1. Jacalyn J. Robert-McComb, PhD, FACSM
Chapter 5 - The Female Athlete Triad: Disordered Eating, Amenorrhea, and Osteoporosis
Jacalyn J. Robert-McComb, PhD, FACSM

2. Learning Objectives After viewing this slideshow, you should have an
understanding of:
the American College of Sports Medicine (ACSM) position stand on the female athletic triad;
the difference between disordered eating and eating disorders;
the progressive nature of menstrual disturbances in athletes;
the difference between osteopenia and osteoporosis;

3. Learning Objectives Continued
the inter-relatedness of disordered eating, amenorrhea, and osteoporosis;
athletes at greatest risk for developing signs and symptoms associated with the triad; and
the growing health concern of the triad for allied health professionals.

4. ACSM’s Position Stand on the Female Athletic Triad
In 1997, ACSM published its Position Stand on the Female Athletic Triad (Otis C, Drinkwater B, Johnson M, et al. 1997).
The Female Athlete Triad is a serious syndrome consisting of disordered eating, amenorrhea, and osteoporosis. The components of the Triad are interrelated in etiology, pathogenesis, and consequences. These disorders occur not only in elite athletes but also in physically active girls and women participating in a wide range of physical activities. The Triad can result in declining physical performance, as well as medical and psychological morbidity’s and mortality.

5. The Difference Between Eating Disorders and Disordered Eating
The term disordered eating includes a spectrum of abnormal eating behaviors that range from mild restricting behaviors and occasional binging and purging to those that meet the diagnostic criteria for Eating Disorders in the Diagnostic and Statistical Manual of Mental Disorders-DSM-IV-TR .

6. Eating Disorders
The primary types of eating disorders are Anorexia Nervosa (AN) and Bulimia Nervosa (BN). American Psychiatric Association. Diagnostic criteria for these disorders can be found in the DSM-IV-TR.

7. DSM-IV- TR Diagnostic Criteria for Anorexia Nervosa (American Psychiatric Association, 2000)
Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
Intense fear of gaining weight or becoming fat, even though under-weight.

8. DSM-IV- TR Diagnostic Criteria for Anorexia Nervosa (American Psychiatric Association, 2000)
Disturbance in the way in 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. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.)

9. DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa (American Psychiatric Association, 2000)
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
eating in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating)

10. DSM-IV-TR Diagnostic Criteria for Bulimia Nervosa (American Psychiatric Association, 2000)
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
The binge eating and inappropriate 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 during episodes of Anorexia Nervosa.

11. Definitions of Amenorrhea (somewhat arbitrary)
Primary Amenorrhea
Acyclic at age 16 with secondary sex characteristics (seems to be general agreement)
Secondary Amenorrhea
The International Olympic Committee defines secondary amenorrhea as having one or fewer menstrual cycles a year.
The ACSM position stand on The Female Athletic Triad defines amenorrhea as the absence of at least 3-6 menstrual cycles a year.

12. Oligomenorrhea (again, definitions are somewhat arbitrary).
Defined by some as:
cycles that occur at intervals longer than 35 days.
Others define amenorrhea as:
cycle length from days with fewer than 6 menses a year.

13. The Progressive Nature of Menstrual Disturbances in Athletes
1. Regular cycles with a shortened luteal phase- progesterone production stops early
2. Regular cycles with inadequate progesterone production
3. Regular cycles with failure to develop and release an egg (ovulation)
4.     Irregular cycles but still ovulating
5.     Irregular cycles and anovulation
6. Absence of menses and anovulation

14. Differentiating Osteoporosis from Osteopenia
The diagnostic criteria for low bone mass as defined by the World Heath Organization is as follows:
normal: bone mineral density (BMD) that is no more than 1 Standard Deviation (SD) below the mean of young adults;
ostopenia: BMD between 1 and 2.5 SD below the mean of young adults;
osteoporosis: BMD more than 2.5 SD below the mean of young adults; and
severe osteoporosis: BMD more than 2.5 SD below the mean of young adults plus one or more fragility fractures.

15. The Inter-Relatedness of Disordered Eating, Amenorrhea, and Osteoporosis
One disorder leads to another: (1) disordered eating  (2)amenorrhea  (3)osteoporosis . 1 2 3

16. Girls who participate in the following sports are most susceptible
Sports where performance is subjectively judged
Sports where athletes wear revealing clothing
Sports with weight categories
Sports where a pre-pubescent body is emphasized

17. The Growing Health Concern of the Triad for Allied Health Professionals
Many colleges and high schools do not use a medical history form that asks questions which might help determine if athletes are at risk of developing the signs and symptoms associated with disordered eating, amenorrhea, and osteoporosis.

18. Responsibility is in our hands
Therefore, it is up to allied health professionals such as athletic trainers, school nurses, team physicians, physical therapists, nutritionists and exercise physiologists to implement such a screening device.

19. Denial is common so questions should be subtle.
Examples of eating/weight history questions
What is your desired weight?
Do you weigh yourself often?
Does worrying about weight take up a significant amount of your time?

20. Examples of menstrual history questions
At what age did you have your first period?
When was your last period?
How many periods have you had in the last 12 months?

21. Examples of stress fracture history
Have you ever had a stress fracture or a stress reaction?
Have you ever had x-rays to rule out a stress fracture or a stress reaction?
Have you ever had a bone scan or a bone density test?
Sample questions come from the University of Colorado Sports Medicine Department at Colorado Springs (with permission)

22. The following Instruments can be found in the Appendices in the text, The Active Female: Health Issues Throughout the Lifespan.
Body Image Concern Inventory
Eating Attitudes Test (EAT-26)
Bulimia Test - Revised (BULIT-R)
Student-Athlete Nutritional Health Questionnaire
Female Athlete Screening Tool

23. Thank You