Selected Topics in Athletic Training

The Importance of Female Athlete Triad Screenings in Athletic Training

Courtney Footskulak
California University of Pennsylvania


Many athletes, as well as certified athletic trainers, are unaware of the effects, signs, and symptoms, and methods of prevention and treatment of the Female Athlete Triad. The purpose of this paper is to outline the components of the triad, the methods used for screening the triad, and the importance of surveying in athletic training.

Background of the Female Athlete Triad

The female athlete triad is a growing problem in female athletics.  Many athletes, as well as certified athletic trainers, are unaware and uneducated as to the effects of the female athlete triad, signs and symptoms, and the use of screening for preventing and treating the triad. The triad consists of three components:  eating disorders or disordered eating, amenorrhea, and osteoporosis (West, 1998). Because the American College of Sports Medicine’s (ACSM) Women’s Task Force identified these three health concerns in 1992, the medical and scientific communities have attempted to alert those individuals who have contact with female athletes to become more informed of the seriousness of these conditions (Warren, 1990).

The prevalence of eating disorders has been rising steadily for the past five decades and is quickly becoming a significant public health concern in female athletics (MacMullen, 2005). An eating disorder, in athletes is characterized by a wide spectrum of maladaptive eating and weight control behaviors and attitudes including concerns about body weight and shape and poor nutrition or inadequate caloric intake (Green, 2005). An eating disorder or disordered eating can range from a mild case such as only engaging in these behaviors a few times a week to very severe case such as not eating for days at a time, or vomiting.  Athletes may be self-motivated or pressured by their coaches, peers, or parents to meet unrealistic body weight or body fat levels, resulting in an eating disorder or some form of disordered eating (Rumball, 2005).

Amenorrhea is the absence of menstrual bleeding and can be classified as either primary or secondary amenorrhea. Primary amenorrhea refers to a female who has not yet had a menstrual cycle by the age of 16 or who is without sexual development by the age of 14.  Secondary amenorrhea refers to a female who has had an absence of menstrual bleeding for either six months or the length of time equivalent to a total of at least three of her pervious cycle lengths (Simpson, 1998). Athletes who begin training before menarche are often more likely to have incidences of amenorrhea than those who begin training after menarche (Pantano, 2009).  Amenorrhea is deficient, absent, or inappropriately secreted pulsatile gonadotropin-releasing hormone (GnRH) (Simpson, 1998).  Abnormal GnRH secretion is said to occur for two reasons. Adrenal axis activation during exercise inhibits the hypothalamic GnRH pulse activator, and/or low caloric intake combined with increased caloric expenditure may result in low energy (Simpson, 1998).

Osteoporosis, third component of the triad, refers to inadequate bone formation and premature bone loss and can result in increased risk of fracture.  The average person experiences bone loss at a rate of 0.5 percent per year.  Osteoporosis in young athletes can increase that rate to anywhere between 2 percent and 6 percent per year, with complete loss reaching 25 percent of the total bone mass (Pantano, 2009).  A correlation has been found between athletes with amenorrhea and decreased bone mineral density (BMD) that supports the connection between these two components of the triad (Simpson, 1998).

Methods of Screening

Screenings for the female athlete triad is becoming more common in female athletics.  Because little was known about the triad until recently, there are very few methods of screening available. The most common ones are for eating disorders as the apparent main factor of the triad, as well as physical and physiological screenings.  Screening may also aid in prevention, a possible key in minimizing the occurrences of the female athlete triad.    

The most often used method of prevention of the triad in athletic training is the use of pre-participation exams, medical history forms, surveys, and questionnaires (Black, 2003).  Athletes are questioned or monitored for disordered eating behaviors, eating habits, nutritional intake, energy level, and history of menses during pre participation screening examination.  These strategies are important for treating and preventing low energy availability, which can lead to menstrual dysfunction and low BMD (Rumball, 2005). The pre-participation examination and medical history form provide an excellent opportunity to screen for triad disorders, to establish a rapport with the athletes, and build a complete medical history on the patient (Black, 2003).

The most widely used test for eating disorders or disordered eating is the Eating Disorders Inventory-2 (Pantano, 2009). This Inventory is a self-report measure of 91 items that questions athletes on age, actual weight, desired weight, height, menstrual history, and exercise habits (Manore, 2007). The Eating Disorders Inventory-2 includes 11 subscales; the three subscales that receive the greatest considerations are the Bulimia, Body Dissatisfaction, and Drive-for-Thinness subscales because they are the core subscales for screening eating disorders. These three subscales measure the athlete’s tendency to engage in binge eating or purging, unhappiness with body image, and concern about height and weight (Pantano, 2009).  Some of the other areas tested in the questionnaire are Ineffectiveness, Interpersonal Distrust, Perfectionism, Maturity Fear, Interceptive Awareness, Impulse Regulation, Social Insecurity, and Asceticism (Manore, 2007).

Along with pre-participation screenings, education and knowledge about the female athlete triad is a key contributor to prevention.  Athletes, coaches, certified athletic trainers, and any other person working with the athlete needs to be educated as to the causes, signs, symptoms, and results of the female athlete triad (Warren, 1990).  Uneducated athletes may not realize the severity of the condition and in turn not go to their certified athletic trainer if a problem arises.  Recognition of signs and symptoms then become increasingly important.

The only part of the female athlete triad that can be recognized simply through signs and symptoms is an eating disorder.  An athlete who suffers from an eating disorder may not necessarily be abnormally thin; however, they may present with bradycardia, hypotension, lanugo hair, and/or a history of fainting.  Parotid swelling, erosion of tooth enamel, a large amount of dental work, and Russell’s sign, which is finger and nail changes on the first and second digits of the dominant hand, are all signs of bulimia (Simpson, 1998).


Improving an athlete’s overall energy availability may be the key to reversing menstrual dysfunction and low bone density in female athletes. Increasing total daily energy intake in moderate increments may be the easiest approach when treating an athlete with the female athlete triad.  In short, focus on a good diet may serve any prevention and/or treatment plan.  The use of screening is very important in the profession of athletic training. Certified athletic trainers are responsible for the prevention, recognition, and treatment of any condition their athletes may face, including the female athlete triad.  The use of screenings would help certified athletic trainers recognize a problem early and prevent the occurrence of more serious medical problems.


West, R.V. (1998).  The female athlete: The triad of disordered eating, amenorrhea and osteoporosis. Journal of Sports Medicine, 26, 63-71.

Warren, B. (1990). Disordered eating patterns in competitive female athletes. International Journal of Eating Disorders, 9, 565-569.

MacMullen, N. J. (1987). Anorexia nervosa: Case findings of families at risk. Journal of Community Health Nursing, 4, 57-60.

Black, D., Larkin, L., Coster, D., Leverenz, L., & Abood, D. (2003). Physiologic screening test for eating disorders/disordered eating among female collegiate athletes. Journal of Athletic Training, 38, 286-297.

Green, M., Scott, N., Diyankova, I., Gasser, C., & Pederson, E. (2005). Eating disorder prevention: an experimental Comparison of high level dissonance, low level dissonance, and no-treatment control.  Journal of Eating Disorders, 13, 157-169.

Rumball, J. S., & Lebrun, C. M. (2005). Use of the preparticipation physical examination form to screen for the female athlete triad in Canadian interuniversity sport universities. Clinical Journal of Sport Medicine, 15, 320-325.

Simpson, W. F., Hall, H. L., Coady, R. C., Dresen, M., Ramsay, J. D., & Huberty M. (1998). Knowledge and attitudes of university female athletes about the female athlete triad. Journal of Exercise Physiology, 6, 208-221.

Reinking, M. F., & Alexander, L. E. (2005). Prevalence of disordered eating behaviors in undergraduate female collegiate athletes and non-athletes. Journal of Athletic Training, 40, 47-51.

Pantano, K. J. (2009). Strategies used by physical therapists in the U.S for treatment and prevention of the female athlete triad. Journal of Physical Therapy in Sports, 10, 3-11.

Manore, M. M., Kam, L. C., & Loucks, A. B. (2007). The female athlete triad: Components, nutrition issues, and health consequences. Journal of Sports Sciences, 25, 61-71.


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