Female Athlete Triad

1. Definition of the Female Athlete Triad
   1. Disordered Eating (Anorexia Nervosa)
   2. Secondary Amenorrhea
   3. Osteoporosis (Stress Fractures)
2. Epidemiology
   1. Eating DisorderIncidence in female athletes: 15-62%
   2. AmenorrheaIncidence
      1. Female Athletes: as high as 66%
      2. Women in general population: 2-5%
3. Etiology: Pressure of competition and Society
   1. Winning
   2. Weight control
   3. Performance
   4. Thinness
4. 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
5. 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
6. Signs
   1. See Anorexia Nervosa
7. 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%
8. 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)
9. Radiology: Wrist and Hand XRay for Bone Health
   1. Premarin 0.625 mg qd for bone Growth Delayed by 2 years
10. 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
11. 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]