Share this article on:


Otis, Carol L. M.D., FACSM; Drinkwater, Barbara Ph.D., FACSM; Johnson, Mimi M.D., FACSM; Loucks, Anne Ph.D., FACSM; Wilmore, Jack Ph.D., FACSM

Medicine & Science in Sports & Exercise: December 1997 - Volume 29 - Issue 12 - p 1671
Letters to the Editor-in-Chief

Dear Editor-in-Chief:

As stated at the very beginning of the Position Stand, we agree with Drs. DiPietro and Stachenfeld that “The majority of girls and women derive significant health benefits from regular physical exercise without incurring health risks” and that “They should be encouraged to be physically active at all phases of their lives.” However, we also believe that“If injuries or medical problems develop, they should be promptly identified and treated by professionals knowledgeable in the care of active women.”

As stated at the conclusion of the Position Stand, we also agree with Drs. DiPietro and Stachenfeld that epidemiological research is needed to determine the prevalence of the Female Athlete Triad. Nevertheless, with female athletes dying and suffering fractures, we, as physiologists and physicians in daily contact with such women, believe that the American College of Sports Medicine, as an institution dedicated to their welfare, has a responsibility to warn athletes, coaches, physicians, and parents about this hazard, regardless of how the population attributable risks of the Triad and obesity may compare.

We are unmoved by the argument that our warning might discourage girls and women from adopting an active lifestyle. Should the American College of Sports Medicine also withdraw its Position Stand on the prevention of thermal injuries during distance running? Should we stop warning the public about the dangers of traumatic and overuse injuries in sports? No, it is our responsibility to study and publicize both the benefits and the hazards associated with strenuous exercise and inadequate nutrition.

Furthermore, we are not willing to prejudge the results of future research by assuming that the origin of the Female Athlete Triad is psychopathological or to adopt policies predicated upon such assumptions before they have been empirically verified in the athletic population. In fact, observational studies of amenorrheic athletes have excluded other athletes with eating disorders and depression (2, 4). Amenorrheic athletes have been found to display the same healthy profile of mood states as other athletes (3). Several studies have found no difference between the weights and body compositions of regularly menstruating and amenorrheic athletes (1-4,6). Contrary to DiPietro's and Stachenfeld's claim, therefore, amenorrhea and osteoporosis are not necessarily preceded by distorted body image, disordered eating, and underweight.

In addition, we now know that dietary restriction is not necessary for reproductive function to be disrupted in physically active women. The endocrine regulation of reproductive function has been disrupted reproducibly by increasing energy expenditure without reducing energy intake(5). Such experimental evidence has demonstrated that reproductive function in physically active women can be suppressed by low energy availability (i.e., dietary energy intake minus exercise energy expenditure), and that the so-called “stress” of exercise has no suppressive effect on reproductive function beyond the impact of its energy cost on energy availability (5). Since all exercise involves energy expenditure, all active young women are at risk. It is the responsibility of parents, coaches, and health care professionals to understand and mitigate that risk.

That is how much we know today. We are not willing to propose specific policies based on premises about which we do not know. What we did in the Position Stand, instead, was to warn the public of yet another demonstrated hazard faced by some athletes, to which girls and women appear to be especially susceptible, to call for the development and implementation of strategies for identifying and providing medical care to affected individuals, to target education at all groups responsible for the health of female athletes, including the athletes themselves, and to urge investigators to study all aspects of the etiology, prevalence, clinical consequences, prevention, and treatment of this condition.

Carol L. Otis, M.D., FACSM

Barbara Drinkwater, Ph.D., FACSM

Mimi Johnson, M.D., FACSM

Anne Loucks, Ph.D., FACSM

Jack Wilmore, Ph.D., FACSM

Back to Top | Article Outline


1. De Souza, M. J., C. M. Maresh, M. S. Maguire, W. J. Kraemer, G. Flora-Ginter, and K. L. Goetz. Menstrual status and plasma vasopressin, renin activity, and aldosterone exercise responses. J. Appl. Physiol. 67:736-743, 1989.
2. Laughlin, G. A. and S. S. C. Yen. Nutritional and endocrine-metabolic aberrations in amenorrheic athletes. J. Clin. Endocrinol. Metab. 81:4301-4309, 1996.
3. Loucks, A. B. and S. M. Horvath. Exercise-induced stress responses of amenorrheic and eumenorrheic runners. J. Clin. Endocrinol. Metab. 59:1109-1120, 1984.
4. 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.
5. Loucks, A. B., M. Verdun, E. M. Heath, T. Law, Sr., and J. R. Thuma. Low energy availability, not the stress of exercise, alters LH pulsatility in exercising women. J. Appl. Physiol., in press.
6. Myerson, M., B. Gutin, M. P. Warren, et al. Resting metabolic rate and energy balance in amenorrheic and eumenorrheic runners.Med. Sci. Sports Exerc. 23:15-22, 1991.
©1997The American College of Sports Medicine