Clinical |

Ob-Gyns Play Key Role in Diagnosing and Treating a Common Condition in Female Athletes

Washington, DC—Ob-gyns have an important role to play in the health of female athletes, according to the latest guidance released from The American College of Obstetricians and Gynecologists (ACOG). Menstruation is a key vital sign, as well as an important factor in recognizing a medical condition observed in physically active girls and women known as the female athlete triad.


In a Committee Opinion released this month, ACOG states that ob-gyns should screen for the following three components of this condition at comprehensive visits for preventive care:

  • low energy availability with or without disordered eating;
  • menstrual dysfunction; and
  • low bone density.

“Amenorrhea, or abnormal absence of menstruation, is often considered “normal” among elite athletes who are often unaware this is the first indicator of a more serious problem, which is not uncommon in female athletes,” said Meredith Loveless, M.D., author of the Committee Opinion and chair of ACOG’s Committee on Adolescent Health Care. “While dancers, gymnasts and runners are at highest risk for the female athlete triad, all athletes are susceptible regardless of body build or sport and a patient doesn’t need to be experiencing all three components to be affected. Even healthcare providers often do not understand that an athlete does not need to have all three components to have female athlete triad and be adversely affected by this condition so increased awareness is important.”

Female athlete triad stems from energy imbalance, which occurs when dietary energy intake minus exercise energy expenditure doesn’t leave adequate energy for remaining body functions. This can lead to dysfunction of the hypothalamus—the control center for the endocrine system which secretes hormones to various organs. When it’s not functioning properly, often due to under-nutrition, it can affect menstrual function and bone health. Many athletes will experience a decrease in estrogen levels, which plays a key role in bone formation and maintenance.

The pressure among female athletes to be lean is tremendous,” said Loveless. “Unfortunately, this can lead to unhealthy behaviors that can cause a host of problems that may not be reversible and can counter their performance goals, including osteoporosis, fracture and diminished athletic performance.”

Among slender build female athletes, clinical disordered eating has been reported between 16 to 47 percent compared to five to 10 percent among the general population. However, many athletes are simply not taking in enough fuel to cover their energy expenditure without having an underlying eating disorder.

According to the Committee Opinion, ob-gyns should consider the menstrual cycle as a vital sign since absence or abnormality of menses is an important marker of overall health. They should conduct a thorough patient history, including questions regarding eating habits, sexual history, exercise regime and symptoms of depression. The visit should also include a physical examination and a pelvic exam if indicated for gynecological reasons.

The overall goal of treatment is the restoration of regular menses, which is the clinical marker for energy balance. The most important aspect of treating female athlete triad is diet and activity modification and a sports nutritionist may play a key role in treatment. There is a common misconception that birth control pills can treat female athlete triad but studies show they have little effect on restoring bone mass density and can make it more difficult to use menstruation as a marker of recovery. They are not a substitute for dietary or activity modifications.

“While some treatments may be perceived by the patient as compromising sports performance, it is important for an ob-gyn to work with a multidisciplinary team, including dieticians and mental health providers, as well as the athlete, their family and coaches to set realistic goals,” said Loveless.

The Committee Opinion #702, "Female Athlete Triad" will be published in the June issue of Obstetrics & Gynecology.

Other recommendations issued in the June Obstetrics & Gynecology

Committee Opinion #701, Choosing the Route of Hysterectomy for Benign Disease

Hysterectomy is one of the most frequently performed surgical procedures in the United States. Selection of the route of hysterectomy for benign causes can be influenced by the size and shape of the vagina and uterus; accessibility to the uterus; extent of extrauterine disease; the need for concurrent procedures; sur­geon training and experience; average case volume; available hospital technology, devices, and support; whether the case is emergent or scheduled; and preference of the informed patient. Vaginal and laparoscopic procedures are considered “minimally invasive” surgical approaches because they do not require a large abdominal incision and, thus, typically are associated with shortened hospitalization and postoperative recovery times compared with open abdominal hysterectomy. Minimally invasive approaches to hysterectomy should be performed, whenever feasible, based on their well-documented advantages over abdominal hysterectomy. The vaginal approach is pre­ferred among the minimally invasive approaches. Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible. Although minimally invasive approaches to hysterectomy are the preferred route, open abdominal hysterectomy remains an important surgical option for some patients. The obstetrician–gynecologist should discuss the options with patients and make clear recommendations on which route of hysterectomy will maximize benefits and minimize risks given the specific clinical situation. The relative advantages and disadvantages of the approaches to hysterec­tomy should be discussed in the context of the patient’s values and preferences, and the patient and health care provider should together determine the best course of action after this discussion.

Committee Opinion #703, Asymptomatic Microscopic Hematuria in Women

Asymptomatic microscopic hematuria is an important clinical sign of urinary tract malignancy. Asymptomatic microscopic hematuria has been variably defined over the years. In addition, the evidence primarily is based on data from male patients. However, whether the patient is a man or a woman influences the differential diagnosis of asymptomatic microscopic hematuria, and the risk of urinary tract malignancy (bladder, ureter, and kidney) is significantly less in women than in men. Among women, being older than 60 years, having a history of smoking, and having gross hematuria are the strongest predictors of urologic cancer. In low-risk, never-smoking women younger than 50 years without gross hematuria and with fewer than 25 red blood cells per high-power field, the risk of urinary tract malignancy is less than or equal to 0.5%. Furthermore, the evaluation may result in more harm than benefit and is unlikely to be cost effective. Thus, data support changing current hematuria recom­mendations in this low-risk group. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society encourage organizations producing future guidelines on the evaluation of microscopic hematuria to perform sex-specific analysis of the data and produce practical sex-specific recommendations. In the meantime, the American College of Obstetricians and Gynecologists and the American Urogynecologic Society recommend that asymptomatic, low-risk, never-smoking women aged 35–50 years undergo evaluation only if they have more than 25 red blood cells per high-power field.

Committee Opinion #704, Human Papillomavirus Vaccination

Human papillomavirus (HPV) is associated with anogenital cancer (including cervical, vaginal, vulvar, penile, and anal), oropharyngeal cancer, and genital warts. The HPV vaccination significantly reduces the incidence of anogenital cancer and genital warts. Despite the benefits of HPV vaccines, only 41.9% of girls in the recommended age group, and only 28.1% of males in the recommended age group have received all recom-mended doses. Compared with many other countries, HPV vaccination rates in the United States are unacceptably low. The U.S. Food and Drug Administration has approved three vaccines that are effective at preventing HPV infection. These vaccines cover 2, 4, or 9 HPV serotypes, respectively. Safety data for all three HPV vaccines are reassuring. The HPV vaccines are recommended for girls and boys aged 11–12 years and can be given to females and males up to age 26 years. The Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists recommend routine HPV vaccination for girls and boys at the target age of 11–12 years (but it may be given from the age of 9 years) as part of the adolescent immunization platform in order to help reduce the incidence of anogenital cancer and genital warts associated with HPV infection. Obstetrician–gynecologists and other health care providers should stress to parents and patients the benefits and safety of HPV vaccination and offer HPV vaccines in their offices.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization.