The cornerstone treatment for any of the component of the Female Athlete Triad is to increase energy availability. Hormone replacement therapy, including birth control pills, are not recommended as a primary treatment.
The Female Athlete Triad - Treatment
Increasing energy availability is the cornerstone treatment for any of the components of the Female Athlete Triad (1,2). This can be achieved by increasing caloric intake (eating more) or by reducing exercise energy expenditure (exercise less). In many athletes, increasing energy availability also means increasing body weight.
If the athlete eats more and gains weight, the menstrual cycles will resume (3,4). Resumption of menses are frequently seen when body weight is increased by 5-10 % (4). Weight gain also significantly improves bone mineral density (BMD) in amenorrhoeic athletes, independent on whether or not menses are resumed (4).
Treatment goals
Treatment goals are dependent on individual circumstances. However, the following specific treatment targets have been recommended by the Female Athlete Triad Coalition Panel (4):
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Reversal of recent weight loss
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Return to a body weight associated with normal menses
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Weight gain to achieve:
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BMI of ≥18.5 kg/m2 (female athletes above age 20)
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≥90 % of predicted weight (female athletes under the age of 20)
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Energy intake should be set at a minimum of 2000 kcal/day; or more likely, a greater energy intake will be required, depending on energy expenditure.
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Energy intake should increase gradually, beginning at 20-30 % above baseline energy needs or the amount of energy required to gain approximately 0.5 kg every 7-10 days (4). This means that an athlete with a daily energy need of 2000 kcal (this is below the average energy need of a female athlete) would need to eat 2400-2600 kcal per day. The International Olympic Committee (IOC) have issued guidelines to add 300-600 kcal per day to improve low EA (5).
Improve nutritional deficiencies
Nutritional deficiencies should also be addressed, including protein, calcium, and vitamin D deficiency (3,4,6). Allthough there is no evidence that increasing calcium intake above recommended values will prevent bone loss in amenorrhoeic athletes, inadequate calcium intake is a risk factor for bone loss (7) and it is therefore important to ensure adequate consumption.
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Statuta, S. M. (2020). The Female Athlete Triad, Relative Energy Deficiency in Sport, and the Male Athlete Triad: The Exploration of Low-Energy Syndromes in Athletes. Current sports medicine reports, 19(2), 43-44.
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Nattiv, A., Loucks, A. B., Manore, M. M., Sanborn, C. F., Sundgot-Borgen, J., & Warren, a. M. P. (2007). The female athlete triad. Med. Sci. Sports Exerc, 39(10), 1867-1882.
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Matzkin, E., Curry, E. J., & Whitlock, K. (2015). Female athlete triad: past, present, and future. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 23(7), 424-432.
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De Souza, M. J., Nattiv, A., Joy, E., Misra, M., Williams, N. I., Mallinson, R. J., . . . Matheson, G. (2014). 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, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013. Br J Sports Med, 48(4), 289-289.
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Nose‐Ogura, S., Harada, M., Hiraike, O., Osuga, Y., & Fujii, T. (2018). Management of the female athlete triad. Journal of Obstetrics and Gynaecology Research, 44(6), 1007-1014.
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Otis, C. L., Drinkwater, B., Johnson, M., Loucks, A., & Wilmore, J. (1997). ACSM position stand: The female athlete triad. Medicine & Science in Sports & Exercise, 29(5), i-ix.
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Drinkwater, B. L., Loucks, A., Sherman, R. T., Sundgot-Borgen, J., & Thompson, R. A. (2005). Position Stand on the female athlete triad.
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Brown, K. A., Dewoolkar, A. V., Baker, N., & Dodich, C. (2017). The female athlete triad: special considerations for adolescent female athletes. Translational pediatrics, 6(3), 144.
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Ross, A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., . . . Jones, G. (2011). The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. The Journal of Clinical Endocrinology & Metabolism, 96(1), 53-58.
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Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., . . . Budgett, R. (2014). The IOC consensus statement: beyond the female athlete triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med, 48(7), 491-497.
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Nasjonalt råd for næring. (2018). Vitamin D i Norge: Behov for tiltak for å sikre god vitamin D-status? Retrieved from https://www.helsedirektoratet.no/rapporter/vitamin-d-i-norge-behov-for-tiltak-for-a-sikre-god-vitamin-d-status/Vitamin%20D%20i%20Norge%20%E2%80%93%20Behov%20for%20tiltak%20for%20%C3%A5%20sikre%20god%20vitamin%20D-status.pdf/_/attachment/inline/b307f785-c4cc-4fde-aec1-ebc86fdd0b4f:829f3ad84cbdf0322f46b3f44d1c6fc14f151a97/Vitamin%20D%20i%20Norge%20%E2%80%93%20Behov%20for%20tiltak%20for%20%C3%A5%20sikre%20god%20vitamin%20D-status.pdf
However, such therapy does not seem to provide a significant benefit on bone mass in amenorrhoeic athletes (3,4). In fact, no pharmacological treatment adequately restores bone loss in athletes with FHA (2). Data on the use of contraceptive use suggests that it may actually cause further harm by further reducing BMD if taken over a long period of time (>2 years) (3,4). This is likely due to its suppressive effect on the production of a hormone called insulin-like growth factor (IGF-1), which is important for bone health (4,5). It is likely that this limits the beneficial effects of estrogen on reducing bone loss (4).
Also, estrogen deficiency is only one of the factors affecting bone health in female athletes with low energy availability (se The Female Athlete Triad). Correcting it through pharmacological treatment does nothing to improve on other factors associated with loss of bone mass in these athletes (2).
The bleeding that occur after starting on hormone replacement therapy are not normal spontaneous menses, but what is called withdrawal bleeding (4). Resumption of menses while using contraceptive therapy therefore often provides a false sense of security in athletes with low energy availability (4,10).
As it does little to improve BMD and may mask low energy availability, the use of oral contraceptives have fallen out of favor in treating athletes with FHA (3). The Female Athlete Triad Coalition (4) recommends that pharmacological treatment should only be offered if menstruation does not resume after 1 year of nutritional therapy (4).
Resistance training
Resistance training is recommended for athletes with low BMD. Under the right circumstances it may prevent and even treat bone loss (4).
This is particularly important in young athletes as peak bone mass is reached by late teenage years or early twenties depending on skeletal site (8). After the peak BMD has been reached, it may only be lost or maintained (3).
Calcium
The recommended daily calcium intake is 1300 mg for individuals aged 9-18, and 1000 mg for individuals aged 19-50 (9). The IOC recommends that amenorrhoeic athletes consume at least 1500 mg/day to assure calcium balance (10).
Vitamin D
The US Endocrine Society recommends a daily vitamin D-intake is 600 international units (IU) or 15 micrograms for all ages between 1-70 (9). Vitamin D deficiency is more often seen in countries with less daylight, and dietary supplements might be recommended.
Proteins
Protein needs for female athletes engaged in intense training are higher than non-athletes, and the ACSM recommends a daily intake of 1.2-1.6 grams per kg body weight (2).
NB! Improving on nutritional deficiencies does not treat menstrual disturbances or loss of bone mass in amenorrhoeic athletes. The only way to do this is to increase energy availability.
Disordered eating
Nutrition counseling and monitoring are sufficient interventions for many athletes with unintentional low energy availability or mild disordered eating (2).
However, when disordered eating is apparent the treatment must focus on the modification of unhealthy attitudes, behaviors and emotions related to food and body image (4). These athletes require interdisciplinary treatment, which should include their primary physician, mental health practitioner and nutritionists.
Hormone replacement therapy (HRT)
Hormone replacement therapy and oral contraceptive pills have often been used as a first-line treatment for amenorrhoeic athletes (3). The idea is that such therapy will correct estrogen deficiency associated with functional hypothalamic amenorrhea (FHA), thereby resuming menses and prevent and treat bone loss in these athletes.
