The Female Athlete Triad

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The Female Athlete Triad

• Presented by
• Jeff Ernst, ATC

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The following articles were used as the main
backbone in the creation of this presentation

• Beals KA Female Athlete Triad Update. Clin
  Sports Med 26 (2007)
• Otis CL, Drinkwater B, Johnson M, et al. ACSM
  Position Stand The Female Athlete Triad. Med Sci
  Sports Exerc 29 (1997)

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What is the Female Athlete Triad?

• 1997 American College of Sports Medicine (ACSM)
  Definition
• Disordered Eating
• Amenorrhea
• Osteoporosis

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1997 ACSM Definition Disordered Eating

• Wide spectrum of harmful or ineffective eating
  behaviors used in attempts to lose weight.
• Ranges in severity from restrictive eating to the
  DSM-IV defined eating disorders.

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1997 ACSM Definition Amenorrhea

• Primary amenorrhea is the absence of menstruation
  by the age of sixteen in a female with secondary
  sex characteristics.
• Secondary amenorrhea is the absence of three or
  more consecutive menstrual cycles after menarche.

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1997 ACSM Definition Osteoporosis

• Disease characterized by low bone mass and
  micro-architectural deterioration of bone tissue.
• Follows World Health Organization (WHO)
  diagnostic criteria.

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World Health Organization (WHO) Diagnostic
Criteria

• Normal bone mineral density (BMD) that is no
  more than 1 standard deviation (SD) below the
  mean of young adults.
• Osteopenia BMD between 1 and 2.5 SD below the
  mean for young adults.
• Osteoporosis BMD more than 2.5 SD below the mean
  for young adults.

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The Female Athlete Triad Today

• 2007 ACSM Definition
• Disordered Eating
• Menstrual Dysfunction
• Low Bone Mineral Density (BMD)

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2007 ACSM Definition Disordered Eating

• Increased emphasis on energy availability.
• Defined as the amount of dietary energy remaining
  for all other physiologic functions after energy
  has been expended in exercise.
• Commonly occurs with poor food choices and
  increasing activity levels without increased
  caloric intake.

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2007 ACSM Definition Menstrual Dysfunction

• Includes the full spectrum of menstrual
  irregularities.
• Greater emphasis placed on luteal suppression,
  anovulation, oligomenorrhea, along with both
  primary and secondary amenorrhea.

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Luteal Suppression

• Also called luteal phase deficiency.
• Generally asymptomatic.
• Shortened luteal phase (between ovulation and
  menstruation).
• May be accompanied by prolonged follicular phase
  resulting in little change in cycle length.

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Anovulation

• Absence of ovulation.
• Generally caused by impairment of follicular
  development resulting from altered hormonal
  status. Enough estrogen is present to stimulate
  some proliferation of the uterine lining
  resulting in slight bleeding.
• Due to the bleeding, many females believe they
  are not suffering from menstrual irregularities.

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Oligomenorrhea

• Irregular menses.
• Used to describe a prolonged length of time
  between cycles.
• 35 or more days between cycles.

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Amenorrhea

• Primary amenorrhea has been redefined by the
  American Society of Reproductive Medicine as the
  absence of menstruation by the age of 15 in
  females with secondary sex characteristics.
• Secondary amenorrhea continues to be defined as
  the absence of three or more consecutive
  menstrual cycles after menarche.

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2007 ACSM Definition Low Bone Mineral Density

• Emphasis has been placed on the full spectrum of
  bone health.
• Spans from low bone mineral density and stress
  fractures to osteoporosis.

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Why the Change?

• Greater emphasis on the full spectrum of
  behaviors and conditions within a given disorder.
• The original version focused more on the extreme
  end point of each disorder.

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How Are They Interrelated?

• Disordered eating and menstrual dysfunction.
• Disordered eating and low bone mineral density.
• Menstrual dysfunction and low bone mineral
  density.

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Prevalence

• Disordered Eating 1 - 62 depending on
  population studied. More prevalent in sports
  that emphasize lean physique.
• Menstrual Dysfunction 6 - 79 depending on
  definitions used in study.
• Low Bone Mineral Density 22 - 50 (mainly
  osteopenia).

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Prevalence of the Triad

• The prevalence of all three components
  simultaneously 0 - 2.2.
• Although rare, any occurrence should warrant
  concern with the healthcare provider.

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Warning Signs

• Ritualized eating
• Food restriction
• Chronic dieting
• Skipping meals
• Fasting
• Laxative use
• Diet pill use
• Obsessive training
• Low self-esteem
• Dry skin and hair

• Constipation
• Chronic diarrhea
• Frequent weight fluctuations
• Fatigue
• Muscle weakness
• Muscle cramps
• Dehydration
• Delayed puberty
• Frequent restroom visits after meals

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Evaluation Options

• History Questionnaire (easy and effective)
• Blood Tests (measure ovarian steroid hormone)
• Dual Energy X-ray Absorptiometry (DXA)

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Treatment Options

• Educate
• Correct energy deficit
• Increase calories by 10 per week until target is
  reached.
• Decrease activity levels to assist in correcting
  energy deficit.
• Limit weight gain to 1-2 pounds per week.

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Treatment Options Continued

• Oral Contraceptives
• Regulates hormones.
• Assists in normalizing menstrual cycle.
• Assists in increasing bone mineral density?
• Vitamin D and calcium supplementation.

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