Female Athlete Triad and Relative Energy Deficiency in Sport (RED-S)

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Introduction

Understanding Menstruation

Puberty

Puberty – transitional stage from childhood up to menarche. This happens to everyone between the ages of 6? to 16 years. Menarche is unique to females.

Other signs of puberty include breast development, pubic hair growth, vaginal mucosal changes

Precocious puberty – when puberty happens before the age of 9 years old. This requires an assessment by a physician

Menarche

Menarche occurs at the beginning of the reproductive stage and is marked by the first menstrual period. It occurs during the late stages of puberty.

The onset of menstruation 11 to 14 years old

Irregular menstrual cycle initially in the first two years of menstruation

No menstruation or signs of puberty by the age of 15 requires further evaluation

Menstruation

Menstrual period is defined as the monthly shedding of the functional layer (the endometrial lining) of the uterus

Ideally, the menstrual cycle is 28 days long. Day 1 is the menses – when the bleeding starts. The bleeding commonly lasts for 5 to 7 days. Menses is included in the follicular phase.

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For more information read:

Menarche to Menopause

Menstruation and Menstrual Rehab

Important definitions

Eumenorrhea - "normal" menstruation, cycle lasts between 25 to 35 days, with typical bleeding lasting between 4 to 7 days and a loss of approximately 30 to 60 ml of blood

Oligomenorrhea - abnormal menstruation - extremely heavy flow, period lasting for longer than 7 days and fluctuations in the length of cycles (can be longer or shorter cycles)

Amenorrhea- the absence of menarche onset

Primary amenorrhea - non menstruation cycle by the age of 16

Secondary amenorrhea - history of menstruation followed by 3 or more months without menstrual cycle

Perimenopause

Period of approximately 4 years leading up to menopause

increasing variability in length of menstrual cycle

hormonal fluctuations

hot flashes

sleep disturbances

mood changes

vaginal dryness and painful sex

Menopause

average age is 51.4 years old

menopause is 12 months from the last menstrual cycle

Post-menopause is the rest of a woman's life after menstruation has ended

Oestrogen levels are significantly lower in post-menopause phase

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At risk of increase in bone loss and increased risk for cardiovascular disease

Female Athlete Triad

Components of the female athlete triad

Menstrual dysfunction

Low bone mineral density

Low energy availability (with or without disordered eating or an eating disorder)

The female athlete triad refers to this interrelationship between these components.

Female engaging in high levels of exercise

Low caloric intake

Development of hypothalamic dysfunction

Menstrual cycle changes

Decrease in bone mineral density

May result in bone stress injury

Triangle diagram of female triad - copyright?

Relationship between female athlete triad and relative energy deficiency in sport

Energy imbalance issue

High energy output - exercise

Low energy input - nutrition

Change the balance through either changing the output or changing the intake

Who is at risk

Female athletes

dancers, gymnasts, runners

high energy output - high levels of exercise

physical appearance component may cause restrictive eating

Male athletes

boxers, mixed martial arts (weight categories)

cyclists - reduced bone loading

runners

Relative Energy Deficiency in Sport (RED-S)

Relative Energy Deficiency in Sport (RED-S) is a relative new syndrome, first introduced in 2014 by the International Olympic Committee. It reflects an evolution of the female athlete triad concept. Similar to the female athlete triad, energy availability is the underlying cause of RED-S. Low energy availability negatively influences physiological processes and athlete performance. The RED-S concept includes the female athlete triad and it acknowledges that men may also be affected by low energy availability.

Definition of RED-S: "impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments on metabolic rate, menstrual function, bone health, immunity, protein synthesis and cardiovascular health"

Low Energy Availability (LEA)

With low energy availability there is discrepancy and inconsistency between an athlete's energy intake (nutrition) and energy expenditure during exercise. This results in the athlete having inadequate energy to support functions needed by the body to maintain optimal health and performance. Low energy availability may be intentional or unintentional. It is important to recognise which form of LEA an athlete may present with as management differs.

Intentional LEA - athlete intentionally restricts dietary intake to control body weight and/or body composition. A complex management plan is necessary with a multidisciplinary team approach (this can include medical, nutritional and mental health support)

Unintentional LEA - athlete is not meeting the demands of the sport, often during periods of increased training or taking part in sports with high energy expenditure. Management may be easier in that athlete education on the nutritional demands of their training load may be sufficient to address the LEA.

Health effects of RED-S or LEA

Table 1 summarises the health effects of low energy availability

Table 1. Health effects of low energy availability

System	Effects
Endocrine	In female athletes: disruption of hypothalamic - pituitary - gonadal axis alterations in thyroid function changes in appetite-regulating hormones decrease in insulin increased growth hormone resistance elevations in cortisol In male athletes: reduction in testosterone
Menstrual function	disruption of gonadotropin-releasing hormone (GnRH), followed by alterations of LH and FSH release and decreased estradiol and progesterone levels lead to functional hypothalamic amenorrhea
Bone health	In female athletes with oligomenorrhea or amenorrhea: decreased bone mineral density (BMD) altered bone micro-architecture decreased estimates of bone strength increased risk for bone stress injuries specific populations at higher risk: cyclists swimmers runners jockeys
Metabolic	decreased resting metabolic rate to conserve energy
Cardiovascular	Studies have reported: atherosclerosis associated with hypoestroginism lower heart rates and systolic blood pressure in amenorrheic athletes compared to eumenorrheic athletes
Gastrointestinal	early satiety with bloating constipation, diarrhea, or both recent diagnosis of irritable bowel syndrome recent food intolerances (dairy, gluten)
Immunological	increased likelihood of illnesses such as upper respiratory symptoms and gastrointestinal tract symptoms
Psychological	Evidence of of mental health issues that lead to LEA and caused by LEA Research shows that female adolescents with amenorrhea may have: increase in mild depressive traits psychosomatic disorders decreased ability to cope with stress social insecurity fear of weight gain
Growth and Development	Slowed growth in adolescents
Sleep	inability to sleep disturbed sleep
Mood	depressed mood increased irritability anxiety

Disordered Eating and Eating Disorder

Eating disorder - mental health condition

Disordered eating - control of food intake, abnormal or incorrect beliefs about what the athlete should be eating

Higher prevalence of disordered eating and eating disorders in sports that are weight-sensitive (gymnastics, dance, runners, boxing)

Disordered eating and eating disorders are multifactorial with culture, family, the individual and genetics playing a role.

Risk and trigger factors related to eating disorders include:

performance pressure

sudden increase in training volume

injury

teammate modeling

team weigh ins

relationship with coach - high conflict and low support environment

Disordered eating is influenced by:

perfectionism

competitiveness

pain tolerance

perceived performance advantage of weight loss

Performance Effects of RED-S

Performance Effects of RED-S
Decreased endurance performance Increased risk of injury Decreased training response Impaired judgement Decreased coordination Decreased concentration Irritability Depression Decreased glycogen stores Decreased muscle strength

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