The Female Athlete TriadThe Female Athlete Triad

Ann M. Heaslett, M.D.Ann M. Heaslett, M.D.

Psychiatrist, Madison, WI USAPsychiatrist, Madison, WI USA

Member USA 100K Team 2002-5Member USA 100K Team 2002-5

The Female Athlete Triad?The Female Athlete Triad?

What is the Female Athlete triad?What is the Female Athlete triad?

Disordered EatingDisordered Eating

AmenorrheaAmenorrhea

OsteoporosisOsteoporosis

The Female Athlete TriadThe Female Athlete Triad

Originally described in 1992Originally described in 1992

First recognized as three separate but First recognized as three separate but unrelated entitiesunrelated entities

Now recognized by the American College Now recognized by the American College of Sports Medicine (ACSM) as a spectrum of Sports Medicine (ACSM) as a spectrum of symptoms and conditions between of symptoms and conditions between health and diseasehealth and disease

The Female Athlete TriadThe Female Athlete Triad

The three spectrums include:The three spectrums include:

Energy availability (which may occur with Energy availability (which may occur with or without disordered eating)or without disordered eating)

Menstrual functionMenstrual function

Bone Mineral DensityBone Mineral Density

The Female Athlete TriadThe Female Athlete Triad

Dysfunction in any of any of the components Dysfunction in any of any of the components can lead to dysfunction of the other can lead to dysfunction of the other components.components.

While energy availability may change daily, While energy availability may change daily, the effects on menstrual cycle may not the effects on menstrual cycle may not occur for months, and an effect on bone occur for months, and an effect on bone mineral density may not occur for years.mineral density may not occur for years.

Energy Balance & Body Wt.Energy Balance & Body Wt.

When an athlete eats enough calories to When an athlete eats enough calories to meet basic and athletic needs, wt should meet basic and athletic needs, wt should be stable. However, it isn’t that simple. be stable. However, it isn’t that simple. When there is a caloric deficit, the brain & When there is a caloric deficit, the brain & body try to help reestablish energy body try to help reestablish energy balance by decreasing resting metabolic balance by decreasing resting metabolic rate. The body begins to conserve rate. The body begins to conserve calories, and this starts a cascade of calories, and this starts a cascade of events we’ll call low energy availability.events we’ll call low energy availability.

Low Energy Availability Low Energy Availability

Can occur with or without a formal eating Can occur with or without a formal eating disorder.disorder.

May be due to abnormal eating behaviors May be due to abnormal eating behaviors such as dietary restraint, binge eating, etc.such as dietary restraint, binge eating, etc.

OR failure increase dietary intake to match OR failure increase dietary intake to match training needs.training needs.

Low energy availability leads to Low energy availability leads to

Disruption of the GnRH pulse generator in Disruption of the GnRH pulse generator in the hypothalamus, possibly because of the hypothalamus, possibly because of changes in:changes in:

- leptin -cortisol- leptin -cortisol

- insulin, IGF-1,glucose, f.a.’s.,ketones- insulin, IGF-1,glucose, f.a.’s.,ketones

- growth hormone- growth hormone

- T3, etc.- T3, etc.

Changes in factors previously Changes in factors previously described have an inhibitory effect described have an inhibitory effect

on the hypothalamuson the hypothalamus

Decreased stimulation of the pituitary with Decreased stimulation of the pituitary with GnRH pulsesGnRH pulses

Decreased LH and FSH pulses, resulting in Decreased LH and FSH pulses, resulting in less stimulation of the ovaries to produce less stimulation of the ovaries to produce progesterone and estrogenprogesterone and estrogen

Abnormal MensesAbnormal Menses

So why are abnormal menses So why are abnormal menses

important?important?

-Because Bone Mineral Density decreases -Because Bone Mineral Density decreases with the number of missed menstrual with the number of missed menstrual cycles accumulated over the months and cycles accumulated over the months and years. This leads to increased incidence years. This leads to increased incidence of stress fractures in active women with of stress fractures in active women with menstrual irregularities.menstrual irregularities.

Bone Mineral DensityBone Mineral Density

60-80% Genetically Determined, peak 60-80% Genetically Determined, peak BMD achieved between ages 11-15BMD achieved between ages 11-15While weight-bearing exercise should While weight-bearing exercise should increase BMD, decreased estrogen increase BMD, decreased estrogen decreases BMD, as do:decreases BMD, as do: -smoking, alcohol, malnutrition-smoking, alcohol, malnutritionWomen with normal menses who are Women with normal menses who are active have 5-15% higher BMD than active have 5-15% higher BMD than sedentary controls.sedentary controls.

OsteoporosisOsteoporosis

May result from failure to achieve peak May result from failure to achieve peak BMD during adolescence or from BMD during adolescence or from accelerated bone lossaccelerated bone loss

Prevalence of the TriadPrevalence of the Triad

Unsure… Why?Unsure… Why?

inadvertant low energy availability-prevalence is inadvertant low energy availability-prevalence is unknownunknown

disordered eating without a formal eating d.o dx disordered eating without a formal eating d.o dx – 28-62% prevalence in thin-build athletes– 28-62% prevalence in thin-build athletes

formal eating disorder – 25-31% prevalence in formal eating disorder – 25-31% prevalence in thin-build athletes compared with 5-9% general thin-build athletes compared with 5-9% general populationpopulation

Prevalence of Menstrual DisordersPrevalence of Menstrual Disorders

Amenorrhea is present in 65-69% of Amenorrhea is present in 65-69% of endurance runners compared to 2-5% in endurance runners compared to 2-5% in the general populationthe general population

Prevalence of Low BMDPrevalence of Low BMD

T-score between -1 and -2.5:T-score between -1 and -2.5:

22-50% prevalence among female 22-50% prevalence among female athletesathletes

T-score less than -2.5:T-score less than -2.5:

0-13% prevalence among female athletes0-13% prevalence among female athletes

These are higher than the 12% and These are higher than the 12% and 2.3%prevalence estimates, respectively, in 2.3%prevalence estimates, respectively, in a normal population distribution.a normal population distribution.

Key ConceptsKey Concepts

It is not necessary to have all three It is not necessary to have all three components of the Triad simultaneously to components of the Triad simultaneously to have negative effects on bone healthhave negative effects on bone health

The triad can be seen in all sports, not just The triad can be seen in all sports, not just those traditionally seen as low body wt those traditionally seen as low body wt sports such as long distance runningsports such as long distance running

Additional Consequences of the Additional Consequences of the TriadTriad

-Increased -Increased cardiovascular riskcardiovascular risk

-Increased risk for -Increased risk for osteoporosisosteoporosis

-Reproductive -Reproductive dysfunctiondysfunction

-Metabolic -Metabolic ConsequencesConsequences

-Excessive fatigue-Excessive fatigue

-Increased recovery -Increased recovery timetime

-Decreased response to -Decreased response to trainingtraining

-Impaired Performance-Impaired Performance

ScreeningScreening

If one component of the Triad is present, If one component of the Triad is present, screen for the other two, as there is screen for the other two, as there is significant likelihood they are present. significant likelihood they are present.

How?How?1. Low Energy Availability: look for high 1. Low Energy Availability: look for high

dietary restraint, high drive for thinness, dietary restraint, high drive for thinness, excessive or compulsive exercise, excessive or compulsive exercise, restriction of specific food groups, restriction of specific food groups, repeated dieting, eating disorder.repeated dieting, eating disorder.

Screening, ContinuedScreening, Continued

2.2. Menstrual dysfunction: how many Menstrual dysfunction: how many periods has the athlete had within the periods has the athlete had within the past 12 months? Has she missed >3 past 12 months? Has she missed >3 periods in a row?periods in a row?

3.3. BMD: consider performing DXA scan of BMD: consider performing DXA scan of the spine and hip if hx of stress fx and/or the spine and hip if hx of stress fx and/or h/o > 6 months of amenorrhea, h/o > 6 months of amenorrhea, oligomenorrhea, disordered eating or oligomenorrhea, disordered eating or eating disorder.eating disorder.

Prevention/TreatmentPrevention/Treatment

Education of the athlete as to how much Education of the athlete as to how much energy is required to do the kind of energy is required to do the kind of training/performance she is asking of her training/performance she is asking of her body. Increasing nutritional intake or body. Increasing nutritional intake or decreasing training volume may be decreasing training volume may be needed to restore/maintain energy needed to restore/maintain energy balance.balance.Provision of adequate Calcium 1200-Provision of adequate Calcium 1200-1500mg/day and Vit. D 400-800IU/day.1500mg/day and Vit. D 400-800IU/day.

Prevention and Treatment, Prevention and Treatment, continuedcontinued

Adding hormones in the way of OCP’s will Adding hormones in the way of OCP’s will not restore BMD unless adequate nutrition not restore BMD unless adequate nutrition is presentis present

Biophosphonates should not be used in Biophosphonates should not be used in young athletes with amennorhea or low young athletes with amennorhea or low BMDBMD

PreventionPrevention

Changing the mindset is important, and Changing the mindset is important, and successful female ultrarunners seem to successful female ultrarunners seem to understand that food is not “the enemy” but understand that food is not “the enemy” but rather what fuels activity and performance and rather what fuels activity and performance and promotes development of training effect and promotes development of training effect and allows for healing and growth.allows for healing and growth.

The Female Athlete Triad is NOT an inevitable The Female Athlete Triad is NOT an inevitable consequence of training and being an athlete.consequence of training and being an athlete.