The Female Athlete Triad

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

3. Disordered Eating • Prevalence of ED in athletes 15-62% • Can be a spectrum from abnormal eating habits to AN/BN • 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

4. Amenorrhea • Spectrum – primary and secondary amenorrhea and oligomenorrhea • Incidence of amenorrhea- 5% in pop 10-20% in athletes 30-50% in elite athletes • 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

5. Amenorrrhea • 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 • 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

6. Bone Mass • Peak bone mass obtained in adolescence • Only minimal increases in BMD 2yrs after menarche • PBM determined by- gender, genetics, diet, exercise, hormones • PBM in women 30% lower than in men • 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 • Estrogen def inc bone turnover and bone resorption, causing a reduction in trabecular and cortical bone • 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

8. Osteoporosis • 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 • 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 • 50% of A. college runners reported stress fx.

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

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

11. Conclusion • Higher incidence of Female Athlete Triad is being seen • 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 • Further investigation of treatment modalities for osteoporosis in the ad age group are being conducted- use of Alendronate • Prevention is key!!