Sports Medicine

, Volume 41, Issue 7, pp 587–607 | Cite as

Obstacles in the Optimization of Bone Health Outcomes in the Female Athlete Triad

  • Gaele Ducher
  • Anne I. Turner
  • Sonja Kukuljan
  • Kathleen J. Pantano
  • Jennifer L. Carlson
  • Nancy I. Williams
  • Mary Jane De Souza
Review Article


Maintaining low body weight for the sake of performance and aesthetic purposes is a common feature among young girls and women who exercise on a regular basis, including elite, college and high-school athletes, members of fitness centres, and recreational exercisers. High energy expenditure without adequate compensation in energy intake leads to an energy deficiency, which may ultimately affect reproductive function and bone health. The combination of low energy availability, menstrual disturbances and low bone mineral density is referred to as the ‘female athlete triad’. Not all athletes seek medical assistance in response to the absence of menstruation for 3 or more months as some believe that long-term amenorrhoea is not harmful. Indeed, many women may not seek medical attention until they sustain a stress fracture.

This review investigates current issues, controversies and strategies in the clinical management of bone health concerns related to the female athlete triad. Current recommendations focus on either increasing energy intake or decreasing energy expenditure, as this approach remains the most efficient strategy to prevent further bone health complications. However, convincing the athlete to increase energy availability can be extremely challenging.

Oral contraceptive therapy seems to be a common strategy chosen by many physicians to address bone health issues in young women with amenorrhoea, although there is little evidence that this strategy improves bone mineral density in this population. Assessment of bone health itself is difficult due to the limitations of dual-energy X-ray absorptiometry (DXA) to estimate bone strength. Understanding how bone strength is affected by low energy availability, weight gain and resumption of menses requires further investigations using 3-dimensional bone imaging techniques in order to improve the clinical management of the female athlete triad.



No funding was used to assist in the preparation of the manuscript. The authors have no conflict of interest.


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Copyright information

© Adis Data Information BV 2011

Authors and Affiliations

  • Gaele Ducher
    • 1
    • 2
  • Anne I. Turner
    • 1
  • Sonja Kukuljan
    • 1
  • Kathleen J. Pantano
    • 3
  • Jennifer L. Carlson
    • 4
  • Nancy I. Williams
    • 2
  • Mary Jane De Souza
    • 2
  1. 1.Centre for Physical Activity and Nutrition Research, School of Exercise and Nutrition SciencesDeakin UniversityBurwoodAustralia
  2. 2.123 Noll Laboratory, Department of KinesiologyPennsylvania State University, State CollegeUniversity ParkUSA
  3. 3.Physical Therapy Program, Department of Health SciencesCleveland State UniversityClevelandUSA
  4. 4.Division of Adolescent Medicine, Department of PediatricsLucile Packard Children’s Hospital at StanfordPalo AltoUSA

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