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New criteria for female athlete triad syndrome?
  1. K M Khan1,
  2. T Liu-Ambrose1,
  3. M M Sran2,
  4. M C Ashe1,
  5. M G Donaldson1,
  6. J D Wark3
  1. 1University of British Columbia, Bone Health Research Group, Departments of Family Practice and Human Kinetics, University of British Columbia, Vancouver, Canada
  2. 2Osteoporosis Program, BC Women's Hospital and Health Centre, Vancouver, Canada
  3. 3Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
  1. Correspondence to:
    Dr Khan, James Mather Building, 5084 Fairview Avenue, Vancouver V6T 1Z3, Canada;

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As osteoporosis is rare, should osteopenia be among the criteria for defining the female athlete triad syndrome?

The American College of Sports Medicine (ACSM) has provided a great deal of impetus to educating healthcare providers, athletes, and the general public about the potential harm of a “serious syndrome consisting of disordered eating, amenorrhoea and osteoporosis”.1 We recognise and respect the importance of research and attention to this clinical problem and commend the ACSM on its contribution to date.2 To their credit, the authors of the most recent position stand acknowledged that there were no data reporting prevalence on this condition,3 and they encouraged further research. Since then, Mayo Clinic physiatrist Tamara Lauder4 has published two important papers showing a 0% prevalence of the female athlete triad (as defined by ACSM) despite 34% of this military population being at risk of disordered eating. Therefore we re-examined the prevalence of one component of the female athlete triad, osteoporosis, in studies of athletic women with menstrual disturbance. The syndrome can be no more prevalent than any one of its diagnostic criteria alone. Thus, if osteoporosis is only present in a small proportion of the population, then it follows that the female athlete triad can only be prevalent in an equally small, or smaller, proportion of that population.


Because of the increasing public awareness of osteoporosis and its complications, medical practitioners must not use the term as a synonym for “low bone mass”.5 The current standard for measuring bone mass (bone mineral density; BMD) is by dual energy x ray absorptiometry, and since 1994 the term osteoporosis has had diagnostic criteria based on this technique.3, 6, 7 Osteoporosis is defined as BMD more than 2.5 standard deviations below the mean of young adults. The term osteopenia describes BMD …

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