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Misunderstood and Misdiagnosed: The Female Athlete Triad

Department of Pediatrics - January 2017


Division Chief of Pediatric Sports Medicine, University Hospitals Rainbow Babies & Children’s Hospital; Associate Professor of Pediatrics, Case Western Reserve University School of Medicine

When a young female athlete presents with lack of energy, menstrual irregularity or the total loss of her period, a stress fracture indicating poor bone health, or any combination of these symptoms of the female athlete triad, many pediatricians may not recognize the syndrome or may misdiagnose an isolated symptom due to a lack of general awareness.

“For young athletes, what first appears to be a single isolated issue may actually be an early warning sign for a serious caloric deficiency due to the tremendous energy output of demanding athletic training,” says Amanda Weiss Kelly, MD, Division Chief of Pediatric Sports Medicine at University Hospitals Rainbow Babies & Children’s Hospital, and Associate Professor of Pediatrics at Case Western Reserve University School of Medicine.

The female athlete triad—a spectrum of symptoms including energy availability, menstrual function and bone health—occurs when energy intake does not adequately compensate for exercise-related expenditures. The impact of these symptoms on a growing adolescent can be serious and long term, as this age group is undergoing an important phase of bone mass accumulation. If left untreated, these young women could face severe cardiovascular, bone health and reproductive consequences in the future.

Estimates for female adolescents experiencing one or more of these symptoms could be as high as 54 percent—though accurate measurement is difficult due to the wide spectrum of symptom severity that patients report, if they report it at all. Some young athletes, parents and coaches may still believe that symptoms like amenorrhea are simply a sign that an athlete is training hard.

Awareness of symptoms is a major challenge for the female athlete triad. Dr. Weiss Kelly and colleagues are part of the international Female Athlete Triad Coalition, which shares information across the U.S. and around the world to try and increase knowledge. As most physicians report little or no training on the triad during medical education and only an estimated 20 percent have general understanding of the symptoms, Dr. Weiss Kelly and a colleague recently published a clinical report about the female athlete triad in the journal Pediatrics outlining prevalence and standard of care. Sports medicine pediatricians also participate in local events about youth athletic activities to educate coaches, athletic trainers and parents about what to look for and when to call the doctor.

“We need to increase knowledge about this on all fronts—from the parents, coaches and athletic trainers who help these kids excel every day, to the front line medical care providers who can intervene early before the symptoms progress and cause long term damage to a young woman’s development,” says Dr. Weiss Kelly.

“The good news is that we’ve had great success compensating for female athlete triad by adjusting and increasing a child’s nutritional intake at key points of the day. For example, adding 200-300 high quality calories to the child’s diet within 15 minutes of physical activity replenishes glycogen, helping her recover faster and even play better the next day.”

A multi-disciplinary approach to helping patients make nutritional and lifestyle adjustments has led to significant improvements in symptoms for many young athletes without the need for additional medical or behavioral health interventions, such as estrogen supplementation or eating disorder treatments.

“Most of these cases are not kids with eating disorders,” Dr. Weiss Kelly concludes. “Many of them can have successful and productive experiences in sports if we can get them to a healthy weight and make sure they are taking in enough calories to compensate for their energy expense.”

Contact Dr. Weiss Kelly at