• Irregular menses
• Secondary Amenorrhea
• Low BMI (underweight)

• Pelvic ultrasound
• Serum follicle-stimulating hormone (FSH)
• Serum thyroid stimulating hormone (TSH)
• Urine pregnancy 

Urine pregnancy test 

The female athlete triad is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density. This term has been updated into Relative Energy Deficiency in Sport (RED-S) by the International Olympic Committee.

The imbalance between caloric intake and energy expenditure leads to decreased pulsatile secretion of gonadotropin-releasing hormones from the hypothalamus. This in turn leads to decreased levels of FSH and luteinizing hormone, which then causes a hypoestrogenic state.

A urine pregnancy test is always the appropriate initial test to evaluate secondary amenorrhea.

When pregnancy test is deemed negative, additional testings with with FSH, luteinizing hormone, thyroidstimulating hormone, and prolactin can be undertaken. In addition, a thorough history and physical examination are important.

Behavioral therapy and dietary counseling may be indicated. Health care providers should screen for eating disorders, such as anorexia nervosa and bulimia, and refer for treatment as needed

• Herrera, J. E. (2018). Sports Medicine and Adaptive Sports. In Braddom’s Rehabilitation Care: A Clinical Handbook (pp. 270-278.e11). Elsevier. https://doi.org/10.1016/b978-0-323-47904-2.00039-8
• Witkop CT, Warren MP. Understanding the spectrum of the female athlete triad. Obstet Gynecol 2010;116:1444–8.
• Nazem, T. G., & Ackerman, K. E. (2012). The female athlete triad. Sports health, 4(4), 302–311. https://doi.org/10.1177/1941738112439685
• Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Committee Opinion No. 651. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e143–6.