NEDA TOOLKIT for Coaches and Trainers
• Disordered eating
• Menstrual irregularity is not usually detectable
by a coach, but it is important to let your
athletes know that missing menstrual cycles is
not normal and they should feel comfortable
going to student health or a specialist to have
this addressed. Missed cycles in athletes are
not always an indication of the Triad, so it
is important to have the athlete evaluated
by a doctor for other medical problems
that may cause amenorrhea (e.g., polycystic
ovarian syndrome or a pituitary tumor). This
evaluation involves various laboratory tests
and sometimes imaging. Once other causes are
ruled out, treatment can proceed with dietary
and exercise adjustments.
Female athletes taking oral
contraceptive pills (OCP) may be
unaware of menstrual irregularities
or think the artificial period created
by the pills will protect her from
decreased bone density. More recent
studies show that this is not the case.
Only natural menstruation produces
the right hormones at the right levels
to build bone mass.
Sample Female Athlete Triad scenarios, with
potential responses
A college freshman cross-country runner increases
her mileage abruptly but does not increase her caloric
intake to compensate for increased training. She is
also experiencing stresses in school. She suffers a
tibial stress fracture.
• Changes in routine and new stresses, both
mental and physical, can take a toll on an
athlete. Talk to new team members early on
about the changes they may experience and
how to cope with them. If you know an athlete
is under mental or physical stress, encourage
her to make use of your school’s counseling
services and/or suggest sports nutrition
counseling, both of which can help improve
physical and mental well-being.
• Prevent this situation by gradually increasing
training during the preseason, as well as
stressing the need for dietary adjustments and
increases to account for the increase in caloric
expenditure. • Send the athlete to a medical professional
to assess her fracture as well as review her
diet, menstrual history and fracture history.
A doctor may decide a DXA scan is warranted,
depending on other risk factors present.
You overhear some seniors on your high school
volleyball team discussing one of their teammates,
who has never gotten her menstrual cycle.
• Send the athlete to a sports medicine specialist
for evaluation. No cycle by the age of 16
is considered primary amenorrhea (versus
secondary amenorrhea, where a female has
begun menses that later stop).
• If a medical cause such as a tumor or polycystic
ovarian syndrome is discovered, it can be
managed by a doctor such as primary care
doctor, endocrinologist or OB/GYN.
• If delayed menses due to extreme exercise
and/or diet (the Triad) is diagnosed, the
athlete’s physician and a dietitian should
address the problem immediately, as she is
missing important estrogen exposure and
dietary support for skeletal development and
bone density.
What are the Triad treatments?
Therapy for the Female Athlete Triad involves a
multidisciplinary approach that includes the coach,
parents, medical professionals, dietitians, psychological
support (e.g., psychiatrist, psychologist, therapist) and
sometimes teammates.
The basis of all Triad treatment is diet and exercise
modification. If the athlete is underweight, energy
balance and weight gain are crucial to treatment
success. The athlete needs to gain an understanding of
the relative number of calories she is burning and the
types of nutrients her body needs.
She may also need counseling to help return to
healthier eating and exercise habits and coping with
the range of emotions that this entails. She may also
benefit from therapies that challenge unhealthy ways
of thinking and promote developing better coping skills.
The most important help you as a coach can provide is
to recognize the warning signs and know where to go to
for help.
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