Female Athlete Triad

By admin Last updated Nov 22, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Kelsey Logan

Basics

Description

A condition of female athletes that refers to disordered eating, functional hypothalamic amenorrhea, and osteoporosis; this condition is a manifestation of the interrelationship of energy availability, menstrual function, and bone mineral density.

Epidemiology

Prevalence

Female athlete triad: Largely unknown; 1–4% in various studies (1)
Disordered eating: 25–62% depending on sport
Amenorrhea: 3–66% (secondary amenorrhea) depending on sport
Osteoporosis: 0–13%

Risk Factors

Sports emphasizing leanness or endurance, such as gymnastics, figure skating, cross-country running or skiing, and diving
Individual sports as opposed to team sports
Early sport-specific training
Punitive measures imposed for weight gain
Unreasonable performance expectations by self or others
Poor body self-image
Social isolation

Etiology

Reduced energy availability or an imbalance between intake and output of calories is the ultimate cause of the disorder.
Restriction of calories may be inadvertent (not taking in enough calories for the demand of the sport) or intentional (to try to lose weight).
Purging of calories may manifest as vomiting, laxative use, or excess exercise/training with little or no recovery periods.
This energy deficit leads to disruption of normal estrogen production through the hypothalamic–pituitary axis, which decreases bone formation and bone production and, in women, a change in menstrual function. Men may demonstrate reduced energy availability and thus a decrease in bone density, also owing to the preceding risk factors.
The etiology is multifactorial.
There is a psychological difference between those misusing exercise, laxatives, or calorie restriction to manage/lose weight and those who inadvertently do not match their calories to their sport.
In many women, the emphasis on leanness in sport, along with the perceived benefits of low body weight (eg, better fitness, agility, speed) causes increased focus on weight-control measures (2).

Commonly Associated Conditions

Psychological disorders such as depression and anxiety

Diagnosis

High index of suspicion required

History

One component of the triad raises suspicion for the others.
Presence of primary (absence of menses by age 15) or secondary amenorrhea (absence of menses for 3 consecutive months)
Presence of stress fracture or history of stress fracture
Review exercise habits and nutritional history for abnormal weight-control behavior involving food and/or exercise.
Review life stressors.
Patient may have fear of weight gain and/or poor body image.
Patient may have comorbid psychological problem (eg, depression).
Symptoms include:
- Amenorrhea
- Stress fracture
- Weight-control behaviors and/or weight loss
- Cold intolerance
- Sore throat/gastroesophageal reflux
- Constipation/GI motility problems
- Light-headedness
- Fatigue
- Depression
- Introversion
- Worsened athletic performance

Physical Exam

Height, weight, body mass index (BMI <18.5 kg/m² considered underweight for women ≥18 yrs of age)
Vital signs for evidence of bradycardia and/or orthostatic hypotension
Observe for fat depletion and muscle wasting.
Integumentary exam for dry skin, lanugo, brittle hair/nails
Ocular exam to evaluate for pituitary and thyroid disorders
Dental examination for evidence of lingual enamel erosion secondary to vomiting
Parotid gland observation/palpation for hypertrophy secondary to vomiting
Thyroid palpation
Cardiac auscultation for evidence of dysrhythmia
Complete neurologic examination, especially cranial nerves and reflexes
Tanner staging
Consider pelvic examination if amenorrheic.
Careful examination of any musculoskeletal pain, looking for stress fracture

Diagnostic Tests & Interpretation

Laboratory results may be normal, even in very undernourished women.

Lab

Pregnancy test
Urinalysis for specific gravity (should be normal unless dehydration is present)
CBC (normal; possibility of anemia)
Erythrocyte sedimentation rate (normal)
Serum electrolytes, blood urea nitrogen, and creatinine (normal, except possibly in the case of bulimia, which may cause electrolyte abnormalities or severe dehydration associated with malnutrition)
Thyroid function tests (normal)
Luteinizing hormone and follicle-stimulating hormone levels (low or normal)
Estradiol level (low)
Serum prolactin (normal)
Serum cortisol (mildly elevated)
Serum testosterone and dehydroepiandrosterone sulfate if concern for androgen excess, such as with polycystic ovary syndrome or adrenal tumors

Imaging

Bone mineral density (BMD) testing with dual-energy x-ray absorptiometry (DXA) if patient has had stress fracture from mild trauma or 6 mos' evidence of hypoestrogenism and/or disordered eating (3)[C]
Reevaluation on same DXA machine yearly if chronic
DXA of posteroanterior spine and hip using lower Z-score to base diagnosis of low BMD

Diagnostic Procedures/Surgery

Progesterone challenge (eg, medroxyprogesterone acetate 10 mg PO daily × 7–10 days): If a period occurs, there is sufficient estrogen to stimulate the endometrium.

Differential Diagnosis

Pregnancy
Pituitary disease
Hyperthyroidism
Hypogonadism
Hyperparathyroidism
Polycystic ovary disease
Adrenal dysfunction
Autoimmune disease
Anabolic steroid use/abuse
Excess glucocorticoid administration
Malabsorption syndromes

P.159

Treatment

Main goal of treatment is to increase energy availability and preserve normal BMD; the normal estrogenic state requires adequate caloric intake to match energy expenditure (4).
Athlete often resists treatment if negative energy balance is intentional. Treatment discussion requires good patient rapport.
Requires team approach (ie, physician, psychologist, athletic trainer, parents, nutritionist, coach) and open communication among all involved
Counsel athlete that achieving energy balance may require increasing caloric intake and/or decreasing caloric expenditure (through decreased exercise).
Identify and modify specific behavior triggers or stressors.
Emphasize performance and injury issues related to negative energy balance (eg, stress fractures are related to low BMD).
Monitor progress closely, as indicated by severity and response to treatment.
May need to restrict patient from sport/training if not making progress or participating in treatment plan
Prevention is best accomplished through education of athletes, coaches, trainers, and parents.

Medication

There is no strong evidence to support either hormone-replacement therapy or oral contraceptive use to increase or protect BMD in athletes with functional hypothalamic amenorrhea, even if they remain amenorrheic (5).
Bisphosphonates are not recommended for women of reproductive age (6).
Treating comorbid psychiatric conditions is essential, and pharmacotherapy for the specific disorder may be useful here.
Multivitamin supplements are commonly recommended.
Supplement calcium at 1,500 mg/d and vitamin D at 400–800 IU/d.

Additional Treatment

Referral

Psychology referral is recommended for cognitive-behavioral therapy; consider family therapy to help identify and cope with stressors.
Nutrition consultant with disordered-eating experience recommended

In-Patient Considerations

Electrolyte disturbance
Severe bradycardia or dysrhythmia
Severe dehydration
Significant psychiatric pathology

Ongoing Care

Frequent follow-up to gauge compliance with treatment plan
Monitor weight; address nutritional concerns and goals at each visit.
Consistent education regarding energy balance and sport performance
Assess physiological and psychological functioning, sport performance (if participating).
Coordinate care with psychology and nutrition consultants.
Menstruation usually occurs (may take a year or more) with improved nutrition and decreased exercise intensity.

Patient Education

Body weight and caloric intake below what is necessary for normal physiological function are detrimental to athletic performance.
BMD may be permanently lowered in adolescents by decreasing bone formation and increasing bone resorption.
Fertility is decreased with amenorrhea but is not totally impaired; it is possible to conceive without having a period. Fertility issues are not thought to be permanent and may normalize with resumption of menses.

Prognosis

Diagnosable eating disorders (eg, anorexia nervosa and bulimia nervosa) are very difficult to treat and rarely are totally resolved. Prognosis is guarded.
Athletes who have perfectionist-driven tendencies are less likely to comply with treatment and have difficulty with recovery.
Appropriate increase in energy availability has the potential to restore normal estrogenic state, normalize menstrual function, and improve BMD.

Complications

Injury forcing the athlete to take time from exercising can exacerbate disordered eating practices (eg, caloric restriction or purging).

References

1. Nichols JF, Rauh MJ, Lawson MJ, et al. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160:137–142.

2. Beals KA, Meyer NL. Female athlete triad update. Clin Sports Med. 2007;26:69–89.

3. The female athlete triad. Med Sci Sports Exerc. 2007;39:1867–1882.

4. Dimarco NM, Dart L, Sanborn CF. Modified activity-stress paradigm in an animal model of the female athlete triad. J Appl Physiol. 2007.

5. Falsetti L, Gambera A, Barbetti L, et al. Long-term follow-up of functional hypothalamic amenorrhea and prognostic factors. J Clin Endocrinol Metab. 2002;87:500–505.

6. Lebrun CM. The female athlete triad: what's a doctor to do? Curr Sports Med Rep. 2007;6:397–404.