Menstrual Disorders in the Athlete

By admin On Oct 14, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Anastasia N. Fischer

Thomas L. Pommering

Basics

Description

Primary amenorrhea is the lack of spontaneous uterine bleeding:
- By the age of 14 yrs without development of secondary sexual characteristics OR
- By the age of 16 yrs with otherwise normal development.
Secondary amenorrhea is as a 3-mo absence of menstrual bleeding in a woman with previous regular menses or a 9-mo absence with previous oligomenorrhea.
Suspect Female Athlete Triad.

Epidemiology

Amenorrhea occurs in 3–64% of female college athletes compared with 2–5% of the general population.

Commonly Associated Conditions

Female Athlete Triad

Diagnosis

History

With amenorrhea, history is directed toward other causes besides hypothalamic amenorrhea: Thyroid disease, androgen excess, anabolic steroids, and autoimmune and pituitary disorders.
Menstrual history:
- Age of menarche
- Last menstrual period
- Frequency and duration of menses
- Longest time between menses
- Physical signs of ovulation (cervical mucous change or menstrual cramps)
- Previous or current hormonal therapy
Diet history
Exercise history
Sexual history

Physical Exam

Tanner stage
Acne
External genitalia abnormalities
Lanugo, or hirsutism
Bradycardia
Behavioral signs of disordered eating: Preoccupation with food and weight, self-criticism, eating alone, excessive water/soda drinking, compulsive and excessive exercise, poor self-image, frequent bathroom trips during and after meals
If anorexia nervosa is present, cachexia, hypotension, alopecia, pruritus, cold intolerance, and yellow skin (hypercarotenemia) also may be observed.
Any other findings consistent with differential diagnosis

Diagnostic Tests & Interpretation

Initial: Pregnancy test, follicle-stimulating hormone, luteinizing hormone, thyroid-stimulating hormone, prolactin
If patient is hirsute, has acne, or polycystic ovary syndrome is suspected, add free testosterone and dehydroepiandrosterone sulfate to the list of studies.
If TSH/prolactin is normal, consider progesterone challenge.

Imaging

Pelvic US if suspect anatomic abnormality
MRI Sella turcica if suspect pituitary problem

Differential Diagnosis

Pregnancy
Hypothalamic dysfunction:
- Gonadotropin-releasing hormone (GnRH) deficiency
- Hypogonadotropic hypogonadism (psychogenic, stress, weight loss, or exercise-induced)
- Eating disorder/Female Athlete Triad
- Drugs (GnRH analogues, medroxyprogesterone acetate, danazol, or oral contraceptives) or systemic illness
- Kallmann syndrome
- Idiopathic (eg, head trauma)
- Space-occupying lesion or infection
Pituitary dysfunction:
- Pituitary neoplasm or prolactin-secreting tumor
- Sheehan syndrome
- Empty-sella syndrome
- Granulomatous disease (eg, sarcoidosis)
- Lawrence-Moon-Biedl syndrome
- Thalassemia major
- Mumps encephalitis

P.387

Ovarian dysfunction:
- Menopause or premature ovarian failure
- Polycystic ovary syndrome
- Ovarian neoplasm
- Turner syndrome (45,X)
- Gonadal dysgenesis
- Autoimmune disease
Uterine dysfunction:
- Asherman syndrome
- Absence of uterus or transverse vaginal septum:
  - Androgen insensitivity
  - Imperforate hymen
  - Mayer-Rokitansky-Kuster-Hauser syndrome (müllerian agenesis)
Endocrine disease:
- Hypothyroidism
- Cushing syndrome
- Adrenal hyperplasia
- Adrenal tumors

Treatment

Treat underlying condition if found
Otherwise, consider hormonal manipulation of menses

Additional Reading

American Academy of Pediatrics. Committee on Sports Medicine and Fitness. Medical concerns in the female athlete. Pediatrics. 2000;106:610–613.

Fagan KM. Pharmacologic management of athletic amenorrhea. Clin Sports Med. 1998;17:327–341.

Ireland ML, Ott SM. Special concerns of the female athlete. Clin Sports Med. 2004;23:281–298, vii.

Manore MM. Dietary recommendations and athletic menstrual dysfunction. Sports Med. 2002;32:887–901.

Marshall LA. Clinical evaluation of amenorrhea in active and athletic women. Clin Sports Med. 1994;13:371–387.

Master-Hunter T, Herman D. Amenorrhea: evaluation and treatment. Am Fam Physician. 2006;73:1374–1382.

Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, et al. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. J Clin Endocrinol Metab. 2005;90:1354–1359.

Rumball JS, Lebrun CM. Preparticipation physical examination: selected issues for the female athlete. Clin J Sport Med. 2004;14:153–160.

Warren MP, Goodman LR. Exercise-induced endocrine pathologies. J Endocrinol Invest. 2003;26:873–878.

Codes

ICD9

307.50 Eating disorder, unspecified
626.0 Absence of menstruation
626.1 Scanty or infrequent menstruation

Clinical Pearls

If patient is amenorrheic just during her competitive years, she is at risk for irreversible bone loss after only 6 mos of amenorrhea. This is especially important because adolescence and early adulthood are times when the patient should be building bone for later life to prevent osteoporosis and its complications. Also, the amenorrhea may just be a symptom of more important issues that may prevail beyond the competitive years and should be addressed, such as Female Athlete Triad.