1. The Female Athlete Triad Ann M. Heaslett, M.D. Psychiatrist, Madison, WI USA Member USA 100K Team 2002-5

2. The Female Athlete Triad?

3. What is the Female Athlete triad? Disordered Eating AmenorrheaOsteoporosis

4. The Female Athlete Triad Originally described in 1992 First recognized as three separate but unrelated entities Now recognized by the American College of Sports Medicine (ACSM) as a spectrum of symptoms and conditions between health and disease

5. The Female Athlete Triad The three spectrums include: The three spectrums include: Energy availability (which may occur with or without disordered eating) Menstrual function Bone Mineral Density

6. The Female Athlete Triad Dysfunction in any of any of the components can lead to dysfunction of the other components. While energy availability may change daily, the effects on menstrual cycle may not occur for months, and an effect on bone mineral density may not occur for years.

7. Energy Balance & Body Wt. When an athlete eats enough calories to meet basic and athletic needs, wt should be stable. However, it isn’t that simple. When there is a caloric deficit, the brain & body try to help reestablish energy balance by decreasing resting metabolic rate. The body begins to conserve calories, and this starts a cascade of events we’ll call low energy availability.

8. Low Energy Availability Can occur with or without a formal eating disorder. May be due to abnormal eating behaviors such as dietary restraint, binge eating, etc. OR failure increase dietary intake to match training needs.

9. Low energy availability leads to Disruption of the GnRH pulse generator in the hypothalamus, possibly because of changes in: - leptin -cortisol - leptin -cortisol - insulin, IGF-1,glucose, f.a.’s.,ketones - insulin, IGF-1,glucose, f.a.’s.,ketones - growth hormone - growth hormone - T3, etc. - T3, etc.

10. Changes in factors previously described have an inhibitory effect on the hypothalamus Decreased stimulation of the pituitary with GnRH pulses

11. Decreased LH and FSH pulses, resulting in less stimulation of the ovaries to produce progesterone and estrogen

12. Abnormal Menses So why are abnormal menses important? -Because Bone Mineral Density decreases with the number of missed menstrual cycles accumulated over the months and years. This leads to increased incidence of stress fractures in active women with menstrual irregularities.

13. Bone Mineral Density 60-80% Genetically Determined, peak BMD achieved between ages 11-15 While weight-bearing exercise should increase BMD, decreased estrogen decreases BMD, as do: -smoking, alcohol, malnutrition -smoking, alcohol, malnutrition Women with normal menses who are active have 5-15% higher BMD than sedentary controls.

14. Osteoporosis May result from failure to achieve peak BMD during adolescence or from accelerated bone loss

15. Prevalence of the Triad Unsure… Why? inadvertant low energy availability-prevalence is unknown inadvertant low energy availability-prevalence is unknown disordered eating without a formal eating d.o dx – 28-62% prevalence in thin-build athletes disordered eating without a formal eating d.o dx – 28-62% prevalence in thin-build athletes formal eating disorder – 25-31% prevalence in thin-build athletes compared with 5-9% general population formal eating disorder – 25-31% prevalence in thin-build athletes compared with 5-9% general population

16. Prevalence of Menstrual Disorders Amenorrhea is present in 65-69% of endurance runners compared to 2-5% in the general population

17. Prevalence of Low BMD T-score between -1 and -2.5: 22-50% prevalence among female athletes 22-50% prevalence among female athletes T-score less than -2.5: 0-13% prevalence among female athletes 0-13% prevalence among female athletes These are higher than the 12% and 2.3%prevalence estimates, respectively, in a normal population distribution.

18. Key Concepts It is not necessary to have all three components of the Triad simultaneously to have negative effects on bone health The triad can be seen in all sports, not just those traditionally seen as low body wt sports such as long distance running

19. Additional Consequences of the Triad -Increased cardiovascular risk -Increased risk for osteoporosis -Reproductive dysfunction -Metabolic Consequences -Excessive fatigue -Increased recovery time -Decreased response to training -Impaired Performance

20. Screening If one component of the Triad is present, screen for the other two, as there is significant likelihood they are present. How? 1. Low Energy Availability: look for high dietary restraint, high drive for thinness, excessive or compulsive exercise, restriction of specific food groups, repeated dieting, eating disorder.

21. Screening, Continued 2. Menstrual dysfunction: how many periods has the athlete had within the past 12 months? Has she missed >3 periods in a row? 3. BMD: consider performing DXA scan of the spine and hip if hx of stress fx and/or h/o > 6 months of amenorrhea, oligomenorrhea, disordered eating or eating disorder.

22. Prevention/Treatment Education of the athlete as to how much energy is required to do the kind of training/performance she is asking of her body. Increasing nutritional intake or decreasing training volume may be needed to restore/maintain energy balance. Provision of adequate Calcium 1200- 1500mg/day and Vit. D 400-800IU/day.

23. Prevention and Treatment, continued Adding hormones in the way of OCP’s will not restore BMD unless adequate nutrition is present Biophosphonates should not be used in young athletes with amennorhea or low BMD

24. Prevention Changing the mindset is important, and successful female ultrarunners seem to understand that food is not “the enemy” but rather what fuels activity and performance and promotes development of training effect and allows for healing and growth. The Female Athlete Triad is NOT an inevitable consequence of training and being an athlete.