Female athlete triad

FEMALE ATHLETE TRIAD

Female Athlete Triad Overview

Case PresentationDefine TriadRisk factorsEpidemiologyMichigan State AthletesScreening toolsTreatment optionsTake home points

Case

18 year old female cross country runnerPre-participation physical for MSUPre-med major, A’s in High SchoolTreated for anorexia at 14 y/o, now “better”Menarche at 15 y/o, menses 2X/year Iron supplements for anemiaNow having problems with foot pain

Female Athlete Triad Overview

Women in sports has increased since the passage of Title IX legislation in 1972.

Athletics can promote healthy lifestyle behaviors and decrease the risk for health problems.

Female athlete triad recognized in the 90sHealth consequences may be irreversible

Female Athlete Triad

Menstrual DysfunctionDisordered EatingDecreased Bone Mineral Density

Menstrual Dysfunction

Primary Amenorrhea– Absence of menarche by 16 y/o

Secondary Amenorrhea– After normal menarche – Absence of menses for 3-12 mo

Oligomenorrhea– Cycles greater than 36 days

Luteal phase dysfunction

Menstrual Dysfunction- Athletic Amenorrhea

Diagnosis of exclusionRule out pregnancyPoor nutritionDecreased GnRH from hypothalamus

– Cortisol, endorphins, androgensLeads to decreased LH and FSH pulses

from anterior pituitary

Disordered Eating- a Spectrum

Caloric restrictionPathogenic weight control behaviorsAnorexia

– Refusal to maintain <85% ideal body weight– Intense fear of gaining weight– Amenorrhea

Bulimia – Binge eating, lack of control– Inappropriate compensatory behavior

Eating disorders NOS

Decreased Bone Mineral Density

Trabecular (axial) and cortical (appendicular)– Trabecular bone more metabolically active

Adequate calcium and estrogen requiredOsteopenia

– Z score 1.0 to 2.5Osteoporosis

– Z score greater than 2.5Duration of amenorrhea correlates linearly with

decreases in bone mineral density

Female Athlete Triad- interrelated components

Low body weight/fatNutritional deficienciesHigh emotional stressChronic intense training

Female Athlete Triad Risk Factors

High risk sportsPerfectionist personalityLow self esteemDistorted body imageSocial isolizationOver controlling coach/parent

Female Athlete Triad Epidemiology

True prevalence is unknownPreparticipation physical exam

– 60% reported irregular menses– 45% not happy with their current weight– 16% suffered a stress fracture

Eating disorder incidence from 15-62%

Michigan State University- Female Athlete Body Composition

103 Female AthletesAll varsity sports recruitedBody composition with DEXAAnthropometric dataMenstrual histories

– 10-12 menses/year- eumenorrheic– 6-9 menses/year- oligomenorrhea– 0-6 menses/year- amenorrhea

No nutritional data

ATHLETES NAge (yrs) Ht (cm) Wt (kg) BMI % Fat FFM (kg)

Total 103 20.2 167.2 63.72 22.7 20.30 50.62

Gymnastics 8 19.7 157.9# 58.64# 23.4 19.71 47.00

Softball 14 20.1 169.4*# 65.69$ 22.8 21.26$ 51.55

Running 25 20.4 165.1# 57.24# 21.0 17.95 46.88

Track 8 20.1 166.3# 63.25 22.8 18.24 51.60

Field Hockey 10 19.8 165.7# 63.19 22.9 20.90 49.93

Soccer 10 19.8 168.2*# 65.92 23.2 21.82$ 51.49

Crew 15 20.5 171.1* 71.48*$ 24.4$ 22.35$ 55.43*$

Swim/Dive 9 20.4 166.0# 64.21 23.3 21.79$ 50.10

Volleyball 4 19.6 182.3* 73.95*$ 22.3 20.57 50.10*$

Menstrual Function         

  Menarche (yrs)

# EM # OM # AM % Abnormal

Yes OCPs

Total 13.5 (1.4) 79 18 6 30.4 34

Gymnastics 14.4 (0.6) 5 2 1 60.0 5

Softball 13.6 (1.7) 12 1 1 16.7 4

Running 13.8 (1.6) 15 6 4 66.7 5

Track 13.4 (1.0) 6 2 0 33.3 3

Field Hockey 12.9 (1.3) 9 1 0 11.1 4

Soccer 12.9 (1.4) 8 2 0 25.0 3

Crew 13.3 (0.9) 13 2 0 15.4 4

Swim/Dive 13.4 (2.0) 8 1 0 12.5 5

Volleyball 14.1 (0.9) 3 1 0 33.3 1

Total and Site-specific BMD      

  N Total Body

L Spine Pelvis Avg Leg

Total103 1.129 0.905 1.129 1.230

Normal Menstruation

79 1.137* 0.917 1.141* 1.234

Abnormal Menstruation

24 1.105 0.865 1.089 1.216

* p<0.05 comparing normal and abnormal menstruation groups

Volleybal

Swimming/Diving

Crew

Soccer

Field Hockey

Track

Running

Softball

Gymnastics

Sport Categories

1.200

1.100

1.000

0.900

0.800

Mean B

MD

TO

TA

L B

OD

Y

Volleybal

Swimming/Diving

Crew

Soccer

Field Hockey

Track

Running

Softball

Gymnastics

Sport Categories

1.200

1.100

1.000

0.900

0.800

Mean B

MD

L S

PIN

E

Volleybal

Swimming/Diving

Crew

Soccer

Field Hockey

Track

Running

Softball

Gymnastics

Sport Categories

1.200

1.100

1.000

0.900

0.800

Mean B

MD

PELV

IS

Volleybal

Swimming/Diving

Crew

Soccer

Field Hockey

Track

Running

Softball

Gymnastics

Sport Categories

1.30

1.20

1.10

1.00

0.90

0.80

Mean B

MD

AVG

LEG

30.028.026.024.022.020.018.016.0

BMI

1.300

1.200

1.100

1.000

BM

D T

OT

AL

Fit line for Total

AbnormalMenstruation

Normal MenstruationMenstrual Function

R Sq Linear = 0.165

Conclusions for MSU Athletes

No athletes met the criteria for osteopenia, regardless of menstrual function

Non-weight bearing activity for the swimmers resulted in lower leg BMDs

Runners low at lumbar spine but leg BMD was normal

More menstrual dysfunction for runners and gymnasts

Screening Tools for Female Athlete Triad

Low body weight and/or BMIHigher risk sports

– Cross-country, swimming, gymnasticsPreparticipation Physical

– Menstrual history– Body image satisfaction– Past illnesses and injuries

Female Athlete Triad Treatment

Treatment Team– Athlete– Parents– Coaches– Athletic trainer/physician– Mental health providers– Dietician

Female Athlete Triad Treatment

Prevention is bestTreatment of eating disorder is multi-

disciplinaryAthletic participation may be discontinuedSlow increase in caloric intakeEstrogen replacement for menstrual

disturbances

TAKE HOME POINTS

PREVENTION is KEYEducation for athletes/coaches/medical

professionalsTreatment requires a multi-disciplinary

approachLifestyle modifications