1. FEMALE ATHLETE TRIAD Dr. Willa Fornetti, DO, MS
Primary Care Sports Medicine
Non Operative Orthopedics

2. Female Athlete Case 15 year old female cross country runner
Complains of left lateral knee pain
6 weeks ago gradual onset with running when her season started
Height 5 ft., 6 in, Weight 110 lbs., BMI is 18
Prior bilateral knee pain, shin splints, Achilles pain in the pas
She doesn’t know how often she gets her menses but “not every month”

3. Female Athlete Triad Overview
History of Women in Sports
Benefits of Exercise
Female Athlete Triad
Risk factors
Prevalence
Health consequences
Screening and diagnosis
Treatment
Summary

4. Women in Sports
In 1972, Title IX significantly changed women’s participation in sports.
Educational amendment meant to provide more educational opportunities for women.
Created equal opportunity for sports
Schools had to offer scholarships and provide the same access to coaching, equipment and facilities
“No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving federal financial assistance.”
This summer Title 9 celebrated it’s 40th anniversary. Article in the Oshkosh Northwestern.

5. Women in Sports High School Athletes Collegiate Athletes
Before Title IX, fewer than 300,000 high school girls (1 in 27) played sports
Now there is 3 million high school girls (1 in 2) play sports
Collegiate Athletes
Mid 1970s fewer than 32,000 women competing in intercollegiate sports
In there were 191,000 (through the NCAA)
Margaret Court, famous tennis player in the 20s

6. Benefits of Exercise Many health benefits!
Female athletes do better in school and have a higher graduation rate
More likely to obtain advanced degrees
More likely to hold leadership roles
Decreased high risk behavior
Less likely to smoke or use drugs
Less teen age pregnancies
Health Benefits: Controls weight, Combats health conditions and diseases, Reduced risk of cardiovascular disease, diabetes and metabolic syndrome, Reduced risk of some cancers, Prevent falls and improve your ability to do daily activities strengthening muscles and bones, Proprioception or balance, Promotes sleep, Improves mood and self esteem, Longer life expectancy, Improved quality of life
A 2002 survey by Oppenheimer Funds found that 82% of female business executives had played organized sports after elementary school.
Women stated that it taught them how to compete in a healthy way and developed their leadership skills

7. Women in Sports
Sports are a great way for women to build strong healthy bodies, self esteem and a life-love love of physical activity.
For some exercise becomes pathologic and detrimental to a woman’s health.
Female athlete triad is a serious health concern that has been identified among athletes.
Tennis player at Wimbledon (ranked 8 in the world) named Daniela Hantuchova-Slovakian. BMI less than 17, wants to be a model

8. Female Athlete Triad Defined
In the 90s:
disordered eating
amenorrhea
osteoporosis
2007 and today:
low energy availability (with or without eating disorder)
menstrual dysfunction
altered bone mineral density
Originally defined by the American College of Sports Medicine in 1992
ACSM Position Stand in 1997 revised in 2007

9. The Female Athlete Triad Defined
Then …

10. Female Athlete Triad Defined
Energy Availability
Disordered Eating
And now. Defined along a continuum of health. They may occur alone or in combination
Energy availability – the difference between incoming calories (diet) and outgoing calories (activity) is the key in this triad. The main impact, and the place you may first notice a problem, is with menstrual function. You could pick up a problem with the triad based on BMD (i.e. numerous fractures, osteopenia on x-ray), but you have a higher likelihood of finding some sort of menstrual dysfunction. It does not have to be a true “anorexia” or “bulimia” – any disordered eating can qualify.
Menstrual Function
Bone Mineral Density (BMD)

11. Female Athlete Triad Energy Availability
Defined as dietary energy intake minus exercise energy expenditure
Energy availability is the amount of dietary energy remaining for other body functions after exercise.
Food In – Activity Out = “left over” energy used for physiologic function

12. Female Athlete Triad Energy Availability
Athletes who are not aware of nutritional needs for their body
Intake is inadvertently restricted
Intake doesn’t match expenditure
Inadequate education regarding energy requirements
Eating Disorders
Anorexia
Bulimia
Eating disorder NOS

13. Female Athlete Triad Criteria for Anorexia Nervosa
Refusal to maintain body weight at or above a minimally normal weight for age and height (body weight less than 85% of that expected).
Intense fear of gaining weight or becoming fat, even though underweight.
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.
In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.

14. Female Athlete Triad Anorexia Nervosa
Patients are usually between the age of 12 yrs and the mid-thirties
90 to 95 % female
Majority are Caucasian, middle-class or upper-middle class families.
The mortality associated with anorexia has been reported to be as high as 9 percent
secondary to cardiac arrhythmia due to electrolyte abnormalities
and/or diminished heart muscle mass
Suicide has also been more common (2 to 5%) in patients with anorexia nervosa.
Out of any psychiatric disorder, anorexia has the highest mortality (death) rate
Christy Henrich – U.S. Olympic gymnast died at age 22 at a weight of 60 pounds of multi-organ failure

15. Female Athlete Triad Criteria for Bulimia Nervosa
Recurrent episodes of binge eating.
Eating larger amounts in a 24 hour period that is larger than most people.
Sense of lack of control over eating during the binge episodes.
Recurrent inappropriate compensatory behavior in order to prevent weight gain
Purging- self induced vomiting, misuse of laxatives, diuretics and enemas
Non Purging- fasting, excessive exercise
The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months
Self-evaluation is unduly influenced by body shape and weight
The disturbance does not occur exclusively during episodes of Anorexia Nervosa
80% female
1-2% of adolescent and young adult women
Often normal body weight

16. Female Athlete Triad Eating Disorder NOS
For disorders of eating that do not meet the criteria for any specific eating disorder:
Criteria for Anorexia Nervosa are met except that the individual has regular menses
Criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual’s current weight is in the normal range
Criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency less than twice a week or for a duration of less than 3 months
Regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food
Repeatedly chewing and spitting out, but not swallowing, large amounts of food
Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa
If an individual doesn’t meet the strict criteria for anorexia or bulimia they fall into this general eating disorder diagnosis… NOS- not otherwise specified.
Overall there is an unhealthy relationship with food and a sense of loss of control.

17. Female Athlete Triad

18. Female Athlete Triad Normal Menses

19. Female Athlete Triad Menstrual Dysfunction
When you do not eat enough calories, hormones from the hypothalamus and pituitary will not be released
These hormones normally signal the ovaries to make estrogen and progesterone and menstrual cycles occur
Estrogen is necessary for bones to grow stronger
WITH ADEQUATE CALORIC INTAKE- Hypothalamus releases gonadatropin-releasing hormone, GnRH pulse signals release of lutenizing hormone and follicle stimulating hormone. LH and FSH act on ovaries to stimulate them to produce estrogen and progesterone
Estrogen- Inhibits bone reabsorption, Activates genes to protect and increase mineralization, Regulates osteoclasts that break down bones, Enhances calcium reabsorption from the gut, Protects bone from reabsorption effects of PTH

20. Female Athlete Triad Menstrual Dysfunction
Amenorrhea- absence of menses > 3 months
Primary- delay in age of menarche
Secondary- occurs after onset of menarche (most common, important to rule out pregnancy)
Oligomenorrhea- cycles greater than 35 days
Anovulation- menses without ovulation
Luteal phase suppression
Delayed menarche often occurs in athletes
Cause of exercise induced menstrual dysfunction is due to decreased energy input
In the first 1-2 years after menarche, irregular cycles are common
Most common is secondary amenorrhea
Essential to rule out pregnancy in secondary amenorrhea
Luteal Phase Suppression leads to decreased endometrial development and poor implantation secondary to decreased luteal phase and progesterone
We use mom’s age of menarche to determine if athlete has delayed menarche
Cause of Menstrual Dysfunction is not due to “stress of exercise” but rather energy input

21. Female Athlete Triad Menstrual Dysfunction
Menstrual dysfunction may be the first detectable problem
Not having menstrual cycles is NOT NORMAL
They should see their primary care physician or OB/GYN for diagnostic evaluation
Contact their physician with your concerns
Unlike eating disorders which tend to be very secretive, the first presenting health concern may be irregular menstrual cycles
If over the age of 18 years, get their permission first
If under the age of 18 years, get their parents and the athletes permission

22. Female Athlete Triad

23. Female Athlete Triad Bone Health
If estrogen is essential for healthy bones and it’s not available in the body… then what happens??
Compact bone on the outside- Cortical bone
Spongy bone on the inside- Trabecular bone
The thicker and more dense bones are the less likely athletes would have bony breakdown/stress fractures

24. Female Athlete Triad Bone Mineral Density (BMD)
BMD is measured by DEXA
Post menopausal women
Hip and lumbar spine measured
Use T scores
> -1 normal
-1 to -2.5 osteopenia
< osteoporosis
Young athletes
Whole body scans
Use Z scores
Z score less than -1 warrants further evaluation

25. Female Athlete Triad Determinants of Bone Mineral Density
Genetics (60-80%)
Exercise and physical activity
Hormones
Nutrition
Smoking, drugs and alcohol

26. Female Athlete Triad Bone Mineral Density
Bone mineral density is like a bank that you are depositing into while you are young, when you are older you continuously with draw from the bank
Peak Bone Mass is achieved between yrs

27. Female Athlete Triad Bone Mineral Density
Bone is a living, dynamic tissue that is constantly remodeling
Loaded bone remodels to become stronger
Athletes in weight bearing sports usually have a 5-15% higher BMD than non athletes
Bone strength and fracture risk depend on density and quality of bone

28. Female Athlete Triad Bone Mineral Density
Mudd LM, Fornetti W, Pivarnik JM. Bone mineral density in collegiate female athletes: comparisons among sports. J Athl Train 2007;42:403-8.

29. Female Athlete Triad Bone Health Consequences
Peak bone mass is achieved between yrs
After age 25 years women loss bone mass at % annually
Lose approximately 2% of BMD per year of amenorrhea or oligomenorrhea instead of gaining the typical 2-4% of bone mass
Loss of BMD may not be reversible
Relative risk for stress fractures 2-4 x greater in amenorrheic than eumenorrheic athletes

30. Female Athlete Triad Bone Mineral Density
Peak Bone Mass is achieved between yrs.

31. Female Athlete Triad

32. Female Athlete Triad Risk Factors
Thin build body type sports
Restrictive dietary intact
Exercise excessively
Vegetarian
Limit types of food
Low self esteem
Family dysfunction
Abuse
More common in sports which emphasis leanness, have weight requirements, wear revealing clothing, or who are judged on the competitors aesthetic appearance
Distance running, gymnastics, figure skating, beach volleyball, rowing, wrestling.

33. Female Athlete Triad Prevalence of Low Energy Availability
Prevalence of low energy availability with or without eating disorders is unknown
Disordered Eating NOS
28-65% prevalence of dietary restriction, binge eating and/or purging behaviors among thin-build athletes
Eating disorders
25-31% prevalence among athletes in thin-build sports
5-9% in the general population
Eating disorders involve secretive behavior, Prevalence is a debated topic and may never be known
Disordered eating habits have been found to be up to 65% in collegiate gymnasts and runners

34. Female Athlete Triad Prevalence of Exercise Menstrual Dysfunction
Depending on the type of sport and competition level, the incidence varies
Secondary Amenorrhea
24% to 26% in female athletes
2-5% in the general population
Greatest incidence for sports that favor a low body weight physique
ballet (6-69%)
runners (24-65%)
Secondary amenorrhea documented as high as 69% for dancers and 65% for long distance runners

35. Female Athlete Triad Prevalence of Decreased Bone Mineral Density
Higher prevalence reported among athletes with disordered eating and/or amenorrhea
Osteopenia (T score -1 to 2.5)
22-50% prevalence among female athletes
12% in the general population
Osteoporosis (T score less than -2.5)
0-13% prevalence reported among female athletes
2.3% in the general population
Many studies have been using T score and not the recommended Z score

36. Female Athlete Triad Prevalence
Studies have shown that prevalence of all three components of the triad is small – 1% to 4%
You do not need all 3 components to have adverse health effects
If one component detected then screen for the rest
Prevalence is a debated topic, we are not sure

37. Female Athlete Triad Health Consequences
Negative consequences to current and future bone health
Stress Fractures
Delayed healing of fractures
Gastrointestinal disorders
Nutrient deficiencies
Excessive Fatigue
Increased Recovery Time
Decreased Training Responses or Adaptations
Decreased or Impaired Performance
Increased risk of future osteoporosis and fractures
Impaired future fertility
Cardiac Arrhythmias
Death
Increased Recovery Time- slow to heal from injuries
Decreased Training Responses or Adaptions- train but less gain
Osteoporosis may be irreversible
High death rate for anorexia

38. Female Athlete Triad Screening and Diagnosis
Screening can occur any time an athlete is evaluated
History-
Past medical
Past surgical
Medications
Menstrual
Psychological
Nutritional assessment
Exercise History
Exercise patterns
Training intensity
Additional exercise outside training
History of injuries
Colleges- pre participation physical exam, annual physical exam
In the training room- anytime and athlete is evaluated for a related problem, recurrent injury, stress fracture or illness
Nutritional assessment- what they’ve eaten in the last 24 hrs, list of forbidden foods, happiness with current weight, history of disordered eating?
Past injuries including stress fractures and overuse injuries

39. Female Athlete Triad Physical Exam Signs of Anorexia
Bradycardia
Hypotension
Lanugo
Hypothermia
Cold intolerance
Yellow Skin
Dry hair and skin
Alopecia
Pruritus
Pruritis- elevated bile acids cause itching

40. Female Athlete Triad Physical Exam Signs for Bulimia
Fatigue
Abdominal pain
Chest pain
Swollen parotid
Sore throat/esophagitis
Erosion of tooth enamel
Knuckle scars/callus
Constipation
Bloodshot eyes
Petechiae of sclera

41. Female Athlete Triad Lab Tests and Imaging Studies
Electrolytes, Complete blood count, Sed rate, Thyroid function, Liver function, Urinalysis
Plain radiographs
3-phase bone scan or MRI for stress fractures
DEXA scan
If amenorrheic for >1 year
BMI less than 18
History of a stress fracture.
If abnormal pituitary function, MRI of head
Pelvic ultrasound
EKG if resting heart rate is less than 50

42. Female Athlete Triad Treatment Team
Athletic Trainer
Primary Care Sports Medicine Physician
Sports Psychologist
Nutritionist
Family
Coaches
Before I talk about treatment, it’s important to discuss that athletes need a treatment “team”

43. Female Athlete Triad Treatment
Treatment for acute orthopedic and medical problems
Counseling, Therapy
Rehabilitation
Lifestyle Modifications
Restoring Energy Deficit

44. Female Athlete Triad Treatment
CORRECTION OF ENGERY DEFICIT!!!
Decreasing intensity of exercise and increasing nutritional intake
Weight gain of 2.5 to 5 lbs
10% decrease in exercise load (duration or intensity)
Birth control pills are no longer recommended
Bisphosphonates not advised for young women
Antidepressants for bulimia, anorexia, depression and anxiety disorders
HRT and OCs have not proven to help – Only use if BMD↓ in athlete > 16 yo with persistent amenorrhea despite adequate nutritional intake and weight.

45. Female Athlete Triad Return to Play
Can continue to play while in treatment
Activity modifications with close monitoring
Restrict private workouts
Withdrawal from activity should not be used as a form of punishment for noncompliance
Difficult cases, resumption of physical activity when the athlete is 10-15% of ideal body weight.

46. Case Revisited She’s been told she is “too thin”
She has seen a gynecologist for irregular menses
She denies any abnormal eating behaviors
Counseling and Education
Contacted her primary care physician
Physical therapy for ITB syndrome
She gained 6 lbs in our 8 week f/u visit
I asked her if anyone ever told her she looked “too thin” Her and her mom looked relieved.
Human body requires energy for everyday function, Fuel her body for better performance, Prevent chronic injuries, Insure strong healthy bones long term
In 6 weeks she had gained 6 lbs through increased nutrition; BMI nearly 19

47. Female Athlete Triad Summary
Watch for components of the triad
low energy availability (with or without eating disorder)
menstrual dysfunction
altered bone mineral density
Occurs across a spectrum
Energy availability is key
Menstrual dysfunction may be more easily detectable

48. Female Athlete Triad Summary
Certain sports have a higher incidence of problems
Early Intervention
Treatment with a medical team approach
Comprehensive evaluation with close monitoring
Education and Prevention
Treatment team- athletic trainer’s relationships with athletes is important!!!
Better education for physicians, athletic trainers, coaches, parents and athletes themselves

49. Female Athlete Triad References
ACSM Information Brochure:
Female Athlete Issues for the Team Physician: A Consensus Statement. MSSE 2003;
Mudd LM, Fornetti W, Pivarnik JM. Bone mineral density in collegiate female athletes: comparisons among sports. J Athl Train 2007;42:403-8.
Nutrition and Athletic Performance: pages
The benefits of physical activity. Centers for Disease Control and Prevention.
The Female Athlete Triad Position Statement: pages

50. Female Athlete Triad
Questions???