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Eating disorders are common in women. Anorexia nervosa and bulimia nervosa are described in detail in Chapter 29-05 and 29-06. The female athlete triad disorder, disordered eating in patients with diabetes, and binge eating disorders are other eating disorders that should be considered.



  • Disordered eating.

  • Menstrual disorders.

  • Low BMD.

General Considerations

Female athletes who participate in sports and activities valuing thinness are at increased risk for developing the female athlete triad disorder. The female athlete triad is described as an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased BMD. The triad includes disordered eating (a spectrum of abnormal patterns of eating, including binge eating, purging, food restriction, prolonged fasting, and the use of diet pills, diuretics, or laxatives), menstrual disorders, and low BMD. Half of all athletes with amenorrhea have BMD at least 1.0 standard deviation below the mean. The BMD is decreased even in those areas subjected to stress during exercise. The diagnosis is made when the female athlete meets the three criteria of the triad.

Clinical Findings

A. Symptoms and Signs

Individuals with the female athlete triad display some pattern of disordered eating and have some menstrual irregularities. Many women have amenorrhea, but others have irregular menses. Typically, the patient has concerns about weight and body image. A history of stress fractures should also raise the clinician's concern.

B. Laboratory Findings

Depending on the severity of the symptoms and whether the patient is binging and purging, the laboratory abnormalities can be similar to those seen in anorexia nervosa or bulimia nervosa. These include electrolyte abnormalities related to binging and purging, metabolic alkalosis due to dehydration and volume depletion, and anemia. BMD, if measured, is decreased.

Differential Diagnosis

The main differential diagnoses include anorexia nervosa, bulimia nervosa, and endocrine disorders such as hyperthyroidism and diabetes mellitus.


Little evidence is currently available about treatment of the female athlete triad. Strategies such as counseling, cognitive-behavioral therapy, and possibly exercise restriction may be helpful. A multidisciplinary approach, including consultation with a nutritionist and communication with the coach and trainers (after obtaining appropriate consent from the patient), may enable common goal setting. Working with athletes to develop a "contract" that outlines their responsibilities, and the goals of treatment may be helpful. The desire to participate in sports and the lure of a performance-enhancing diet may motivate some patients to pursue treatment.

Hutson  MJ  et al. Effects of low energy availability on bone health in endurance athletes and high-impact exercise as a potential countermeasure: a narrative review. Sports Med. 2021;51:391.
[PubMed: 33346900]  
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