Female athlete triad
Encyclopedia
Female Athlete Triad is a syndrome in which eating disorders (or low energy availability), amenorrhoea
/oligomenorrhoea and decreased bone mineral density (osteoporosis
and osteopenia
) are present. Also know simply as the Triad, this condition is seen in females participating in sports that emphasize leanness or low body weight. The Triad is a serious illness with lifelong health consequences and can potentially be fatal.
While most athletes do not meet the criteria to be diagnosed with an eating disorder such as anorexia nervosa
or bulimia nervosa
, many will exhibit disordered eating habits. Some examples of disordered eating habits are fasting; binge-eating; purging; and the use of diet-pills, laxatives, diuretics, and enemas. By restricting their diets, athletes worsen the problem of low energy availability.
Having low dietary energy from excessive exercise and/or dietary restrictions leaves too little energy for the body to carry out normal functions such as proceeding through a regular menstrual cycle or conducting bone maintenance.
There are two types of amenorrhea. A woman who has been having her period and then stops menstruating for ninety days or more is said to have secondary amenorrhea. Primary amenorrhea is characterized by delayed menarche. Menarche is the onset of a girl’s first period. Delayed menarche may be associated with delay of the development of secondary sexual characteristics.
Immediate Effects of Low Bone Density. Patients with female athlete triad get osteoporosis due to hypoestrogenmia, or low estrogen levels which is part of amenorrhea. With estrogen deficiency, the osteoclasts live longer and are therefore able to resorb more bone. In response to the increased bone resorption, there is increased bone formation and a high-turnover state develops which leads to bone loss and perforation of the trabecular plates. As osteoclasts break down bone, patients see a loss of bone mineral density. Low bone mineral density renders bones more brittle and hence susceptible to fracture. Because athletes are active and their bones must endure mechanical stress, the likelihood of experiencing bone fracture is particularly high.
Additionally, because those suffering with female athlete triad are also restricting their diet, they may also not be consuming sufficient amounts vitamins and minerals which contribute to bone density; not getting enough calcium or vitamin D further exacerbates the problem of weak bones.
Long Term Effects of Low Bone Density. Bone mass is now thought to peak between the ages of 18-25. Thus, behaviors which result in low bone density in youth could be detrimental to an athlete’s bone health throughout her lifetime.
, figure skating
, ballet
, diving
, swimming
, and long distance running
are examples of sports which emphasize low body weight. The Triad is seen more often in aesthetic sports such as these versus ball game sports. Women taking part in these sports may be at an increased risk for developing female athlete triad.
Upon physical examination, a physician may also note the following symptoms: elevated carotene in the blood, anemia
, orthostatic hypotension
, electrolyte irregularities, hypoestrogenism
, vaginal atrophy
, and bradycardia
.
Pharmacologic Treatment. Patients are also sometimes treated pharmacologically. To both induce menses and improve bone density, doctors may prescribe cyclic estrogen
or progesterone
as is used to treat post-menopausal women. Patients may also be put on oral contraceptives to stimulate regular periods. In addition to hormone therapy, nutrition supplements may be recommended. Doctors may prescribe calcium supplements. Vitamin D supplements may be also used because this vitamin aids in calcium absorption. Bisphosphonates and calcitonin
, used to treat adults with osteoporosis, may be prescribed, although their effectiveness in adolescents has not yet been established. Finally, if indicated by a psychiatric examination, the affected athlete may be prescribed anti-depressants and in some cases benzodiazepines to help in alleviating severe distress at mealtimes.
Amenorrhoea
Amenorrhoea , amenorrhea , or amenorrhœa, is the absence of a menstrual period in a woman of reproductive age. Physiological states of amenorrhoea are seen during pregnancy and lactation , the latter also forming the basis of a form of contraception known as the lactational amenorrhoea method...
/oligomenorrhoea and decreased bone mineral density (osteoporosis
Osteoporosis
Osteoporosis is a disease of bones that leads to an increased risk of fracture. In osteoporosis the bone mineral density is reduced, bone microarchitecture is deteriorating, and the amount and variety of proteins in bone is altered...
and osteopenia
Osteopenia
Osteopenia is a condition where bone mineral density is lower than normal. It is considered by many doctors to be a precursor to osteoporosis. However, not every person diagnosed with osteopenia will develop osteoporosis...
) are present. Also know simply as the Triad, this condition is seen in females participating in sports that emphasize leanness or low body weight. The Triad is a serious illness with lifelong health consequences and can potentially be fatal.
Low Energy Availability
Energy availability is defined as energy intake minus energy expended. Energy is taken in through food consumption. Our bodies expend energy through normal functioning as well as through exercise. In the case of female athlete triad, low energy availability may be coupled with eating disorders, but not necessarily so. Athletes may experience low energy availability by exercising more without a concomitant change in eating habits, or they may increase their energy expenditure while also eating less.While most athletes do not meet the criteria to be diagnosed with an eating disorder such as anorexia nervosa
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
or bulimia nervosa
Bulimia nervosa
Bulimia nervosa is an eating disorder characterized by binge eating and purging or consuming a large amount of food in a short amount of time, followed by an attempt to rid oneself of the food consumed, usually by purging and/or by laxative, diuretics or excessive exercise. Bulimia nervosa is...
, many will exhibit disordered eating habits. Some examples of disordered eating habits are fasting; binge-eating; purging; and the use of diet-pills, laxatives, diuretics, and enemas. By restricting their diets, athletes worsen the problem of low energy availability.
Having low dietary energy from excessive exercise and/or dietary restrictions leaves too little energy for the body to carry out normal functions such as proceeding through a regular menstrual cycle or conducting bone maintenance.
Amenorrhea
Amenorrhea, defined as the cessation of a woman’s menstrual cycle for more than three months, is the second disorder in the Triad. Weight fluctuations from dietary restrictions and/or excessive exercise affect the hypothalamus’s output of gonadotropic hormones. Gonadotropic hormones “stimulate growth of the gonads and the secretion of sex hormones.” (e.g. gonadotropin-releasing hormone, lutenizing hormone and follicle stimulating hormone.) These gonadotropic hormones play a role in stimulating estrogen release from the ovaries. Without estrogen release, the menstrual cycle is disrupted.There are two types of amenorrhea. A woman who has been having her period and then stops menstruating for ninety days or more is said to have secondary amenorrhea. Primary amenorrhea is characterized by delayed menarche. Menarche is the onset of a girl’s first period. Delayed menarche may be associated with delay of the development of secondary sexual characteristics.
Osteoporosis
Osteoporosis is defined by the National Institutes of Health as ‘‘a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.’’Immediate Effects of Low Bone Density. Patients with female athlete triad get osteoporosis due to hypoestrogenmia, or low estrogen levels which is part of amenorrhea. With estrogen deficiency, the osteoclasts live longer and are therefore able to resorb more bone. In response to the increased bone resorption, there is increased bone formation and a high-turnover state develops which leads to bone loss and perforation of the trabecular plates. As osteoclasts break down bone, patients see a loss of bone mineral density. Low bone mineral density renders bones more brittle and hence susceptible to fracture. Because athletes are active and their bones must endure mechanical stress, the likelihood of experiencing bone fracture is particularly high.
Additionally, because those suffering with female athlete triad are also restricting their diet, they may also not be consuming sufficient amounts vitamins and minerals which contribute to bone density; not getting enough calcium or vitamin D further exacerbates the problem of weak bones.
Long Term Effects of Low Bone Density. Bone mass is now thought to peak between the ages of 18-25. Thus, behaviors which result in low bone density in youth could be detrimental to an athlete’s bone health throughout her lifetime.
At Risk Populations
GymnasticsGymnastics
Gymnastics is a sport involving performance of exercises requiring physical strength, flexibility, agility, coordination, and balance. Internationally, all of the gymnastic sports are governed by the Fédération Internationale de Gymnastique with each country having its own national governing body...
, figure skating
Figure skating
Figure skating is an Olympic sport in which individuals, pairs, or groups perform spins, jumps, footwork and other intricate and challenging moves on ice skates. Figure skaters compete at various levels from beginner up to the Olympic level , and at local, national, and international competitions...
, ballet
Ballet
Ballet is a type of performance dance, that originated in the Italian Renaissance courts of the 15th century, and which was further developed in France and Russia as a concert dance form. The early portions preceded the invention of the proscenium stage and were presented in large chambers with...
, diving
Diving
Diving is the sport of jumping or falling into water from a platform or springboard, sometimes while performing acrobatics. Diving is an internationally-recognized sport that is part of the Olympic Games. In addition, unstructured and non-competitive diving is a recreational pastime.Diving is one...
, swimming
Swimming (sport)
Swimming is a sport governed by the Fédération Internationale de Natation .-History: Competitive swimming in Europe began around 1800 BCE, mostly in the form of the freestyle. In 1873 Steve Bowyer introduced the trudgen to Western swimming competitions, after copying the front crawl used by Native...
, and long distance running
Long-distance track event
Long-distance track event races require runners to balance their energy. These types of races are predominantly aerobic in nature and at the highest level, exceptional levels of aerobic endurance is required more than anything else...
are examples of sports which emphasize low body weight. The Triad is seen more often in aesthetic sports such as these versus ball game sports. Women taking part in these sports may be at an increased risk for developing female athlete triad.
Symptoms of the Triad
Clinical symptoms of the Triad may include disordered eating, fatigue, hair loss, cold hands and feet, dry skin, noticeable weight loss, increased healing time from injuries, increased incidence of bone fracture and cessation of menses. Affected females may also struggle with low-self esteem and depression.Upon physical examination, a physician may also note the following symptoms: elevated carotene in the blood, anemia
Anemia
Anemia is a decrease in number of red blood cells or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin...
, orthostatic hypotension
Orthostatic hypotension
Orthostatic hypotension, also known as postural hypotension, orthostasis, and colloquially as head rush or dizzy spell, is a form of hypotension in which a person's blood pressure suddenly falls when the person stands up or stretches. The decrease is typically greater than 20/10 mm Hg, and may be...
, electrolyte irregularities, hypoestrogenism
Hypoestrogenism
Hypoestrogenism refers to a lower than normal level of estrogen, the primary sex hormone for women. In general, lower levels of estrogen may cause differences in the breasts, genitals, urinary tract and skin....
, vaginal atrophy
Atrophic vaginitis
Atrophic vaginitis is an inflammation of the vagina due to the thinning and shrinking of the tissues, as well as decreased lubrication...
, and bradycardia
Bradycardia
Bradycardia , in the context of adult medicine, is the resting heart rate of under 60 beats per minute, though it is seldom symptomatic until the rate drops below 50 beat/min. It may cause cardiac arrest in some patients, because those with bradycardia may not be pumping enough oxygen to their heart...
.
Treatment
Multidisciplinary Approach. Athletes diagnosed with female athlete triad should be treated using a multidisciplinary approach. Patients are recommended to work with a dietician who can monitor their nutritional status and help the patient work towards a healthy goal weight. Patients should also meet with a psychiatrist or psychologist to address the psychological aspects of the Triad. Finally, it is generally recommended that athletes reduce the amount of time they spend exercising by 10-12 percent. Therefore, it is important that trainers and coaches are made aware of the athlete’s condition and be part of her recovery.Pharmacologic Treatment. Patients are also sometimes treated pharmacologically. To both induce menses and improve bone density, doctors may prescribe cyclic estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
or progesterone
Progesterone
Progesterone also known as P4 is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy and embryogenesis of humans and other species...
as is used to treat post-menopausal women. Patients may also be put on oral contraceptives to stimulate regular periods. In addition to hormone therapy, nutrition supplements may be recommended. Doctors may prescribe calcium supplements. Vitamin D supplements may be also used because this vitamin aids in calcium absorption. Bisphosphonates and calcitonin
Calcitonin
Calcitonin is a 32-amino acid linear polypeptide hormone that is producedin humans primarily by the parafollicular cells of the thyroid, and in many other animals in the ultimobranchial body. It acts to reduce blood calcium , opposing the effects of parathyroid hormone . Calcitonin has been found...
, used to treat adults with osteoporosis, may be prescribed, although their effectiveness in adolescents has not yet been established. Finally, if indicated by a psychiatric examination, the affected athlete may be prescribed anti-depressants and in some cases benzodiazepines to help in alleviating severe distress at mealtimes.
See also
- Eating disorders
- Anorexia nervosaAnorexia nervosaAnorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
- Bulimia
- Body dysmorphic disorderBody dysmorphic disorderBody Dysmorphic Disorder is a type of mental illness, a somatoform disorder, wherein the affected person is exclusively concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of his or her physical features...
- GonadotropinGonadotropinGonadotropins are protein hormones secreted by gonadotrope cells of the pituitary gland of vertebrates. This is a family of proteins, which include the mammalian hormones follitropin , lutropin , placental chorionic gonadotropins hCG and eCG and chorionic gonadotropin , as well as at least two...