The Female Athlete Triad
Prevalence in Female Athletes
- 13% in judged sports, 3% in refereed sports - Significantly higher rates of eating disorders found in elite athletes (20%) than in female control group (9%)
Osteoporosis
- A disease characterised by low bone mass and deterioration of bone tissue, resulting in bone fragility and increased risk of fracture - Bone is living tissue, constantly being absorbed and replaced - OP occurs when creation of new bone doesn't keep up with the removal of old bone - With the absence of oestrogen, bone growth is decreased - Loss of mass occurs because absorption of calcium from the bone continues to occur at a higher rate - As bone mass decreases, the risk of fractures, especially stress fractures increases.
Who is at risk?
- All female athletes - Female athletes involved in weight/appearance conscious sports and activities - At risk athletes include: - Gymnasts - Rowers - Divers - Swimmers - Runners - Dancers - Figure skating
Eating Disorder Stats
- Almost 50% of people with eating disorders meet the criteria for depression - Only 1 in 10 men and women with eating disorders receive treatment - Eating disorders have the highest mortality rate of any mental illness
Signs and Symptoms of ED
- Amenorrhea - Dehydration - GI problems - Hypothermia (cold intolerance) - Stress fractures (and other overuse injuries) - Significant weight loss - Dental and gum problems - Endocrine - Renal - CV problems - Muscle cramps, weakness or fatigue
Secondary Amenorrhea
- Amenorrhea is common in athletes, but is not normal or healthy - Coaches or family MD may think this is normal, but it is not - Have to educate your athletes that this is not normal
Psychological/Behavioral S/sx of ED
- Anxiety and/or depression - Claims of feeling "fat" despite being underweight/thin - Excessive exercise - Unfocussed, difficulty concentrating - Preoccupation with weight and eating - Avoidance of eating and eating situations - Use of laxatives, diet pills, etc.
Personality Characteristics
- Competitive atmosphere - Pressure to succeed - Heightened body awareness - Compulsiveness and perfectionism - Fluctuating self-esteem with performance - Ability to block pain and hunger - Willingness to take unnecessary risks to win - Importance of aesthetics in sport - Belief that body leanness optimises performance - Lack of identity beyond their sport
Sequence of Triad Components
- Diagnosis generally occurs in the following order: - Stress fracture - Menstrual dysfunction - Low energy availability - Development of the triad is in the following order - Low energy availability - Menstrual dysfunction - Osteoporosis/stress fracture
Prevention
- Education is crucial in the prevention of female athlete triad - Education should include - Team physicians, other health care providers, athletic trainers, coaches, parents and athletes. - Early detection reduces symptoms and can decrease the likelihood of long-term effects - PPE exam should be used as a screening tool
How common are disordered eating habits?
- Epidemiologic data is difficult because of the secretive nature of the disease - Athletes try to hide their symptoms or behaviours - Most cases aren't diagnosed until advance symptoms are apparent
Causes of Athletic Amenorrhea
- Most cases of menstrual dysfunction in athletes are related to an imbalance between energy demand and energy supply - Energy supply is low from lack of calories - When this happens, the hypothalamus shuts down the reproductive system and reduces levels of oestrogen
Loss of oestrogen
- Oestrogen is needed to promote both calcium absorption and deposition in the bone - When the hypothalamus shuts down oestrogen production this does not happen - Therefore without oestrogen, premature bone loss can occur - This leads to the final component of the female athlete triad - osteoporosis
Calcium and Bone Death
- Peak bone mass is achieved between the ages of 10-20 with small additions between the ages of 20-30 years - A well balanced diet with adequate calcium (1300-1500mg/day) is necessary for prevention and treatment of osteoporosis - An amenorrheic athlete can lose 5% of bone mass in one year. Some of this is irreversible even with treatment
Differential Diagnosis
- Pregnancy - Hypothalamic dysfunction - Pituitary dysfunction - Ovarian dysfunction - Uterine dysfunction - Endocrine disease
Bone Density
- Testing - DEXA scanning
History
- The ACSM first identified the female athlete triad in 1992 and later published the first commentary about it in 1993 - ACSM developed a Position Stand in 1997; revised in 2007 - Stated that low energy availability is the corner stone on which this develops - But components are now looked at as a continuum
What is the female athlete triad?
- The female athlete triad involves the relationship and often sequential development of: - Low energy availability - Irregular menses - Poor bone health - An athlete with signs or symptoms of any one of these components should be evaluated for the other two because of this relationship
What % of people with anorexia and bulimia are male?
10-15% However, they are less likely to receive treatment
Disordered eating/low energy availability
Can be from: - Excessive energy expenditure - Calorie, protein or fat restrictions - Weight, control measures such as diet pills, laxatives, excessive exercise - Self induced vomiting More advanced issues: - Clinical eating disorders such as anorexia nervosa or bulimia nervosa
Cause of Triad
Cause is unknown - Emotion stress appears to be a significant fact - Increased responsibility/academics - Higher performance standards - New environment
What is low energy availability?
Imbalance of calories in and calories out (therefore common in endurance athletes).
Menstrual Dysfunction
The normal cycle: - 28 days - 10-13 cycles per year Menarche - the first menstrual period Amenorrhea involves the absence of menses - Primary (hasn't has their first) - Secondary (were once regular, and now no longer have it)