Female Athlete Triad and Relative Energy Deficiency in Sport (RED-S)
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Top Contributors - Wanda van Niekerk and Jess Bell
Introduction[edit | edit source]
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
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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