Female Athlete Triad

1
Female Athlete Triad

• An ounce of prevention
• is worth a pound of cure.

• Michelle M. Wilson MD, Neha Chowhdary MD, Sara
  Baird, MD
• Greenville Health System
• Steadman Hawkins Clinic of the Carolinas

2
Objectives

• Define female triad
• Review the components of the triad individually
• Discuss health consequences
• Epidemiology
• Mechanisms
• Screening and diagnosis
• Prevention, Treatment and Return to Play

3
FAT Case

• Anna is a 16 y/o junior gymnast who presents with
  right leg pain x 2 weeks.
• She has been working hard in the off-season to
  get lean in the hopes of earning a college
  scholarship.
• She is 53 and weighs 103 pounds, down from the
  114 pounds at the beginning of the season.
• You suspect stress fracture. What is your
  approach?

4
History

• Timeline
• 1972 Title IX legislation provided for greater
  female participation in athletics
• 1992 ACSM coined the term Female Athlete Triad
• 1997 ACSM published the Female Athlete Triad
  Position Stand
• 2007 Revision of ACSMs position stand

5
Definition

• Female Athlete Triad refers to the
  interrelationships among energy availability,
  menstrual function, and bone mineral density.
• Clinical manifestations include eating disorders,
  functional hypothalamic amenorrhea, and
  osteoporosis

6
Introduction

• Low energy availability (with or without eating
  disorders), amenorrhea, and osteoporosis, alone
  or in combination, pose significant health risks
  to physically active girls and women.
• The potentially irreversible consequences of
  these clinical conditions emphasize the critical
  need for prevention, early diagnosis, and
  treatment.
• Each clinical condition is now understood to
  comprise the pathological end of a spectrum of
  interrelated subclinical conditions between
  health and disease

7
Shift in approach
8
Energy Availability

• The amount of dietary energy remaining for other
  body functions after exercise training. (Dietary
  energy intake minus exercise energy expenditure)
• Low energy availability leads to reduced energy
  used for cellular maintenance, thermoregulation,
  growth, and reproduction.
• This may restore energy balance and promote
  survival but impairs health.
• May be inadvertent or intentional (eating
  disorders).

9
Energy Availability and Eating Disorders

• Clinical mental disorders often accompanied by
  other psychiatric illnesses.
• Anorexia nervosa
• restrictive eating in which the individual views
  herself as overweight
• afraid of gaining weight even though she is at
  least 15 below expected weight for age and
  height.
• Amenorrhea is a diagnostic criterion for anorexia
  nervosa
• Bulimia nervosa
• usually in the normal weight range,
• repeat a cycle of overeating or binge-eating and
  then purging or other compensatory behaviors such
  as fasting or excessive exercise

10
Menstrual Function

• Amenorrhea is defined as the absence of menstrual
  cycles lasting more than three months
• Amenorrhea beginning after menarche is called
  secondary amenorrhea.
• Primary amenorrhea refers to a delay in the age
  of menarche, the defining age for primary
  amenorrhea was recently reduced from 16 to 15
  years of age.
• Many retrospective surveys have established that
  menarche often occurs later in athletes than in
  nonathletes.

11
Bone Mineral Density

• Osteoporosis
• "a skeletal disorder characterized by
  compromised bone strength predisposing a person
  to an increased risk of fracture
• Not always caused by accelerated bone mineral
  loss in adulthood but rather caused by not
  accumulating optimal BMD during childhood and
  adolescence.
• Bone strength and the risk of fracture depend on
  the density and internal structure of bone
  mineral and on the quality of bone protein, which
  may explain why one person suffers fractures
  while another with the same BMD does not.

12
Bone Mineral Density

• BMD in premenopausal women and children are
  expressed as Z-scores to compare individuals to
  age and sex-matched controls (based on
  recommendations from the ISCD).
• Z-scores below -2.0 are termed "low bone density
  below the expected range for age" in
  premenopausal women and as "low bone density for
  chronological age in children.
• The term osteopenia should not be used and
  osteoporosis be diagnosed in these populations
  only when low BMD is present with secondary
  clinical risk factors that reflect an elevated
  short-term risk of bone mineral loss and
  fracture.
• Secondary risk factors include
• chronic malnutrition
• eating disorders
• hypogonadism
• glucocorticoid exposure
• previous fractures

13
Bone Mineral Density

• Athletes in weight-bearing sports usually have
  5-15 higher BMD than nonathletes.
• Z-score lt -1.0 in an athlete warrants further
  investigation, even in the absence of a prior
  fracture.
• ACSM defines the term "low BMD" as a history of
  nutritional deficiencies, hypoestrogenism, stress
  fractures, and/or other secondary clinical risk
  factors for fracture together with a Z-score
  between -1.0 and -2.0.
• To reflect an increased risk of fragility and
  fracture, ACSM defines "osteoporosis" as
  secondary clinical risk factors for fracture with
  BMD Z-scores -2.0.
• An athlete's BMD reflects her cumulative history
  of energy availability and menstrual status as
  well as her genetic endowment and exposure to
  other nutritional, behavioral, and environmental
  factors.
• Therefore, it is important to consider both where
  her BMD is currently and how it is moving along
  the BMD spectrum.

14
Health Consequences

• Sustained low energy availability, with or
  without disordered eating, can impair health.
• Psychological problems associated with eating
  disorders include
• low self-esteem
• Depression
• anxiety disorders
• Medical complications involve the cardiovascular,
  endocrine, reproductive, skeletal,
  gastrointestinal, renal, and central nervous
  systems.
• Amenorrheic women are infertile, due to the
  absence of ovarian follicular development,
  ovulation, and luteal function.(may ovulate while
  recovering-unplanned pregnancy)
• Consequences of hypoestrogenism seen in
  amenorrheic athletes include
• impaired endothelium-dependent arterial
  vasodilation which reduces the perfusion of
  working muscle
• impaired skeletal muscle oxidative metabolism
• elevated low-density lipoprotein cholesterol
  levels
• vaginal dryness

15
Health Consequences

• BMD declines as the number of missed menstrual
  cycles accumulates and the loss of BMD may not be
  fully reversible.
• Stress fractures occur more commonly in
  physically active women with menstrual
  irregularities and/or low BMD with a relative
  risk for stress fracture two to four times
  greater in amenorrheic than eumenorrheic
  athletes.
• Fractures also occur in the setting of
  nutritional deficits and low BMD.
• Any premenopausal fracture unrelated to trauma
  is a strong predictor for postmenopausal fractures

16
Prevalence

• Disordered eating
• Only two large, well-controlled studies have
  diagnosed clinical eating disorders according to
  the Diagnostic and Statistical Manual of Mental
  Disorders to obtain unbiased and reliable
  estimates of the prevalence of eating disorders
  in elite female athletes in different types of
  sports.
• One found eating disorders in 31 of elite female
  athletes in "thin-build" sports compared to 5.5
  of the control population.
• The other found that 25 of female elite athletes
  in endurance sports, aesthetic sports, and
  weight-class sports had clinical eating disorders
  compared to 9 of the general population.
• A small study of collegiate gymnasts (N 42)
  found a prevalence of disordered eating behaviors
  as high as 62.

17
Prevalence

• Secondary amenorrhea
• Varies widely with sport, age, training volume,
  and body weight
• Reported as high as 69 in dancers and 65 in
  long-distance runners(2-5 in the general
  population).
• Distance runners, prevalence of amenorrhea
  increased from 3 to 60 as training mileage
  increased from lt13 to gt113 kmwk-1 while their
  body weights decreased from gt60 to lt50 kg.
• Prevalence of secondary amenorrhea is higher
  (67) in female runners less than 15 years of
  gynecological age compared to older women (9).

18
Prevalence

• Primary amenorrhea
• less than 1 in the general population
• more than 22 in cheerleading, diving and
  gymnastics
• Subclinical menstrual disorders typify both
  highly trained and recreational eumenorrheic
  athletes luteal deficiency or anovulation was
  found in 78 of eumenorrheic recreational runners
  in at least one menstrual cycle out of three

19
Prevalence

• Low BMD
• Systematic review of studies using the WHO
  T-scores for diagnosis
• Osteopenia 22-50 and osteoporosis 0-13 in
  female athletes
• Normal population 12 and 2.3

20
Prevalence

• The Triad
• Only three studies of female athletes have
  investigated the simultaneous occurrence of the
  triad.
• Only one diagnosed eating disorders.
• The prevalence of the entire Triad in elite
  athletes from 66 diverse sports (4.3 8/186) was
  similar to controls (3.4)
• The other two studies referenced BMD Z-scores to
  instrument norms. One found the entire Triad in
  2.7 of collegiate athletes from seven diverse
  sports. The other found the entire Triad in 1.2
  of high school athletes.
• None estimated energy availability, diagnosed
  subclinical menstrual disorders or the cause of
  amenorrhea, or assessed changes in BMD.

21
Risk Factors

• Athletes at greatest risk for low energy
  availability are those who
• restrict dietary energy intake
• exercise for prolonged periods
• Vegetarians
• limit the types of food they will eat
• Other factors include
• Environmental and social factors
• psychological predisposition
• low self-esteem
• family dysfunction
• abuse
• biological factors
• genetics
• Risk factors for stress fracture include low BMD,
  menstrual disturbances, late menarche, dietary
  insufficiency, genetic predisposition,
  biomechanical abnormalities, training errors, and
  bone geometry (e.g., narrower tibia width,
  shorter tibia length)

22
Mechanisms

• Low energy availability
• Inadvertent vs. intentional
• Dieting may not lead to an eating disorder (be
  mindful of the situation where the athlete is
  told to lose weight)
• Nutritional counseling is essential for
  prevention of inadvertent low energy
  availability.

23
Mechanisms

• Menstrual disorders
• Animal experiments, decreasing dietary intake by
  gt30 has consistently caused infertility and
  skeletal demineralization.
• Menstrual disorders as a result of the triad
  result from the pituitary gland.
• LH pulsatility is disrupted within 5 days when
  e.a. is reduced by gt33(lt30kcal/kg)
• LH pulsatility reflects the pulsatile secretion
  of GnRH from the hypothalamus.

24
Mechanisms

• Menstrual disorders (cont)
• Low e.a. alters levels of metabolic hormones (GH,
  IGF-1, T3, insulin, cortisol, and leptin) and
  substrates(glucose, fatty acids, and ketones).
• These are thought to disrupt signaling pathways
  disrupting GnRH pulsatility.

25
Mechanisms

• Menstrual disorders
• Long-term prospective experiments, luteal
  deficiency and anovulation have been induced in
  young women by increasing exercise energy
  expenditure alone.
• In female monkeys, amenorrhea has been induced by
  increasing exercise energy expenditure without
  reducing dietary energy intake.
• Then their ovulation was restored by increasing
  energy intake without moderating the exercise
  regimen.
• This type of amenorrhea is called functional
  hypothalamic amenorrhea

26
Mechanisms

• Low BMD
• Estrogen deficiency likely account for a small
  part of the abnormal bone remodeling in athletes
  with functional hypothalamic amenorrhea (unlike
  postmenopausal women).
• Malnutrition reduces the rate of bone formation
  and is often a complicating factor.
• In a randomized clinical trial, the rate of bone
  resorption increased and the rate of bone
  formation declined within 5 d after energy
  availability was reduced below 30 kcalkg in
  exercising women.
• Resorption increased when energy availability was
  restricted enough to suppress estradiol, and bone
  formation was suppressed at higher energy
  availabilities in dose-response relationships
  resembling those of insulin, T3 and IGF-I
  (hormones that regulate bone formation).
• Low energy availability may also suppress bone
  formation via effects on other hormones,
  including cortisol and leptin

27
Diagnosis
28
Diagnosis

• Recognition of high-risk athletes
• Screening Methods
• Physiologic Measurements

29
Recognition Whos at risk?

• Subjective performance athletes
• Dance, Gymnastics, Diving, Figure skating
• Endurance Athletes
• Distance runners, Cyclists, Cross-Country Skiing
• Body contour-revealing sports
• Volleyball, Swimming, Diving, Cheerleading
• Weight category sports
• Horse Racing, Wrestling, Rowing

30
Screening Methods

• Medical History Questionnaire
• Food frequency or dietary recall
• Detailed menstrual history questionnaire (age of
  menarche, frequency duration of menses, oral
  contraceptive use)
• Use subtle questions
• Degree of perceived stress during missed workout
• Intensity of exercise
• Level of competition
• External stressors family, coping skills, risky
  behaviors

31
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32
YES NO OTHER
Have you had a menstrual period?
How old were you when you had your first menstrual period?
When was your last period?
How many days does your period last?
Have you ever missed 3 or more consecutive periods?
33
YES NO OTHER
Does your menstrual cycle change with a change in the intensity, freq, or duration of training?
Do you ever have trouble with heavy bleeding?
Do you ever experience cramps during your period?
Are you on OCP or hormones?
Have you ever been treated for anemia?
Do you have family hx of osteoporosis?
34
Screening Instruments

• Survey of Eating Disorders among Athletes (SEDA)
• Athletic Milieu Direct Questionnaire (AMDQ)
• Female Athletic Screening TOOL (FAST)
• College Health Related Information Survey (CHRIS)
• The Physiologic Screening Test (PST)
• The Health, Weight, Dieting, and Menstrual
  History Questionnaires

35
Physiologic Measurements Assessing Body
Composition

• Monitor only under the following conditions
• Qualified and trained individual who is
  proficient in result interpretation
• Serial measurements performed by the same
  individual
• Registered dietician available if nutritional
  support is needed

36
Physiologic Measurements Assessing Body
Composition

• De-emphasize the importance of an ideal body
  weight or body fat composition. Better to use a
  range among athletes in a given sport.
• Emphasize changes estimates not absolute fat mass
  or lean muscle mass in athletes during the
  season.
• Avoid public discussion of the results, including
  coaches.
• Establish at least 2-3 month intervals between
  serial measurements.

37
Physiologic Measurements

• Assessing Body Composition
• Calculating the Body Mass Index
• Laboratory Evaluation
• Bone Densitometry

38
Physiologic Measurements BMI

• BMI should be used as a screening tool to
  determine appropriateness of athletes body
  weight for height, which varies with age sex.
• According to the World Health Organization, if
  18 years, BMI lt18.5 kg/m2 underweight.
• If 14-18 years old, the 5th percentile of the
  Center for Disease Control and Prevention growth
  charts is underweight.
• Pre-adolescent (lt12 yrs) focus on height/weight
  and maturity.

39
Physiologic Measurements

• Laboratory Data
• CBC
• Electrolytes
• Pregnancy test if amenorrhea present
• FSH, LH, Prolactin
• Thyroid function tests
• Electrocardiogram (EKG) consider for athletes
  with disordered eating behavior if history of
  syncope, palpitations, or resting heart rate lt50
  bpm.

40
Physiologic Measurements Bone Densitometry

• T-Score a comparison of the patients BMD with
  the average peak adult BMD.
• Z-score a comparison with age-matched controls.
• In premenopausal women, a Z-score lt-2.0 is low
  bone density below the expected range for age.
• A Z-score lt-1.0 in an athlete requires further
  evaluation since athletes tend to have higher BMD
  (by 5-15) than age-matched controls.

41
Physiologic Measurements Bone Densitometry
42
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43
Case Review

• After a thorough history to include medical and
  menstrual health questionaire, you determine that
  Anna is consuming approximately 900 calories/day
  and has not has not menstruated in over 6 months.
  She is notably thin on exam and has mild facial
  lanugo. Her parents recently divorced and she is
  taking 4 AP classes this semester.
• Lab work is negative for pregnancy but
  demonstrate an iron defiency anemia and low
  vitamin D levels. X-ray is negative but MRI
  reveals a grade 2 medial tibia stress reaction.
  DXA reveals a Z-score of -1.9.
• Whats your approach to treatment and prevention?
  Return to sport?

44
Treatment and Prevention
45
Prevention

• The keys to prevention are increased awareness
  and sensitivity to the condition.

46
Treatment Goal

• Reach a healthy weight and maintain, treating
  both the physical manifestations of the female
  triad as well as the underlying psychological
  condition that contributes to this unhealthy
  behavior

47
Approach to treatment

• Multidisciplinary Team
• Physician
• Registered dietitian
• Mental health provider for those with an eating
  disorder
• Athletic trainer
• Other valuable members include athletes coach,
  exercise physiologist, parents, and family
  members.

48
Outpatient vs. Inpatient Treatment

• Criteria for inpatient treatment includes the
  following
• Weight lt85 of healthy body weight
• Syncopal episodes or arrhythmia
• Abnormal vital signs, electrolyte imbalances or
  dehydration
• Severe body image disturbances or suicidal intent
• Failure to respond to outpatient program x 3
  months
• Concomitant use of alcohol/drugs

49
Outpatient Treatment Approach

• Set a goal weight
• Create a patient contract to make them
  accountable
• Counseling/education
• Medications
• Close follow up

50
Non-pharmacological Therapy

• Dietary
• Increased caloric intake with return of normal
  menses (not induced by birth control pills) leads
  to decreased bone resorption and increased BMD in
  hypothalamic amenorrhea.
• Increase energy availability by increasing energy
  intake, reducing energy expenditure, or a
  combination.
• Counsel patient on the need for an energy
  availability of 30 kcal/kg lean body mass/day at
  minimum.
• Nutrition consult to address necessary foods such
  as dairy, iron-rich, and proteins.
• Calcium 1500 mg/day
• Vitamin D 400-800 IU/day
• Vitamin K 60-90 IU/day
• Protein 1g/kg of body weight/day

51
Non-pharmacological therapy

• Psychologist consult to address both mental and
  physical stress and discuss disordered thoughts
  about eating
• Family counseling may be beneficial to address
  parental pressures on the adolescent that may
  have triggered the disordered eating behavior.

52
Pharmacological therapy

• Antidepressants-used for anorexia/bulimia with
  associated depression/anxiety
• AAP recommends OCP use for treatment of
  amenorrhea if athlete is over 16 years old or if
  she is 3 years post-menarche.
• Evidence of the effectiveness HRT and OCP usage
  in order to increase BMD in women with functional
  hypothalamic amenorrhea is mixed. No evidence to
  support use of HRT/OCP in females with anorexia
  induced amenorrhea.
• Pharmacological restoration of regular menstrual
  cycles with OCP will not normalize the metabolic
  factors that impair bone formation, health, and
  performance.
• Bisphosphonates are not recommended in young
  women.
• Emerging data on folic acid supplementation and
  reversal of endothelial dysfunction in this
  population.

53
Return to Play

• Consider the athlete injured, even in the
  absence of stress fracture or other
  musculoskeletal injury
• No specific guidelines for return to sports but
  athletes being treated for an eating disorder
  should meet minimal criteria to continue training
  and competition
• Cannot be more than 15 underweight
• Must be showing improvement and compliance with
  treatment plan
• RTP must be agreed upon by team and can be
  rescinded at any time

54
Case Review

• In addition to treatment for stress fracture,
  Anna underwent counseling with both a dietician
  and psychologist. She was followed closely by
  her coach as well as her team trainer and
  physician.
• She increased her caloric intake by 100 kcal/day
  each week until she was consuming an average of
  1600 kcal/day. She exercised relative rest for 2
  months and began taking a calcium and vitamin D
  supplement daily.
• She gained 7 pounds and was allowed to return to
  practice gradually. 3 months later she weighed
  in at her original weight of 114 pounds and had
  resumed normal menstrual cycles without the use
  of OCP. She was allowed to return to competition
  and went on to perform at the collegiate level.

55
Conclusion

• Low energy availability with or without eating
  disorders, hypothalamic amenorrhea, and low BMD
  alone or in combination pose significant health
  risks to physically active girls and women.
• Prevention, recognition, and treatment of these
  clinical conditions should be a priority in those
  who work with female athletes. Increased energy
  availability and restoration of gonadal function
  are the cornerstones of treatment.

56
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