Female Athlete Triad

Descriptive text is not available for this image BASICS

Syndrome of three interrelated clinical entities: low energy availability (LEA) (with or without disordered eating [DE]), menstrual dysfunction (MD), and low bone mineral density (LBMD)

DESCRIPTION

  • Female athlete triad first described in 1992 to include DE, amenorrhea, osteoporosis
  • In 2007, American College of Sports Medicine (ACSM) updated definition to: components including LEA (with or without DE), MD, LBMD with each component representing an inter-related spectrum ranging from health to dysfunction.
  • LEA is fundamental to the triad and full recovery not possible without correction of it.
  • 2014 International Olympic Committee’s (IOC) position statement from 2014 deviated to consider “Relative energy deficiency in sport” (RED-S)
    • Focus on energy deficiency and its broader physiologic effects beyond bone and menstrual health, ranging from growth to cardiovascular.
    • Emphasized similar syndrome in males
  • Male athlete triad; LEA, functional hypothalamic hypogonadism, and LBMD.
  • Concept of energy deficiency in men involving reproductive and bone abnormalities
    • Men seem to be more resilient to the effects of LEA compared to women, requiring more severe energetic perturbations before alterations are observed. Recovery of the hypothalamic pituitary gonadal axis can be observed more quickly in men than in women; male triad needs to be further evaluated.

EPIDEMIOLOGY

Prevalence

  • Prevalence: 3/3 criteria (EA, MD, LBMD): 0–16%; 2/3 criteria: 3–27%; 1/3 criteria: 16–60%.
  • DE higher than general population
  • MD: Prevalence of secondary amenorrhea is ~60% in female athletes vs to 2–5% in the general population.
  • LBMD: Using the WHO criteria for LBMD, prevalence of osteopenia (T-score between −1 and −2) ranges from 0% to 40% in female athletes, vs. ~12% in the general population.
  • Full triad is more prevalent in lean and weight-bearing sports (1.5–6.7%), including swimming and cross-country, vs. non-lean sports (0–2%), including volleyball and softball.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Energy availability is defined by energy intake minus exercise energy expenditure.
    • LEA can occur either intentionally or inadvertently (e.g., increasing training or DE).
    • Results in energy shunted from reproduction to more critical functions (thermoregulation cellular maintenance)
    • Leads to suppression of luteinizing hormone (LH) pulse frequency and thus MD
      • This suppresses ovulation and estrogen concentrations, causing decreased bone formation and increased bone resorption, leading to LBMD.
  • Triad elements exist along a bidirectional continuum of severity, ranging from “healthy” to “unhealthy.”
  • Additionally, LEA effects endothelial dysfunction and lipids.

RISK FACTOR

  • History of menstrual irregularities and amenorrhea; history of stress fractures and recurrent or nonhealing injuries; history of critical comments about eating or weight from parent or coach; history of depression; history of dieting; personality factors (perfectionism and/or obsessiveness), overtraining, and inappropriate coaching behaviors
  • Lean physique sports with an aesthetic component (ballet, figure skating, gymnastics, distance running, diving, and swimming) or sports with weight classifications (martial arts and wrestling); frequent weigh-ins, consequences for weight gain, and win-at-all-cost attitude all increase risk.
  • A lack of family or social support; intense training hours; social isolation or entering a new environment (boarding school or college); an athlete with comorbid psychological conditions (anxiety, depression, and/or obsessive-compulsive disorder)
  • Age: A Japanese study found stress fracture in teenagers with the triad but no stress fractures in athletes in their 20s.

GENERAL PREVENTION

  • Education of athletes (middle school through college), coaches, trainers, parents, and physicians; young athletes are extremely impressionable and may turn negative comments and unhealthy advice into maladaptive eating and exercising habits.
  • General screening during preparticipation exam (PPE) and annual physicals
  • Female Athlete Triad Coalition has 11-question screening to use during PPE.
  • Screen athletes presenting with “red flag” conditions such as fractures, weight changes, fatigue, amenorrhea, bradycardia, orthostatic hypotension, syncope, arrhythmias, electrolyte abnormalities, or depression.
  • Screen for other conditions that may accelerate bone loss, including steroid use, tobacco use, alcohol use, and hyperthyroidism.
  • IOC consensus statement (2023) recommends only testing body composition in athletes <18 years of age for medical purposes due to risk of detrimental medical and psychological outcomes with unnecessary testing (1).

COMMONLY ASSOCIATED CONDITIONS

  • Anorexia nervosa, bulimia nervosa, avoidant or restrictive food intake disorder, and other psychological disorders, including low self-esteem, depression, and anxiety
  • LBMD predisposes athletes to stress fractures and may not be fully reversible. This may lead to a higher rate of fractures after menopause.

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