5 Female Athlete Triad

Question 1

The female athlete triad consists of what three inter-related disorders?

Answer 1

Osteoporosis
Disordered eating
Amenorrhea

Question 2

The full impact of the female athlete triad may not be realized until…

Answer 2

They reach menopause, when bone loss is accelerated

Question 3

The female athlete triad was first described by the American College of Sports Medicine in ______

Answer 3

1992

But disorders related to bone density, stress fractures, and eating disorders have been reported decades before the syndrome was named (dates back to the 50s in competitive athletes)

Question 4

What athletes are at risk for the female athlete triad?

Answer 4

Those participating in sports emphasizing a low body weight (Tae Kwon Do, Judo, wrestling, Long distance running) or subjective judging of appearance (gymnastics, figure skating, ballet, diving, dancing)

Athletes are more likely to develop the triad if socially isolated and lack a social support

Question 5

Prevalence of eating disorders is ______ among female athletes compared to ______ for the control population

Answer 5

25-62% vs 6-9%

Highest (62%) among college gymnasts

Question 6

Prevalence of amenorrhea is _____ for athletes compared to ____ for the control population

Answer 6

69% vs 2-5%

Prevalence is dependent on training volume and age (dancers, distance runners)

Subclinical menstrual disorders (luteal phase deficiency, anovulation) found in 78% of recreational runners

Question 7

Prevalence of osteopenia (low bone mineral density) is _____ in athletes compared to ____ for control

Answer 7

22-50% vs 12%

Question 8

How does the female triad occur?

Answer 8

Pressures to perform and perceived requirement to maintain low body mass —> high training volume + low energy intake + psychological stress and increased stress hormones —> physiological disturbances in the endocrine control of the menstrual cycle —> increased risk in developing amenorrhea —> decreased production of ovarian estrogen —> decreased bone mineral density and increased risk of low BMD/osteoporosis

Question 9

Things that can lead an athlete to begin “dieting”

Answer 9

Athlete believes that attaining a lower body weight will enhance performance

Emotional stressors:
• Death of a coach or family member
• Growth spurt
• Illness that prevents training
•Moving to university setting
•Pressure/difficult standards

Question 10

Once an athlete begins dieting…

Answer 10

Diet becomes increasingly restrictive and unhealthy and training becomes excessive

Caloric restriction —> menstrual dysfunction and decreased bone mineral density

Question 11

Energy availability promotes…

Answer 11

Bone health, and preserves eumenorrhea and estrogen production

BMD is average for age, or above in certain sports

Question 12

In unhealthy conditions, low energy availability ….

Answer 12

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

Question 13

How does reduced energy availability w/ or w/o eating disorder lead to impaired health?

Answer 13

WHen energy availability is too low, mechanisms reduce amount of ATP for cell function, thermoregulation, growth, and reproduction. This compensation promotes survival to conserve energy, but impairs health

Question 14

Things that can lead to low energy availability in athletes

Answer 14

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 or purging

Question 15

Clinical mental disorder characterized by fear of gaining weight or views of oneself as overweight

Answer 15

Anorexia nervous a

Question 16

Clinical mental disorder characterized by normal weight with cycles of binge eating then purging with other behaviors such as excessive exercise and fasting

Answer 16

Bulimia nervosa

Question 17

Pulsatility of GnRH (and in turn LH/FSH) is disrupted within ______ when energy availability is reduced from ______ to ______.

Answer 17

Within 5 days
From 45 (normal) to 30 kcal/kg FFM/day (FFM = fat free mass)

Leads to decreased E2 production, and in turn, accelerating bone resorption, and decreasing bone mineral density

Question 18

Reducing energy intake is associated with ________ LH amplitude but ______ pulse frequency

Answer 18

Increased amplitude

Reduced frequency

Question 19

Menstrual cycle with a luteal phase less than 10 days or with low progesterone

Answer 19

Luteal phase defect

Follicular phase is prolonged by cycle length does not change

Athlete will ovulate and menstruate

Question 20

Menstrual cycle without ovulation due to low levels of estrogen and progesterone and impaired follicular development

Answer 20

Anovulation

Athlete will often menstruate but cycles can be either shortened or prolonged

Question 21

Absence of menstrual cycle lasting more than 90 days

Answer 21

Secondary amenorrhea (occurring after menarche)

Primary amenorrhea (delayed menarche) can also develop in young athletes

Question 22

A period of 35 days or more between cycles or irregular menses

Answer 22

Oligomenorrhea

Question 23

T-score below ______ is defined as osteoporosis

Answer 23

2.5 SD

Question 24

T-score of _______ is termed low bone mass

Answer 24

1 to 2.5 SD below normal

Question 25

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)

Answer 25

T-score

Question 26

Comparison of the patient’s BMD to an age-matched population and considering the patient’s sex and ethnicity

Answer 26

Z-score

Question 27

Z-score of ________ is considered below the expected range for the age

Answer 27

-2.0 SD or lower

Should prompt scrutiny for coexisting problems (alcoholism, glucocorticoid treatment, hypogonadism)

Question 28

The pathophysiological basis of the triad is primarily a _______ issue.

Answer 28

Nutritional

Low energy intake from eating disorders/behaviors present with a spectrum of menstrual dysfunction —> can predict for future of low BMD

Addressing skeletal issues related to nutritional/hormonal deficiences in this population is a high priority