1. The Female Athlete Triad 1.Amenorrhea –Menstrual dysfunction has long been known to be associated with exercise. 2.Disordered Eating –Eating disorders are a cause of lower bone mineral density and premature osteoporosis. 3.Premature Osteoporosis –Amenorrhea secondary to hypoestrogenism is associated with osteoporosis

2. Amenorrhea Can be associated with: –Infertility –Osteoporosis –Cholesterol abnormalities Etiology: –disrupted release of GnRH leading to lower LH levels.

3. Training-related menstrual dysfunction Luteal phase deficiency: short luteal phase, decreased progesterone levels, normal cycle length and menses. Anovulatory cycles: estrogen level is normal but no progesterone, cycles are long and irregular. Exercise-associated amenorrhea: can be reversed by an increase in calorie intake or a reduction in training intensity.

4. Evaluation of Amenorrhea Hx & PE Pregnancy Test, FSH/LH, TSH/T4, Prolactin Progesterone Challenge: –If (+) ->unopposed estrogen: Anovulation, PCOS, Adrenal Androgen Excess –If (-) -> Progesterone and Estrogen: EAA, Anorexia Nervosa, Ovarian Failure

5. Osteoporosis Risk Factors Female sex Asian or Caucasian race Age Sedentary Lifestyle Thinness Tobacco use Decreased bone mineral density Prolonged corticosteroid use Decreased calcium intake Estrogen deficiency

6. Disordered Eating Eating disorders exist on a continuum from skipping meals to using diet pills, diuretics, or laxatives, to purging to Anorexia Nervosa. The hallmark is distorted body image. Up to 62% of college athletes practice some form of pathologic weight control behavior.

7. General Predisposing Risks Chronic dieting Low self-esteem Family dysfunction Physical or sexual abuse Biological factors (currently unknown) Perfectionism Lack of nutrition knowledge

8. Sport-specific Risks Emphasis on weight for performance or appearance Pressure to lose weight from parents, coaches, judges or peers Drive to win at any cost Self-identity tied to sport Exercises through injury Overtrained and undernourished

9. Shared Features: Athletes & Anorectics Fad diets Controlled caloric consumption Specific carbohydrate avoidance Low body weight Resting bradycardia and hypotension Increased physical activity Amenorrhea or oligomenorrhea Anemia

10. Distinct Features: Athletes vs. Anorectics Purposeful training Increased Exercise Tolerance Good Muscular Development Accurate Body Image Body Fat Level in Normal Range Aimless physical activity Poor or decreasing performance Poor muscular development Flawed Body Image Low Body Fat

11. Caloric Requirements for Sport 2200-2500 Cal/day for 10-20 hours of exercise per week. Up to 4000 Cal/day for endurance exercises. Endurance athletes require increased protein (1.2-1.4 g/kg). 5-8 g/kg of carbohydrate

12. Symptoms of Inadequate Calories Fatigue Irritability, hunger, difficulty concentrating Frequent injuries Poor athletic performance Growth failure in adolescence Weight loss Amenorrhea

13. Distinct Features: Athletes vs. Anorectics Increased Plasma Volume Efficient Energy Metabolism Increased VO2 Increased HDL2 Electrolyte Abnormalities Cold Intolerance Dry Skin Cardiac Arrhythmias Lanugo hair Leukocyte Dysfunction

14. Prevention Education to dispel myths regarding body weight and body fat and their relationship to performance: athletes often mistakenly feel that the lower their body fat the better their performance. Nutrition education regarding a healthy diet: more calories are often required to improve performance and health.