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Coaching Concerns in Physically Active Girls and Young Women-Part II: Practical Application of Research

Pantano, Kathleen J PhD, PT

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Strength and Conditioning Journal: April 2010 - Volume 32 - Issue 2 - p 68-72
doi: 10.1519/SSC.0b013e3181c4e647
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Despite the emerging evidence and increased exposure about the female athlete triad, there are many questions about the female athlete triad and its development that remain unanswered. This leads researchers and those involved in the care of the athlete to further explore and validate existing theories concerning the pathophysiology involved in its development and the reversal and/or prevention of menstrual dysfunction. Losses in bone mass, if present, can be prevented by increasing dietary intake. In addition, understanding how the conditions of the female athlete triad affect sports performance has yet to be fully explored. These questions further challenge coaches to rely on future evidence, which supports the use of specific mechanisms to detect and prevent athletes from developing the scope of the disorder. The following information provides coaches with an understanding of the limitations in current knowledge of the female athlete triad and how the research applications can apply to the coaching profession.



Chronic stress is defined as exposure to multiple minor stressful events, which become internally manifested when ineffective coping strategies are used to deal with these traumatic events (4,14). It is theorized that chronic stress could be a potential cause of menstrual dysfunction in female athletes because of the effect that it can have on hormones responsible for reproductive function. Chronic stress has been implicated as a cause for infertility in women (4,6,29) in similar mechanisms in which low energy availability causes menstrual dysfunction in female athletes; however, chronic stress as a cause of menstrual dysfunction in female athletes has not yet been explored (4).

How an individual perceives and responds to stress may be inherent in his/her personality (4) or may be learned as a result of environmental influences. Chronic stress is thought to induce infertility in women by lowering levels of metabolic hormones such as thyroxine (T4) (4,6,29). A decrease in energy availability then signals the hypothalamus to inhibit hormone release from the pituitary gland and ovaries, which disrupts menstruation and ovulation (4,6,14). Evidence suggests that women who exercise under chronic stress conditions have decreased thyroxine levels in their systems compared with those who exercise when not chronically stressed (3). The demands of sport participation and competition, perfectionist or obsessive personality traits, and emotionally stressful transitions (i.e., puberty, going away to college, loss of parent or coach) may trigger chronic stress in female athletes (8,28). Studies conducted on the effect of chronic stress and infertility in women report that relaxation techniques and learning effective coping mechanisms for dealing with stress through cognitive behavioral therapy have been successful in treating some women with functional hypothalamic amenorrhea (3). Further investigation should determine whether a similar relationship exists between chronic stress and menstrual dysfunction in female athletes.


Another important medical concern in female athletes is the relationship between low energy availability, menstrual dysfunction, and cardiovascular disease (10,19). Recent studies suggest that estrogen deficiencies associated with amenorrhea cause endothelial cell dysfunction in the arterial walls (i.e., a reduction in flow-mediated dilation), facilitating the buildup of atherosclerotic plaque. Women with menstrual dysfunction, caused by low energy availability, have been reported to have high cholesterol and elevated low-density lipoprotein (LDL) profiles. High cholesterol and elevated LDL profiles are risk factors associated with atherosclerosis, hypertension, and cardiac failure (10,19).

Estrogen usually has a protective effect on vascular function and serum lipoprotein profiles: Estrogen can lower LDL cholesterol levels, increase high-density lipoprotein cholesterol levels, improve blood flow, and reduce the risk of atherosclerosis. These benefits may be diminished or lost when estrogen levels become deficient (15,19). Hormone replacement therapy (HRT) and oral contraceptive pills (OCP) have been used to restore menstruation in young women with functional hypothalamic amenorrhea; however, the success of HRT and OCP as a form of treatment has proven to be inconsistent in the literature. Pharmacological treatment for amenorrhea continues to be controversial (13) for this reason. Determining whether the resumption of menstruation through nutritional supplementation, or treatment with other pharmacological agents, can decrease the risk of heart disease in athletes with the triad would be important to determine. Coaches need to be aware of cardiovascular complications that can occur in female athletes with the triad, and adequate screening for these conditions is essential.

An important concern for coaches is the effect that the female athlete triad can have on the athlete's overall health and well-being, and, perhaps, how it may affect their sports performance. Because low energy availability reduces the amount of glycogen availability, athletic performance can be impaired by fatigue, a loss of endurance, and loss of motor coordination (26). If fluid intake is restricted to induce weight loss, the athlete can become susceptible to dehydration, a loss of body temperature regulation, and heat-related disorders (26). As of yet, no study has quantified the effect that low energy availability has on sports performance, even though it is assumed that adequate nutrition optimizes sports performance and is promoted for the prevention of the triad conditions. Studies that substantiate the extent in which low energy availability affects sports performance would provide support for current strategies used for treatment and prevention of the triad.


Of further interest to coaches, and to health professionals, is the relationship between the triad conditions and the incidence of musculoskeletal injury. Given the influence that hormone levels have on ligament laxity and muscle stiffness (12,22,30), it would be important to determine if there is a link between the triad conditions and soft-tissue injuries. It is widely recognized that athletes with menstrual dysfunction caused by low energy availability are at greater risk of stress fractures than athletes with normal menstrual cycles, (2,7,9) but whether the triad symptoms increase risk of other musculoskeletal injuries is not known.

Distinct phases of the menstrual cycle correspond with elevated levels of hormones, which are thought to contribute to ligament laxity and tearing. To further illustrate, elevated hormone levels during the menstrual cycle are thought to be responsible for sex differences in knee laxity and increased rates of anterior cruciate ligament injuries in female athletes (20,22,30). Because athletes with the triad experience deficiencies in nutrition and hormone levels, it is possible that they may experience fewer musculoskeletal injuries than athletes who have normal menstrual cycles. Reduced hormone levels could potentially increase the strength or stiffness of the soft tissues surrounding the joints, resulting in decreased injury rates (20), although, currently, there is no evidence to support this fact. Alternatively, female athletes with the triad who train at high volumes and intensities, however, may be more vulnerable to muscle fatigue, which can lead to greater mechanical joint stresses, as well as a general loss of physical endurance that could increase the likelihood of traumatic and repetitive strain injuries. Further exploration into determining the relationship between the female athlete triad and the risk of musculoskeletal injury would be an important finding not only for coaches but also for all those involved in the care of the athlete.



The American Academy of Pediatrics, American College of Sports Medicine (ACSM), International Olympic Committee (IOC), and Female Athlete Triad Coalition (1,11,12,27) advocate sports participation for girls and young women of all ages and in all levels of competition. Physical activity in children and adolescents has been widely promoted in recent years due to the obesity epidemic (presently, 16% of the population under the age of 19 is overweight or obese (16)). Despite a concentrated focus on reducing the prevalence of overweight and obese children and adolescents in the United States and worldwide, the female athlete triad has continued to receive attention from researchers, health professionals, and the media as an important health care concern (13,21,23-26) because of its potential long-term health consequences. To address the importance of the female athlete triad, ACSM published a new Position Stand in 2007 (13), which outlined changes and recent scientific advances that have been made since the original Position Stand was published in 1997 (17). Although coaches are not directly involved in treatment of the female athlete triad, it is important that they understand the distinct but interrelated conditions of the triad because they play a key role in identifying athletes who display certain risk factors for the conditions and can aid in preventing symptom progression. Because awareness is the first step in changing behavior, coaches need to be educated about the triad conditions, so that they can properly educate their athletes, and should receive support for education from school administrators, health professionals, and colleagues. Implementing mandatory, formal, educational programs may be necessary to help coaches understand and promote healthy behaviors in their athletes.

The IOC has also supported coaches by making training recommendations, such as discouraging the practice of sport specialization for children younger than 10 years (11). Rather than focusing on one sport, coaches are encouraged to expose and encourage athletes to participate in a variety of sports to help them develop a broad range of physical skills. Proper coaching and exercise training can prevent or minimize risk factors associated with musculoskeletal injuries and conditions such as the female athlete triad. Athletes should be instructed and guided by coaches to safely increase exercise intensity (i.e., volume, frequency) at the appropriate time and stage of development (2).



Coaches are instrumental in preventing conditions such as the female athlete triad because they can positively influence athletes' behaviors by promoting healthy habits associated with physical activity. Because coaches work closely with the athlete, they have firsthand knowledge about athletes who display “at-risk” behaviors for the female athlete triad requiring further medical follow-up. Because coaches witness athletes' behaviors during practices, competitions, team meetings, and road trips, they have the advantage of routinely noticing behaviors that may be the cause for further concern before others are aware of these actions. High school coaches additionally have access to athletes' academic performance, as well as family and social environments, which serve as an advantage when unhealthy behaviors may be suspected.

If concerns about weight loss or weight gain are raised, coaches have an added responsibility to communicate these concerns to the athlete, the athlete's parents, or to an appropriate health care professional. Research has indicated that athletes who receive guidance in adjusting their caloric intake to match their energy needs or are supervised in reducing their weight, if weight loss is necessary, are less likely to develop disordered eating and eating disorders (26).


Preparticipation examinations organized by coaches and conducted by health care professionals prior to the season can help identify athletes who may be at risk for developing the female athlete triad. Menstrual history taken by the team physician or an appropriate health professional can provide valuable information regarding the first 2 triad components. Further medical follow-up, such as risk of cardiovascular disease, would be required in athletes with amenorrhea. Preseason screening examinations can also be an opportunity to screen for musculoskeletal injuries and provide educational lectures or pamphlets for athletes (and parents) about healthy eating, getting proper rest and recovery from physical activity, avoiding substance abuse, and improving mental focus for sport (and academics).

Once symptoms are identified, referral to an appropriate health professional can facilitate treatment and prevent the more deleterious effects of the female athlete triad syndrome. Athletes with the triad may display varied symptoms, which require a multidisciplinary team approach (physicians, coach, athletic trainer, dietitian, sports psychologist, and physical therapist) for treatment. Referring athletes to health care professionals who understand the special needs of the female athlete is important for avoiding the harmful effects of low energy availability/disordered eating and menstrual dysfunction on bone health. By focusing on healthy strategies to gain optimal sports performance, rather than emphasizing physical attributes such as body weight and body fat, coaches can make a significant impact on athletes.

Nutritional counseling may be one of the most important clinical interventions that can be implemented. Often increasing caloric intake or decreasing physical activity can reverse amenorrhea. A physician or dietitian can further evaluate whether treatment from a mental health professional, such as a sports psychologist, is necessary. Although early warning signs may not always indicate that the athlete will develop the female athlete triad, the likelihood of developing low bone mineral density will increase as symptoms progress. Therefore, careful monitoring of athletes who are at risk for developing the triad is extremely important for preventing the triad.


With regard to prevention, coaches in all sports and levels of competition need to encourage athletes to have adequate nutrition and recovery from exercise, which are essential for maintaining good health and enhancing sports performance. In addition to adequate nutrition, athletes must have proper fluid replacement (such as water or an electrolyte replacement fluid). Keeping well hydrated effectively helps the body to process food, remove heat from exercising muscles, and produce energy. The National Athletic Trainer's Association recommends that adequate amounts of fluid must be taken in before, during, and after physical activity (specific guidelines can be found on their Web site at Athletes need to be educated that a certain amount of nutrients, vitamins, minerals, and body weight are necessary for optimal bone health and physical performance. De-emphasizing that a certain body weight or body fat percentage is necessary to achieve optimal performance is likely to discourage disordered eating and the development of eating disorders. When educated coaches suspect that an athlete is symptomatic, then they should interact with that athlete and be specific about their suspicions, while providing emotional support and encouraging them to seek medical care (5). Coaches can gain the athlete's trust by showing their support for treatment and reassuring them that their position in the team will not be jeopardized.

By enlisting support from school administrators, coaches can effectively implement a preventative program for the triad. If a system is not already in place, coaches should establish a team of health professionals who are available to communicate with and refer athletes to when necessary. Colleges and high schools should endorse a written policy that provides coaches with a plan of action to follow when physical or psychological warning signs for the female athlete triad are observed or suspected (5). Having a policy in place guarantees that the athlete will receive proper medical follow-up and takes pressure off coaches to decide what the appropriate procedure should be. When the athlete's health is in danger, a policy that restricts the athlete from competition or training may be needed. Because treatment may be required for recovery from the conditions of the triad, enforcing a minimal requirement before the athlete is able to continue athletic participation is essential (i.e., a certain percentage of weight gain or a certain number of days of rest) (5). The best interest of the athlete should always be kept in mind.

Recognizing and preventing the female athlete triad may require coaches to change their perception about what is healthy for female athletes. Many coaches believe that because amenorrhea is prevalent in female athletes, it is a “normal” consequence of exercise (18) rather than a nutritional deficiency. If athletes also perceive that amenorrhea is normal or common, and sense that it is uncomfortable for coaches to discuss menstruation with them, it is doubtful that the athlete will recognize or report menstrual irregularities as a problem. If coaches are uncomfortable talking to athletes about menstruation, they should recruit a qualified health care team member who has good rapport with the athlete. Athletes who have not had a menstrual period for more than 3 months should be referred to a physician for diagnosis, treatment, and continued monitoring of menstrual cycles.


Coaches have an important responsibility in identifying athletes with symptoms of the triad and referring them to appropriate resources when a problem is suspected. Being aware of predisposing risk factors and understanding the underlying physical and psychological causes for low energy availability and disordered eating is critical. Coaches must understand that extremely low body weight, amenorrhea, and obsessive patterns of behavior do not enhance sports performance but are signs indicating a need for further medical follow-up. Although coaches do not implement treatment strategies for the triad, they can provide support to the athlete and the multidisciplinary team (physicians, dietitians, sports psychologists, athletic trainers, and physical therapists) who become involved in the athlete's intervention. Close communication with the team of health professionals treating the athlete, while respecting the athlete's privacy, is likely to facilitate successful treatment and the athlete's healthy return to sport. Early recognition, treatment, and prevention of the triad can preserve bone health, prevent stress fractures and other musculoskeletal injuries, as well as promote psychological and cardiovascular health in female athletes.

Coaches can promote positive and open communication to athletes about eating and exercise habits. Having an “open-door” policy with athletes encourages them to ask questions or discuss sports concerns they are not comfortable asking parents or friends about. Gaining a coach's trust is particularly important when disordered eating and menstrual dysfunction become personal concerns or an athlete becomes concerned about another teammate. Knowledge is a powerful tool; by understanding the female athlete triad, coaches can assure that sport participation for the female athlete can be a positive and rewarding life experience.


1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine. Preparticipation Physical Evaluation (3rd ed). Minneapolis, MN: McGraw-Hill, 2004. pp. 1-104.
2. Bennell KL, Matheson G, Meeuwisse W, and Brukner P. Risk factors for stress fractures. Sports Med 28: 91-122, 1999.
3. Berga SL and Loucks TL. Use of cognitive behavior therapy for functional hypothalamic amenorrhea. Ann N Y Acad Sci 1092: 114-129, 2006.
4. Berga SL, Mortola JF, Girton L, Suh B, Laughlin G, Pham P, and Yen SS. Neuro-endocrine aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 68: 301-308, 1989.
5. Bonci CM, Bonci LJ, Granger LR, Johnson CL, Malina RM, Milne LW, Ryan RR, and Vanderbunt EM. National Athletic Trainers' Association Position Statement: Preventing, detecting, and managing disordered eating in athletes. J Athl Train 43: 80-108, 2008.
6. Brundu B, Loucks TL, Adler LJ, and Berga SL. Increased cortisol in the cerebrospinal fluid of women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 91: 1561-1565, 2006.
7. Duncan CS, Blimkie CJ, Cowell CT, Burke ST, Briody JN, and Howman-Giles R. Bone mineral density in adolescent female athletes: Relationship to exercise type and muscle strength. Med Sci Sports Exerc 34: 286-294, 2002.
8. Engel SG, Johnson C, Powers PS, Crosby RD, Wonderlich SA, Wittrock DA, and Mitchell JE. Predictors of disordered eating in a sample of elite Division I college athletes. Eat Disord 4: 333-343, 2003.
9. Guest NS and Barr SI. Cognitive dietary restraint is associated with stress fractures in women runners. Int J Sport Nutr Exerc Metab 15: 147-159, 2005.
10. Hoch AZ, Dempsey RL, Carrera GF, Wilson CR, Chen EH, Barnebei VM, Sandford PR, Ryan TA, and Gutterman DD. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med Sci Sports Exerc 35: 377-383, 2003.
11. International Olympic Committee (IOC) Consensus Statement on the female athlete triad. April, 2002. Available at: report917.pdf. Accessed October 22, 2009.
12. Lemoine S and Granier P. Estrogen receptor alpha mRNA in human skeletal muscles. Med Sci Sports Exerc 35: 439-443, 2003.
13. Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, and Warren MP. The female athlete triad: Position Stand. Med Sci Sports Exerc 39: 1867-1881, 2007.
14. Marcus MD, Loucks TL, and Berga SL. Psychological correlates of functional hypothalamic amenorrhea. Fertil Steril 76: 310-316, 2001.
15. Miller VM and Duckles SP. Vascular actions of estrogens: Functional implications. Pharmacol Rev 60: 210-241, 2008.
16. Ogdan CL, Carroll MD, and Curtin LR. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 295: 1549-1555, 2006.
17. Otis CL, Drinkwater B, Johnson M, Loucks AL, and Wilmore J.American College of Sports Medicine position stand: The female athlete triad. Med Sci Sports Exerc 29: i-ix, 1997.
18. Pantano KJ. Current knowledge, perceptions and interventions used by college coaches in the U.S., regarding the prevention and treatment of the female athlete triad. North Am J Orthop Sports Phys Ther 1: 195-207, 2006.
19. Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, and Hirschberg AL. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. J Clin Endocrinol Metab 90: 1354-135, 2005.
20. Romani W, Patrie J, Curl LA, and Flaws JA. The correlations between estradiol, estrone, estriol, progesterone, and sex hormone-binding globulin and anterior cruciate ligament stiffness in healthy, active females. J Women Health 12: 287-297, 2003.
21. Scott P. When being varsity-fit masks an eating disorder. New York Times. September 14, 2006:12, sect E.
22. Shultz SJ, Kirk SE, Sander TC, and Perrin DH. Sex differences in knee laxity change across the female menstrual cycle. J Sports Med Phys Fitness 45: 594-603, 2005.
23. Sundgot-Borgen J. Pathologic weight control methods and self-reported eating disorders in female elite athletes and control. Scand J Med Sci Sports 3: 150-155, 1993.
24. Sundgot-Borgen J. Prevalence of eating disorders in elite female athletes. Int J Sport Nutr 3: 29-40, 1993.
25. Sundgot-Borgen J. Risk factors and triggers for the development of eating disorders in female elite athletes. Med Sci Sports Exerc 26: 414-419, 1994.
26. Sundgot-Borgen J and Larsen S. Nutrient intake and eating behavior of female elite athletes suffering from anorexia nervosa, anorexia athletica and bulimia nervosa. Int J Sport Nutr 3: 431-442, 1993.
27. The Female Athlete Triad Coalition. October, 2007. Available at: Accessed October 22, 2009.
28. Thompson RA and Sherman RT. “Good athlete” traits and characteristics of anorexia nervosa. Are they similar? Eat Disord J Treat Prev 7: 181-190, 1999.
29. Williams NI, Berga SL, and Cameron JL. Synergism between psychosocial and metabolic stressors: Impact on reproductive function in cynomolgus monkeys. Am J Physiol Endocrinol Metab 293: E270-E276, 2007.
30. Wojtys EM, Huston L, Boynton MD, Spindler KP, and Lindenfeld TN. The effect of menstrual cycle on anterior cruciate ligament in women as determined by hormone levels. Am J Sports Med 30: 182-188, 2002.

low energy availability; disordered eating; menstrual dysfunction; low bone density; female athlete

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