The Female Athlete Triad

John Furia, MD


Medscape General Medicine. 1999;1(1) 

In This Article


Amenorrhea occurs in 2% to 5% of the general female population.[13] In athletes, the prevalence is higher, ranging from 3.4% to 44%.[13,19,20,21]

Amenorrhea is the most recognizable symptom of the Female Athlete Triad, and is not a benign condition. Many coaches and athletes used to believe that amenorrhea was nothing to be concerned about; it was evidence that the athlete was training at an intense level. There are some coaches who still hold this to be true.

Amenorrhea presents in two forms. Primary amenorrhea is the complete absence of menstruation by age 16 in a female with secondary sex characteristics.[5] Secondary amenorrhea is the absence of 3 to 12 consecutive menstrual periods after menarche.[15]

Secondary amenorrhea should never be considered a normal response to intense training. Once amenorrhea is detected, the etiology must be determined.

Exercise-associated amenorrhea (EAA) is the most common cause of secondary amenorrhea in athletes.[15] EAA is believed to be the result of a disorder in the hypothalamus and results in a hypo-estrogen state.[9,15] Specifically, there is a decrease in the pulse frequency of gonadotrophic-releasing hormone.[22,23] This results in a decrease in the frequency of luteinizing hormone from the pituitary.[22,23] In time, low estrogen levels can result in diminished bone mineral density and osteoporosis.

EAA is a diagnosis of exclusion; other causes of amenorrhea, such as pregnancy, hypothyroidism, pituitary tumors, etc. must be ruled out[15] before EAA can be ruled in.

The American Academy of Sports Medicine now recommends that all athletes with secondary amenorrhea be screened for other components of the Triad -- disordered eating and osteoporosis.[9]