Symptoms of the Female Athlete Triad and concussion have some similarities. They both have menstrual cycle dysfunction issues, and one of the treatment options for concussion could exacerbate bone density issues with the triad. I think that diagnosis and treatment options for concussion can draw upon and use triad diagnosis and treatment guidelines. Also, I think that athletes being reviewed for the triad should be screened for concussion and vice-versa. In both instances, athletes might not report symptoms. It’s important for the medical community to be able to spot both.
Detailed discussion of the triad is far, far beyond the scope of this website. There are numerous references available online, so you could research this more if you’d like. On this page, I’m including just a few key points of the triad and am providing discussion about the triad in relation to concussion identification and recovery management.
Characteristics
The Triad consists of three main components:
- Low energy availability (EA) and disordered eating (DE)
- Menstrual cycle dysfunction: secondary amenorrhea (lack of periods)
- Low bone mineral density (BMD)
An athlete diagnosed with any one of these components alone is considered to have the Triad. In such a case, it is suggested to look at the other components too to see if the athlete has those issues as well.
Sports Most Common to the Triad
Sports that have a higher focus on appearance seem to have more instances of triad issues, especially disordered eating. Such sports include gymnastics, swimming, figure skating, and long-distance running. [2] Personally, I could see this being an issue with triathlon or other endurance sports, although I’ve not seen that mentioned anywhere at this point. Triathlon requires extensive training and energy expenditure and includes high-intensity running, cycling, and swimming.
Triad History and Timeline
| 1992 | Recognized by the American College of Sports Medicine (ACSM) [1] |
| 1997 | ACSM Position Stand updated [1] (via ref note 2; now designated as a Retired Statement) |
| 2002 | Female Athlete Triad Coalition established [2] |
| 2007 | ACSM Position Stand updated [1] |
| 2014 | Updated and released in March: 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad [3] |
| 2018 | Female Athlete Triad Coalition updated to become the Female and Male Athlete Triad Coalition [2] |
RED-S
In March 2014, the International Olympic Committee (IOC) also released an updated version of their Position Stand regarding the triad. They’re expanding the focus to include males and have renamed their version to RED-S. [4] [5] Because I haven’t seen anything mentioning RED-S from the Female Athlete Triad Coalition and they just released their comprehensive guidelines a week or so ago, I’m going to continue to focus on the new Female Athlete Triad Consensus Statement. There’s so much information in the new guidelines that I think it’s important to review and focus on them at this point. Currently, I also don’t have time to look into RED-S in more detail, although I’m sure I will at some point. Apart from this paragraph, all other information on this page refers to the Female Athlete Triad as defined in the latest consensus statement and earlier versions.
Low Energy Availability and Amenorrhea
The amenorrhea commonly found with the triad is secondary amenorrhea. Within that category, there are two types, two terms mentioned: functional hypothalamic amenorrhea (FHA) and athletic amenorrhea.
Low energy availability means that there isn’t enough nourishment to sustain adequate levels of energy. When it gets too low, amenorrhea may occur. Other issues with menstrual dysfunction may also occur. Those include Luteal Phase Defect (LPD) and anovulation.
LPD results in a shorter luteal phase. That can result in more bleeding episodes, as hormone levels are too low to sustain proper functioning of the corpeus luteum. Anovulation means that ovulation does not occur. In that case, hormone levels aren’t sufficient to generate the “pulse” needed to initiate ovulation. Without ovulation, no progesterone is produced. Progesterone can help with concussion recovery.
Treatment for Amenorrhea
An interesting aspect of treatment options for the triad and concussion is how amenorrhea and menstrual dysfunction are addressed.
The recommended treatment for amenorrhea due to the triad is increasing and managing nutritional intake to ensure there are adequate energy levels to resume normal cycles – not using birth control pills to manage the menstrual cycle.
For concussion, treatment options of which I’ve heard are to use birth control pills to manage and regulate menstrual cycle dysfunction. I’ve never seen it mentioned anywhere to look at low energy availability and DE, which is common to the triad. If an athlete has a concussion and has undiagnosed amenorrhea, LPD, or anovulatory cycles which could initially be addressed by nutrition, why not look at that first before prescribing birth control pills?
Also, another important consideration is the type of birth control used for treatment in these two medical situations. For the triad, it’s advised to not use combination birth control pills as it can worsen the bone density issues. [3] [10] For comprehensive details about BMD and the use of birth control, see the latest triad guidelines. [3]
Another aspect of prescribing birth control pills for concussion is with regard to the puberty and mid-adolescent life phases. In both of those age groups, menstrual cycles are not always regular yet. Primary amenorrhea can delay menarche (one’s first period). A late menarche can result in a longer timeframe for ovulation to become regular; it could take 8-12 years for that to occur. [6] Mid-adolescence (high school years) is a main time period for bone development. If that doesn’t occur as it should, bone loss would be permanent. If girls are experiencing menstrual dysfunction as a result of concussion and are being prescribed birth control pills, I wonder if it would have an adverse effect on becoming ovulatory or having bone development occur as it should. In reviewing statistics from the CDC, it’s clear that birth control pills are being prescribed for these age groups. [7] There are no specifics regarding reasons for prescribing birth control pills. It’s not possible to determine from those statistics whether the pills are prescribed for medical reasons (such as menstrual cycle regulation) or for contraceptive purposes. I think it’s important to review the practice of prescribing birth control pills to girls in these two age groups.
Return to Play
A current, ongoing main topic of discussion in concussion recovery is Return to Play (RTP). Everyone wants to have some guidelines to determine when a concussed athlete can resume sports activities. The new consensus statement for the triad includes Return to Play guidelines, which is a new addition.
The triad RTP guidelines include risk assessments to determine if there’s a low, medium, or high risk, which is then used to determine whether to provide a full or provisional/limited clearance, or a full restriction.
What’s notable about the triad RTP guidelines is that they use menstrual cycles and amenorrhea as a risk factor. This is something that also can result from a concussion. I think that, for females, it would be helpful to use the triad RTP guidelines in conjunction with concussion RTP guidelines. Combine them.
Algorithm for Triad Amenorrhea Diagnosis
The new triad guidelines also include an algorithm that clinicians and medical personnel can use to determine if a female has amenorrhea due to the triad. [1: pg. 100] The first steps are to review endocrine hormones related to the menstrual cycle (LH, FSH, nCG) and other pituitary hormones such as TSH (an indicator for hypothyroidism). In short, endocrine issues are checked first.
Because hypothalamic and endocrine issues can result after concussion, I think that this algorithm can also be used for concussion treatment and management. Like the RTP guidelines, I think the triad tests should be combined with concussion review. Athletes don’t always report concussion. [8] [9] They don’t always report triad issues, either. I think it would be helpful to look for the triad when seeing patients for concussion and vice-versa. These two medical issues have similar symptoms. Why not review them together?
Questions
- If a person wasn’t having periods, gets a concussion and has to stop exercise or training, and her period resumes, might that be a clue that she had triad issues? A treatment for the triad is to scale back on training and exercise and increase nutritional intake.
- If a female has LPD and her luteal phase is shortened, resulting in a longer follicular stage, might that result in higher risk for ACL injury in general? It’s known that ACL injuries are more common during the follicular stage. If there are a number of athletes with LPD and longer follicular stages, perhaps that’s why the incidence numbers are higher. That’s a guess and a question.
Summary
As I read more about the triad, I was surprised to see how many similarities there were with concussion. The same types of menstrual dysfunction common to the triad are also seen with concussions. Amenorrhea, LPD, anovulation – all those situations have been studied, reviewed, and have resulted in guidelines for triad treatment and RTP.
An important point to keep in mind, I think, is it seems that a main approach to treatment for menstrual issues with the triad is a focus on nutrition and adequate energy levels. Birth control is not the first option. Yet the opposite is true with concussion: birth control is a first option for treatment of menstrual dysfunction. I’ve never heard or read about low energy availability as a consideration for concussion treatment. I think it would be useful to look at nutrition when determining how to treat concussion in female athletes.
Also, I think it’s very important to first determine if an athlete with concussion has a preexisting triad issue. If she already had amenorrhea and low energy issues, perhaps it would prolong recovery. In which case, maybe it’s best to treat the Triad first, then the concussion. Get the menstrual cycle working again and see how that affects the concussion (if at all). Maybe that would hasten the concussion recovery. I think it’s worth considering.
There’s quite a bit of data available for menstrual cycles and athletes. The triad has been studied for many years. I think that concussion researchers could get a jump start on this by reviewing the previous studies and the new guidelines just released.
[1] Matzkin, Elizabeth MD; Curry, Emily J.; Whitlock, Kaitlyn PA-C Female Athlete Triad: Past, Present, and Future Journal of the AAOS July 2015; 23(7):p 424-432
[2] Female and Male Athlete Triad Coalition femaleandmaleathletetriad.org
[3] DeSouza MJ, Nattiv A, Joy E, Misra M, Williams N, Mallinson R, Gibbs J, Olmsted M, Goolsby M, Matheson G “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, CA, May 2012, and 2nd International Conference Held in Indianapolis, IN, May 2013 Clinical” Journal of Sport Medicine Volume 24, Number 2, March 2014
[4] “IOC Medical Commission to reveal new insights into the Female Athlete Triad” olympics.com January 17, 2014
[5] Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N, Sherman R, Steffen K, Budgett R, Ljungqvist A “The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S)” British Journal of Sports Medicine (March) 2014;48:491-497
[6] American Academy of Pediatrics “Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign” Pediatrics 2006;118;2245
[8] O’Kane J, Spieker A, Levy M, Neradilek M, Polissar N, Schiff M. “Concussion Among Female Middle School Soccer Players “ JAMA Pediatrics January 2014
[9] Reeves H “Cheerleaders, at Risk of Concussion, Hide Symptoms” New York Times September 13, 2013
[10] Golden NH, Lanzkowsky L, Schebendach J, Palestro CJ, Jacobson MS, Shenker IR “The effect of estrogen-progestin treatment on bone mineral density in anorexia nervosa” Journal of Pediatric and Adolescent Gynecology 2002 Jun;15(3):135-43
