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The Female Athlete Triad

The Female Athlete Triad. Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College. Female Athlete Triad. Syndrome consisting of Disordered Eating, Amenorrhea, and Osteoporosis

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The Female Athlete Triad

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  1. The Female Athlete Triad Keren Kazis, M.D. Adolescent Medicine Department of Pediatrics New York Medical College

  2. Female Athlete Triad • Syndrome consisting of Disordered Eating, Amenorrhea, and Osteoporosis • 1.9 million female athletes in HS and College level sports with 3800 females in the Olympics • Imbalance in energy intake vs expenditure (low cal, high ex) leading to dysregulation of the HPO axis causing amenorrhea • Low estrogen levels can cause low BMD leading to osteoporosis and inc fracture risk

  3. Disordered Eating • Prevalence of ED in athletes 15-62% • Can be a spectrum from abnormal eating habits to AN/BN • Female athletes consume 20-30% less than RDA and expend 700Kcal/day • Unrealistic expectations placed on female athletes to maintain low body weights- gymnastics, ballet dancers, figure skating

  4. Amenorrhea • Spectrum – primary and secondary amenorrhea and oligomenorrhea • Incidence of amenorrhea- 5% in pop 10-20% in athletes 30-50% in elite athletes • Amenorrheic athletes initiate training earlier than eumenorrheic athletes, even prior to menarche • Ballet dancers- menarche of 15.4 yrs vs controls at 12.5 yrs

  5. Amenorrrhea • Mechanism- Hypothalamic dysfunction suppressing HPO axis- dec pulse freq of GNRH- dysfunction of LH and FSH -ovarian suppression and low estrogen • Secondary to excessive exercise and/or dieting • Bullen et al –excessive exercise even without weight loss can cause menstrual irregularities • Hormonal changes in athletic women with NL cycles-Shortened luteal phase(dec progesterone), dec LH pulse frequency

  6. Bone Mass • Peak bone mass obtained in adolescence • Only minimal increases in BMD 2yrs after menarche • PBM determined by- gender, genetics, diet, exercise, hormones • PBM in women 30% lower than in men • Estrogen deficiency in adolescence may cause a decrease in PBM

  7. Osteoporosis • Def: reduction in the quantity of bone, resulting in bone that is thin or brittle • Estrogen def inc bone turnover and bone resorption, causing a reduction in trabecular and cortical bone • Dec BMD leads to an increased fracture risk • Drinkwater et al- comparison of Vertebral BMD of A vs E athletes- found A athletes had BMD equiv to women 51.2 yrs of age

  8. Osteoporosis • Biller et al- BD lower in women with HA, women with primary HA lower BD than women with secondary HA • BMD lower in women who develop AN pre vs post-menarchal • Drinkwater et el- BMD after resumption of menses- inc but not as high as eumenorrheic group – not completely reversible!!!!! • Warren et al- as age of menarche inc in ballet dancers there is a higher incidence of stress fx • 50% of A. college runners reported stress fx.

  9. Diagnosis, Prevention and Treatment • Identify the female adolescent at risk – pre-participation physical • History, physical and blood work similar to ED • DEXA scan if amenorrheic > 6 mths • Prevention- Education of athletes, trainers, coaches, and family of the dangers of the Triad • Multidisciplinary approach • Increase caloric intake and dec intense exercise

  10. Treatment- Oral Contraceptives • AAP recommendations – over 16 with HA should receive hormone replacement • Seeman et al-Inc BD in adult AN on OCP’s • Gibson et al- small but not sig benefit of OCP’s on BD in runners with HA • Klibanski et al-no sig change in BD in adult AN on OCP’s, but inc in BD with very low weight (70% of IBW) • Golden et al- no sig difference in BD of Ad AN on OCP’s, difficult to determine resumption of menses

  11. Conclusion • Higher incidence of Female Athlete Triad is being seen • Components of the Triad- ED, amenorrhea and osteoporosis can lead to increased fracture risk • Cause of dec in BD is multifactorial and exogenous estrogen alone may not be beneficial • Further investigation of treatment modalities for osteoporosis in the ad age group are being conducted- use of Alendronate • Prevention is key!!

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