L49 Female Athlete Triad

EA (energy availability) =

dietary intake (EI) - exercise energy expenditure (EEE) normalized to fat free mass (FFM) (EI - EEE)/FFM

Unhealthy conditions:

Low energy availability impairs bone health indirectly by inducing amenorrhea and removing estrogen 's effect on bone formation. Overtime, bone mineral accrual is slowed and BMD is below average for age.

Anovulation:

• Menstrual cycle without ovulation • Low levels of estrogen and progesterone • Impaired follicular development • Athlete will often menstruate (cycles either shortened or prolonged)

The female athlete triad consists of three inter-related disorders:

Osteoporosis Disordered eating Amenorrhea

Energy availability promotes what?

bone health and preserves eumenorrhea and estrogen production. BMD is average for age, or above in certain sports.

When energy availability is too low, mechanisms reduce amount of ATP for what?

cell function, thermoregulation, growth, and reproduction. This compensation promotes survival to conserve energy, but impairs health

1. Athletes exhibiting a spectrum of behaviors such as:

• Not taking in enough food to offset for exercise cost • Taking measures such as food restriction, use of laxatives, diuretics, enemas, skipping meals • Abnormal eating practices: binge eating and purging

Amenorrhea(secondary):

• Secondary amenorrhea, occurring after menarche. • Absence of menstrual cycle lasting more than 90 days • Primary amenorrhea, delayed menarche, may also develop

Why are the corners of the triad inter-related?

(1) Pressures to perform at optimal levels and (2) perceived requirement to maintain a low body mass. Results in a high training volume combined with low energy intake. Psychological stress and increased production of stress hormones Physiological disturbance in the endocrine control of the menstrual cycle Increased risk in developing amenorrhea Decreased production of ovarian estrogen Decreased bone mineral density Increased risk of low BMD/osteoporosis

GNRH and LH/FSH pulsatility:

- Pulsatility disrupted within 5 days when energy availability (EA) is reduced from 45 (normal) to 30 kcal/kg FFM/day. - Leads to decreased E2 production, in turn, accelerating bone resorption, and decreasing bone mineral density (BMD).

Female athletes participating in sports emphasizing a low body weight or subjective judging of appearance:

Aesthetic or prepubertal component: gymnastics, figure skating, ballet, diving, dancing Weight component: Tae kwon do, judo, wrestling, long distance running **Athletes more likely to develop the triad are socially isolated and lack a social support (unlike in team sports) as a result of extreme focus on training.

Emotional stressors

-death of a coach/family member -growth spurt -illness that prevents training -moving to university setting -pressure /difficult standards

Oligomenorrhea:

• A period of 35 days or more between cycles • Irregular menses

2.Athletes with clinical mental disorders;

• Anorexia nervosa (fear of gaining weight/views herself as overweight). • Bulimia nervosa (normal weight with cycles of binge eating then purging with other behaviors such as excessive exercise and fasting).

Bone Mineral Density

• Bone health, expressed as BMD, ranges from optimal bone health to osteoporosis. • The WHO has defined thresholds for low bone mass and osteoporosis based upon BMD measurements. • BMD is based on T-scores or Z-scores. - T-score (more commonly used): BMD compared to a young normal reference mean. US standards use data for a healthy 30-year-old of the same sex and ethnicity as the patient. • T-score below 2.5 SD is defined as osteoporosis (-2.5). • T-score of 1 to 2.5 SD below is termed low bone mass (-1 to -2.5). • Normal bone density is defined as a value within 1 SD of the mean (-1 or higher). - Z-score = Comparison of the patient's BMD to an age-matched population and considering the patient's sex and ethnicity. • Z-score of -2.0 SD or lower is considered below the expected range for age (-2.0). • Z-score of lower than -2.0 should prompt scrutiny for coexisting problems (alcoholism, glucocorticoid treatment, hypogonadism)

Concluding Remarks

• Female participation in sports has increased dramatically over the last 30 years. • The prevalence of the Triad, or one (or two) component (s) of it, has also increased. • The pathophysiological basis of the triad is a nutritional issue. • Low energy intake from eating disorders/behaviors present with a spectrum of menstrual dysfunction. • Menstrual dysfunction can predict for future of low BMD. • Addressing skeletal issues related to nutritional/hormonal deficiencies in this population is a high priority.

Luteal phase defect (LPD):

• Menstrual cycle with a luteal phase less than 10 days or with low progesterone • Follicular phase is prolonged, but cycle length does not change • Athlete will ovulate and menstruate