Jan 29, 2015
Catching Up with the Triad

Although most sports medicine professionals are familiar with the female athlete triad, studies show they are not using the most effective screening protocols.

By Dr. Jill Thein-Nissenbaum

Jill Thein-Nissenbaum, DSc, PT, SCS, ATC, is an Assistant Professor in the Doctor of Physical Therapy Program and an Athletic Trainer at the University of Wisconsin. She can be reached at: [email protected].

More athletic trainers, physicians, coaches, parents, and athletes are aware of the female athlete triad than ever before. They know it is a serious condition involving energy availability, menstrual disturbances, and low bone mass that affects millions of female athletes, with potentially devastating long-term consequences.

While awareness is increasing, screening athletes for the triad is still inadequate. A study that appeared in the Clinical Journal of Sport Medicine last year found that the protocols used by colleges and universities to identify the condition are incomplete and not effective. In addition, a 2005 study in The Journal of School Nursing discovered that the majority of high school athletic programs do not properly screen their female athletes for triad-related issues.

Most athletic trainers recognize the need for screening, but they aren’t always clear on the best methods or they think the process is too time-consuming. There are over half a dozen screening tools to choose from, and some are extensive. With more options now available, it is time to re-evaluate current screening protocols in order to improve the effectiveness of testing, diagnosing, and treating the triad.


In 1992, the American College of Sports Medicine (ACSM) identified an association of disordered eating, amenorrhea, and osteoporosis in female athletes and named it the female athlete triad. The ACSM published a Position Stand on the syndrome in 1997 and updated it in 2007 with broader definitions along spectrums of energy availability, menstrual function, and bone mineral density.

We now look at the three areas of the triad on a continuum. For example, instead of saying yes, an athlete has an eating disorder or no, she does not, we may say that an athlete shows signs of disordered eating. By definition, she hasn’t been diagnosed with an eating disorder, but if not addressed, she may move along the continuum to a full-blown eating disorder. This is applicable for the other two components of the triad as well.

Below is a closer look at each of the three spectrums in the updated Position Stand.

Energy availability ranges from optimal energy, to reduced energy, to low energy. Reduced or low energy can be a result of disordered eating, but it doesn’t have to be. Some females may not be aware of their caloric needs. Studies have found the prevalence of disordered eating at the high school level to be 18 to 41 percent. At the college and elite levels, it is 15 to 32 percent.

Menstrual function ranges from eumenorrhea (normal menses), to subclinical menstrual disorders (such as primary or secondary amenorrhea or oligomenorrhea), to amenorrhea. Menstrual abnormalities are estimated to affect up to 54 percent of the adolescent athletic population and up to 65 percent of female athletes at the college level. Menstrual disorders are often related to low energy availability, although they can sometimes occur in isolation.

Bone mineral density ranges from optimal bone health, to low bone mineral density, to osteoporosis. Because approximately 50 percent of peak bone mass is accrued during adolescence, it is a critical time for optimizing nutrition and participating in weight-bearing exercise. Unfortunately, the prevalence of decreased bone mineral density in high school female athletes is approximately 21.8 percent.

While each of the three components of the triad runs on its own continuum, they are also intimately linked. When an athlete shows symptoms somewhere along the continuum in one area, she is likely to also struggle with the other two areas. For example, decreased energy availability, as seen with disordered eating, forces certain bodily systems such as the menstrual cycle into shut-down mode, because there is simply not enough energy available to keep the system running. A lack of menses is associated with low estrogen levels, thereby causing decreased bone mass acquisition.

In a study published in Medicine & Science in Sports & Exercise last year, researchers from Pennsylvania State University attempted to determine the prevalence of the three triad components in females aged 18 to 25. The authors found that up to 16 percent of females exhibited signs of all three triad components. Three to 27 percent showed signs of two of the pieces, and 16 to 60 percent exhibited symptoms in one of the areas.

The large ranges reported in the above and other studies, which are due to the variability in the populations studied as well as the lack of universal definitions, further highlights that diagnosis can be elusive. In order to give a clearer picture of the prevalence of the triad, the health care professional should match the female they are concerned about with literature that best reflects her sport type, age, and level of competition.

Another hindrance to diagnosis is that athletes may move along the continuum at different rates. It is imperative that if one of the triad components is identified, appropriate screening for the other two occurs. Early diagnosis is paramount because research shows that immediate treatment decreases not only the chances of an athlete moving along the continuum, but her risk for negative long-term effects of the full triad.


The optimal method of screening females for the triad involves an annual preparticipation physical exam (PPE) and a questionnaire. The exam should include the following tests: blood count (to check for anemia); electrolytes (to check low potassium, high chloride); creatinine (to check kidney function); albumin, total protein, and cholesterol (markers of general nutritional status, all low when caloric intake is low); TSH (thyroid function); urine pregnancy test; electrocardiogram (to assess for bradycardia or conduction delays).

There are several options to choose from for the questionnaire (see “Survey Options” below) with the best choice for most colleges and high schools being the Female Athlete Triad Screening Questionnaire (below). Developed by the Female Athlete Triad Coalition, this survey works well because it covers all three components of the triad and is easy to have a large group complete. It starts by focusing on the disordered eating components of the triad, which sets up the other two components.

The study mentioned at the beginning of this article in the Clinical Journal of Sport Medicine looked at how NCAA Division I institutions screened college athletes at risk for the triad. Researchers asked the schools about the frequency with which they screened their athletes and for a sample of their PPE forms. All Division I universities were invited to participate and 74 percent submitted information on the frequency of their PPEs, while 83 percent provided the authors with a sample of their PPE forms.

The results revealed a number of inconsistencies with the screening process. While they found that almost all universities required a PPE for incoming athletes, only 32 percent required an annual PPE. Returning athletes at these institutions were only required to update their medical history annually, usually with their athletic trainer. Those athletes were only referred to a physician if the athletic trainer identified a “red flag” on the history update.

Regarding the 12 items on the Female Athlete Triad Screening Questionnaire, only nine percent of the schools included nine or more of the recommended questions, whereas 44 percent asked less than five. Critical questions, including those addressing whether athletes lost weight to meet the image requirements of a sport, if athletes used vomiting, diuretics, and/or laxatives to lose weight, and the number of menses experienced in the past 12 months were omitted from more than 40 percent of the PPE forms.

So why are colleges not doing a very thorough job at screening? There are several factors in play.

First of all, many universities have used the same screening process for years. Because no obvious gaps have been discovered, they may feel that “if it ain’t broke, don’t fix it.” However, females who have subtle signs and symptoms of one or more of the components of the triad are not appropriately being identified with the existing screening process. Since early diagnosis is so critical, this is a problem.

For example, with adequate screening processes in place, an athlete with oligomenorrhea may be identified. If she is not identified at this point, she may continue along the spectrum and acquire amenorrhea.

A related problem is the lack of annual physical exams. The majority of athletes are screened for the triad through a PPE only once during their college careers. But the triad can develop–or further develop–at any time during an athlete’s life. Screening for it when they arrive at college is a good first step, but subsequent screenings are also important.


Changing protocols can seem burdensome. But updating your screening for the triad does not have to be a major undertaking. It may simply involve revisiting your annual returning athlete procedures and adding some questions to your PPE surveys.

The first area to examine is PPEs. While ideally we would give athletes a full exam by a physician every year, for most colleges, this is too costly and time-consuming. This is something we faced here at the University of Wisconsin, where we have several hundred female athletes.

For returning athletes, we found it is much more feasible to have our athletic trainers perform an abbreviated screening process instead of a full PPE. A written survey combined with a brief physical examination is a quick, yet effective solution. This can include giving each female athlete the Female Athlete Triad Coalition screening tool (see “12 Questions” below), which can reveal subtle signs and symptoms related to the triad, and simple physical examination techniques, including blood pressure, resting heart rate, and weight. Although asking the athlete to report their weight is common, obtaining their actual weight is more accurate.

At Wisconsin, we also ask our athletes what their highest and lowest weights were in the past six months, something the Triad Coalition survey does not include. It is helpful to know if the athlete has lost a significant amount of weight over the past year, because even if the loss is gradual, she may have very slowly fallen into a negative energy balance either intentionally or unintentionally.

If one of our athletes reports less than 10 to 12 periods per year and/or has experienced significant weight loss in the past six months, she is referred to the team physician. Based upon the physician’s findings, the athlete may be referred for further testing, such as a cardiac work-up (if electrolytes are abnormal), to our nutritionist, and/or to our sports psychologist.

One additional area to consider is the reliability of self-report questionnaires. Research has shown that conditions are underreported when these techniques are utilized. One way to potentially make these self-reports more accurate is to have athletes log pertinent information for three or more days.

For example, having the athlete keep an exercise and food-intake diary for three days will provide the athletic trainer, physician, and nutritionist with a greater amount of information. Trends, such as poor breakfast consumption or inadequate caloric consumption prior to practice, will be more obvious if athletes are asked to report them in this manner.

Screening for components related to the female athlete triad is critical at every competitive level. Athletic trainers need to keep abreast of current literature and information related to the female athlete triad, and when necessary, suggest changes to current practices. Even minor updates to the screening process may help detect issues that will decrease the negative long-term effects of triad-related conditions.

To view the full list of references for this article, visit: www.Training-Conditioning.com/references.

Figure 1

Figure One: The spectrums of menstrual function, energy availability, and bone mineral density within the female athlete triad.

Sidebar: 12 QUESTIONS

The Female Athlete Triad Screening Questionnaire, from the Female Athlete Triad Coalition, includes the following questions:

1. Do you worry about your weight or body composition? 2. Do you limit or carefully control the foods that you eat? 3. Do you try to lose weight to meet weight or image/appearance requirements in your sport? 4. Does your weight affect the way you feel about yourself? 5. Do you worry that you have lost control over how much you eat? 6. Do you make yourself vomit or use diuretics or laxatives after you eat? 7. Do you currently or have you ever suffered from an eating disorder? 8. Do you ever eat in secret? 9. What age was your first menstrual period? 10. Do you have monthly menstrual cycles? 11. How many menstrual cycles have you had in the last year? 12. Have you ever had a stress fracture?

Sidebar: Survey Options

As more studies have identified the need for screening female athletes for the triad, researchers have developed the following options for use.

Eating Disorder Examination-Questionnaire (EDE-Q): Adapted from the Eating Disorder Examination, an interview between an athlete and a specially trained administrator, the EDE-Q includes subscales on restraint, shape concern, weight concern, and eating concern.

Survey of Eating Disorders among Athletes (SEDA): Identifies eating abnormalities and sports-related environmental factors that may contribute to the onset or development of disordered eating, such as performance thinness and appearance thinness.

Female Athlete Triad Screening Questionnaire: From the Female Athlete Triad Coalition, this tool has eight questions geared towards eating behaviors, three on menstrual dysfunction, and one on bone health.

Female Athlete Screening Tool (FAST): Examines atypical exercise and eating behaviors in female athletes via a four-point Likert scale.

Athletic Milieu Direct Questionnaire (AMDQ): Identifies disordered eating in NCAA Division I female athletes using Likert scales and multiple and dichotomous responses.

The Health, Weight, Dieting, and Menstrual History Questionnaire: Divided into categories for the assessment of disordered eating, dieting behaviors, and body image in female athletes.

Preparticipation Physical Examination, 4th edition: Includes questions about stress fracture history, eating attitudes, and menstrual history. It is reviewed by the physician prior to the physical examination.

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