? A randomized exploratory investigation of two peer-led interventions. Body Image. 2012;9:31–42.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Dell Children’s Medical Center of Central Texas, University of Texas at Austin, Dell Medical School, 4900 Mueller Blvd, Austin, TX, 78723, USA

    Maria C. Monge M.D.

Authors
  1. Maria C. Monge M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Maria C. Monge M.D. .

Editor information

Editors and Affiliations

  1. Department of Obstetrics and Gynecology, Hofstra Northwell School of Medicine, Manhasset, New York, USA

    Heather L. Appelbaum

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Monge, M.C. (2016). The Female Athlete Triad and Abnormal Pubertal Development. In: Appelbaum, H. (eds) Abnormal Female Puberty. Springer, Cham. https://doi.org/10.1007/978-3-319-27225-2_9

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-27225-2_9

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-27223-8

  • Online ISBN: 978-3-319-27225-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation