Screening for Bone Stress in Athletes With Menstrual Disturbances

Abstract

Athletes who experience menstrual disturbances, such as amenorrhea or oligomenorrhea, are at increased risk for bone stress injuries due to alterations in hormonal milieu and impaired bone metabolism. Early and effective screening is crucial for preventing long-term skeletal complications and optimizing athletic performance. This review synthesizes current evidence regarding epidemiology, pathophysiology, risk factors, clinical presentations, diagnostic strategies, management, emerging therapies, and clinical guidelines for bone stress screening in this vulnerable population.

Introduction

Menstrual disturbances in athletes, commonly seen in endurance and aesthetic sports, are a core component of the Female Athlete Triad and the broader Relative Energy Deficiency in Sport (RED-S) syndrome. They signal underlying energy imbalance and hormonal dysregulation, which significantly impact bone health. The clinical imperative is to identify at-risk individuals early, mitigate bone stress injuries, and implement multidisciplinary management strategies.

Epidemiology / Disease Burden

The prevalence of menstrual disturbances among athletes ranges from 10% to 44%, varying by sport and training intensity. The incidence of bone stress injuries is markedly higher in athletes with amenorrhea compared to their eumenorrheic counterparts, with stress fractures reported in up to 31% of female collegiate runners. These injuries not only impair athletic participation but also predispose to chronic skeletal deficits, increasing the risk for osteoporosis and fragility fractures later in life.

Pathophysiology

Menstrual disturbances reflect disruptions in the hypothalamic-pituitary-gonadal axis, most often secondary to chronic energy deficiency. This leads to hypoestrogenism, which impairs osteoblastic bone formation and accelerates bone resorption. The resulting low bone mineral density (BMD) compromises skeletal integrity, increasing susceptibility to microdamage and stress injuries under repetitive loading. Additional hormonal derangements such as elevated cortisol and suppressed insulin-like growth factor-1 further exacerbate bone loss.

Risk Factors

Key risk factors include participation in sports emphasizing leanness or weight control (e.g., long-distance running, gymnastics, ballet), high training volumes, restrictive eating behaviors, psychological stress, and a history of previous stress fractures. Genetic predisposition, delayed menarche, and insufficient calcium/vitamin D intake also contribute to risk stratification. Awareness of these factors supports targeted screening in high-risk groups.

Clinical Features

Bone stress injuries typically present with localized pain exacerbated by activity and relieved by rest. In the context of menstrual disturbances, clinicians should maintain a high index of suspicion, particularly when pain is insidious and disproportionate to training loads. The absence of overt trauma, coupled with a history of menstrual irregularity, energy deficits, or disordered eating, strengthens the clinical suspicion for underlying bone pathology.

Diagnosis

Diagnosis relies on a combination of detailed history, physical examination, and imaging. Assessment should include menstrual and dietary history, training patterns, and psychosocial factors. Physical exam may reveal localized tenderness and swelling. Imaging modalities such as MRI are preferred for early detection of stress reactions before radiographic changes become evident. Dual-energy X-ray absorptiometry (DXA) is essential for evaluating BMD, while laboratory tests assess hormonal profiles and nutritional status.

Treatment & Management

Management is multidisciplinary, encompassing nutritional rehabilitation to restore energy balance, modification of training loads, psychological support, and pharmacological interventions where necessary. Restoration of regular menses is a primary goal, as it is associated with improved bone outcomes. Calcium and vitamin D supplementation should be optimized. Hormonal therapy (e.g., transdermal estrogen) may be considered in persistent cases, though emphasis remains on addressing the underlying energy deficit.

Recent Advances / Emerging Therapies

Emerging research highlights the utility of individualized risk assessment tools and biomarkers for early detection of bone stress injuries. Novel imaging techniques, such as high-resolution peripheral quantitative computed tomography (HR-pQCT), offer insights into bone microarchitecture beyond standard DXA. Investigational therapies targeting bone turnover pathways, including anti-sclerostin and parathyroid hormone analogs, are being evaluated for refractory cases, though robust evidence in athletic populations is pending.

Guideline Recommendations

Contemporary guidelines from the American College of Sports Medicine and International Olympic Committee advocate routine screening for menstrual function and bone health in female athletes, especially those in high-risk disciplines. Screening protocols should include menstrual history, dietary assessment, physical examination, and periodic DXA scans. Early intervention and education are prioritized to prevent irreversible skeletal damage and optimize lifelong bone health.

Conclusion

Bone stress screening in athletes with menstrual disturbances is a clinical priority with significant implications for both short-term performance and long-term skeletal health. Multidisciplinary, guideline-based approaches facilitate timely identification and management of at-risk athletes, reducing the burden of bone stress injuries and enhancing overall wellbeing. Continued research into novel diagnostic and therapeutic modalities promises to further refine preventive strategies in this high-risk population.