Female Athlete Triad

Aka: Female Athlete Triad

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II. Definitions

  1. Female Athlete Triad
    1. Disordered Eating (Anorexia Nervosa)
    2. Secondary Amenorrhea
    3. Premature Osteoporosis (Stress Fractures)

III. Background

  1. Female Athlete Triad was originally defined by American College of Sports Medicine (1984)
    1. Disordered Eating
    2. Amenorrhea
    3. Premature Osteoporosis
  2. International Olympic Committee renamed Female Athlete Triad as RED-S (2014)
    1. See Relative Energy Deficiency in Sport (RED-S)
    2. Relative energy deficiency
    3. Results in impaired physiologic functioning affecting multiple systems beyond original definition
      1. Impaired metabolic rate, Protein synthesis
      2. Amenorrhea or Oligomenorrhea
      3. Impaired cardiovascular health
      4. Low Bone Mineral Density

IV. Epidemiology

  1. Eating Disorder Incidence in female athletes: 15-62%
  2. Amenorrhea Incidence
    1. Female Athletes: as high as 66%
    2. Women in general population: 2-5%

V. Etiology: Pressure of competition and Society

  1. Winning
  2. Weight control
  3. Performance
  4. Thinness

VI. Diagnosis

  1. Eating Disorder
    1. Anorexia Nervosa
    2. Bulimia Nervosa
  2. Amenorrhea
    1. Menarche delayed 5 months per year athletic training
    2. Nutrition is lowest common denominator
  3. Osteoporosis
    1. Old bones at a young age is associated with triad
    2. Osteoblasts are Estrogen dependent
    3. Athlete triad is Estrogen deficient state

VII. Risk Factors

  1. College age
  2. Appearance sports
    1. Gymnastics
    2. Figure skating
    3. Diving
    4. Dancing
  3. Endurance sports
    1. Long distance Running
    2. Cross Country Skiing
    3. Swimming
    4. Rowing
  4. Weight limits
    1. Wrestling
    2. Martial arts
    3. Rowing
  5. Enablers
    1. Judges
    2. Coaches
    3. Parents
  6. Athlete characteristics
    1. Perfectionist
    2. Goal oriented
    3. Highly dependent on external approval
    4. Win at all cost

VIII. Signs

  1. See Anorexia Nervosa

IX. Prevention

  1. Keep high index of suspicion
  2. Recognize triad early
  3. Secondary Amenorrhea
    1. Increase body weight by 2 kilograms
    2. Decrease Exercise activity by 10%

X. Treatment

  1. Multidisciplinary team
    1. Primary Physician, Psychologist, and Nutritionist
    2. Trainer and Coach
    3. Parents
  2. Threshold for intervention
    1. Menstrual periods missed
    2. Pounds lost
    3. Excessive Exercise
  3. Pre-participation Exam
    1. Weight range history and Ideal Weight over last year
    2. Menstrual history
  4. Education
    1. Nutrition for peak performance
    2. Proper training (No Overtraining)
    3. Safe weight loss (less than 2 pounds per week)
    4. Decrease activity intensity part of year
    5. Oral Contraceptive cycling
  5. Nutrition
    1. Maintain adequate calorie intake
    2. Maintain adequate Carbohydrates, Protein and fat
    3. Maintain adequate Calcium
      1. Calcium 1500 mg/day (e.g. Tums 3-4 times per day)

XI. Radiology: Wrist and Hand XRay for Bone Health

  1. Premarin 0.625 mg qd for bone Growth Delayed by 2 years

XII. Prognosis

  1. Eating Disorder
    1. See Anorexia Nervosa
  2. Amenorrhea associated morbidity
    1. Infertility
    2. Endometrial Cancer
  3. Osteoporosis associated morbidity
    1. Female athlete at age 20 may have 70 year old bone
    2. Increased Stress Fractures
    3. Increased Vertebral Fracture
    4. Increased Hip Fractures

XIII. References

  1. Hobart (2000) Am Fam Physician 61(11):3357-67 [PubMed]
  2. Otis (1997) Med Sci Sports Exerc 29:i-ix [PubMed]
  3. Sanborn (2000) Clin Sports Med 19(2):199-213 [PubMed]

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