Working Diagnosis:
Functional Hypothalamic Primary Amenorrhea

Treatment:
She met with one of the team doctors, the coach, and the sports nutritionist. They came up with the goals for the patient to start her periods naturally and improve bone health. The patient was started on Vitamin D 1000 IU and 1200-1500 mg of Calcium per day. With the nutritionist, she added 800 more calories to her daily intake.

Outcome:
Patient gradually gained weight and 3.5 weeks after she started seeing the nutritionist, she started her periods naturally. She was 47.4 kg when she stared her periods and had a normal BMI. Patient continues to get her periods regularly. After menarche, she started to have acne and menstrual cramps. She also became sexually active so then wanted to be placed on oral contraceptives. A little over a month after she got her first period, she had returned to clinic due to right groin and buttock pain. AP x-ray of pelvis showed right ischial tuberosity stress fracture. There was an incidental note of skeletal immaturity (with note of persistent apophyses along bilateral iliac crests and ischial tuberosities) Case Photo #2 . She was diagnosed with a stress fracture and was non-weightbearing for 6 weeks, at which time she became pain-free and allowed to start progressing to dry land running.

Author's Comments:
This patient met criteria for the female athlete triad, with low energy availability, low bone mineral density, and menstrual dysfunction; however, she had menarche within 3 weeks of eating more and decreasing mileage. Despite suffering a stress fracture, she started her periods on her own by increasing her energy availability, which is the main goal of the female athlete triad. A consensus statement, which was published after this case, recommended a return to play guideline that would have disqualified the patient when she first presented.

Editor's Comments:
We cannot know how this athlete was counseled previously, but it appears an extensive workup was done, twice, without followup intervention. Perhaps diatary advice was given and she was not ready to hear that until now. The amenorrhea in this case was apparently easily reversed, but unfortunately she had already seen bone density consequences of her low energy availability.

References:
1. De Souza MJ, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Br J Sports Med. 2014; 48: 289.
2. Hobart, J, and Smucker, D. The Female Athlete Triad. American Family Physician. Vol 61 (11): 3357-3364. June 1, 2000
3. Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen, J, Warren MP. American College of Sports Medicine position stand: the female athlete triad. Med Sci Sports Exerc. 2007; 38 (10): 1867 – 1882.
4. Warren, Michelle. Amenorrhea and infertility associated with exercise. Up to Date. July 2013.

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