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 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 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 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 Low estrogen levels can cause low BMD leading to osteoporosis and inc fracture risk

3. Disordered Eating Prevalence of ED in athletes 15-62% Prevalence of ED in athletes 15-62% Can be a spectrum from abnormal eating habits to AN/BN Can be a spectrum from abnormal eating habits to AN/BN Female athletes consume 20-30% less than RDA and expend 700Kcal/day 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 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 Spectrum – primary and secondary amenorrhea and oligomenorrhea Incidence of amenorrhea- Incidence of amenorrhea- 5% in pop 10-20% in athletes 30-50% in elite athletes 10-20% in athletes 30-50% in elite athletes Amenorrheic athletes initiate training earlier than eumenorrheic athletes, even prior to menarche 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 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 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 Secondary to excessive exercise and/or dieting Bullen et al –excessive exercise even without weight loss can cause menstrual irregularities 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 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 Peak bone mass obtained in adolescence Only minimal increases in BMD 2yrs after menarche Only minimal increases in BMD 2yrs after menarche PBM determined by- gender, genetics, diet, exercise, hormones PBM determined by- gender, genetics, diet, exercise, hormones PBM in women 30% lower than in men PBM in women 30% lower than in men Estrogen deficiency in adolescence may cause a decrease in PBM 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 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 Estrogen def inc bone turnover and bone resorption, causing a reduction in trabecular and cortical bone Dec BMD leads to an increased fracture risk 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 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 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 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!!!!! 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 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. 50% of A. college runners reported stress fx.

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

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

11. Conclusion Higher incidence of Female Athlete Triad is being seen Higher incidence of Female Athlete Triad is being seen Components of the Triad- ED, amenorrhea and osteoporosis can lead to increased fracture risk 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 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 Further investigation of treatment modalities for osteoporosis in the ad age group are being conducted- use of Alendronate Prevention is key!! Prevention is key!!