Female Athlete Triad and Relative Energy Deficiency in Sport (RED-S)
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Introduction[edit | edit source]
In recent years there has been an upward trend in participation in women's sport. Efforts are made to engage women of all ages in sport and exercise and this is seen in the increase of female athletes being included in national teams at events such as the Olympic games.
The increased awareness of the female athlete as a unique population is highlighted in recent research. A woman's body responds differently to exercise than a male's body, yet much of the research informing sports medicine is based on studies investigating male participants. There are unique anatomical and physiological differences between sexes and this needs to be taken into consideration. It is crucial to understand the unique and individual considerations for the female athlete across all the various transitions in their lifespan. This is necessary for performance and the athlete's career.
Understanding the Female Developmental Process[edit | edit source]
The diagram below depicts the transitions a female will pass through in an average life span. Common signs and symptoms for the onset of each of these transitions are listed below.
Puberty[edit | edit source]
- Puberty – transitional stage from childhood up to menarche[1][2]
- This happens to everyone, but menarche is unique to females.
- Other signs of puberty in females include:
- breast development
- pubic hair growth
- vaginal mucosal changes
- growth spurt
- increase in body odour
- oilier hair and skin
- Precocious puberty – when puberty happens before the age of 8 years in females and 9 years in males. Assessment by a physician is required when this occurs.[3]
Menarche[edit | edit source]
- 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, typically between the ages of 10 and 16.[4]
- 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[5]
Menstruation[edit | edit source]
A menstrual period is defined as the monthly shedding of the functional layer (the endometrial lining) of the uterus.[6] The menstrual cycle last between 25 to 35 days and an "ideal" 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. After the cessation of bleeding, the endometrium starts to thicken until the egg is released (ovulation). The next phase is the luteal phase and during this phase the egg can either be fertilised and implanted in the thickened endometrium. If the egg is not fertilised the egg and the thickened part of the endometrium are broken down and expelled. This is the beginning of menses (day 1).
Review Female Anatomy: Female Genital Tract
Read more: Menarche to Menopause and 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[5]
- 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)[8]
- Amenorrhea- the absence of menarche onset
- Primary amenorrhea - non menstruation cycle by the age of 16[9]
- Secondary amenorrhea - history of menstruation followed by 3 or more months without menstrual cycle in someone who was previously menstruating regularly or more than 6 months in someone who has irregular cycles[10]
Perimenopause[edit | edit source]
- Period of approximately 4 years leading up to menopause ("period prior to cessation of menses")[11]
- Increasing variability in length of menstrual cycle[12]
- Hormonal fluctuations[12]
- Hot flashes[12]
- Sleep disturbances[12]
- Mood changes[12]
- Vaginal dryness and painful sex[12]
Menopause[edit | edit source]
- The average age of menopause is 51.4 years old[5][12]
- Menopause is 12 months from the last menstrual cycle[13]
- Post-menopause is the rest of a woman's life after menstruation has ended[13]
- Female sex hormone levels such as oestrogen levels are significantly lower in post-menopause phase[14]
- Health issues to be aware of when women are going through menopause:
Female Athlete Triad[edit | edit source]
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 |
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 Impaired performance Delayed recovery |
Screening for RED-S and Female Athlete Triad
Menstruation is a vital sign
Investigate this in pre-participation screenings and any female athlete who presents for care
Screen for primary and secondary amenorrhea, dysmenorrhea and oligomenorrhea
Remember amenorrhea may indicate energy deficiency, may lead to osteoporosis and bone stress injuries. It may also be an indication that the athlete has an eating disorder.
Screen for the use of contraceptive medication that may affect menstrual cycles
Nutritional Intake Problems
Common mistakes include
Decreasing overall intake
Increase in high fibre/high protein foods
Cutting out particular types or categories of food
Screening questions:
Are foods being enjoyed for pleausre
Is time set our each day for appropriate fulleing
Is there variety in food intake
Is there awareness of hunger signals
Is there an awarenes of fullness
Body weight
Rapid decrease in body weight
loss of more than 10 percent of body weight in 3 months
loss of more than 5 percent of body weight in 1 month
Low percentage body fat
less than 12 percent body fat in females
less than 7 percent body fat in males
Expected weight. growth curves in paediatric and adolescent athletes
Body weight can be used as an estimate of low energy availability (LEA)
BMI drops below 17. 5
drop of body weight below 85 % of their body weight
greater than 10 percent loss of body weight in one month
Training changes
understand an athlete's normal / usual training routine
current training regime
any increases in
duration
intensity
competitions
frequency
Cultural and Social Determinants
Periods of fasting
Food culture
Food insecurity
Financial insecurity
Risk assessment tools
Female Athlete Triad Cumulative Risk Assessment
Modified female athlete triad cumulative risk assessment for males
RED-S Clinical Assessment Tool (RED-S CAT)
Low Energy Availability in Females Questionnaire (LEAF-Q)
LEAM-Q?
Prevention of RED-S
Education and increased awareness is necessary among athletes and healthcare professionals, coaches, trainers, managers
Female athletes have this notion that it is "normal" to have irregular menstrual cycles
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References[edit | edit source]
- ↑ Lee HS. Why should we be concerned about early menarche?. Clinical and experimental pediatrics. 2021 Jan;64(1):26.
- ↑ Howard SR. Interpretation of reproductive hormones before, during and after the pubertal transition—Identifying health and disordered puberty. Clinical Endocrinology. 2021 Nov;95(5):702-15.
- ↑ Kota AS, Ejaz S. Precocious puberty. InStatPearls [internet] 2022 Jul 4. StatPearls publishing.
- ↑ Lacroix AE, Gondal H, Shumway KR, Langaker MD. Physiology, menarche. InStatPearls [Internet] 2022 Mar 17. StatPearls Publishing.
- ↑ 5.0 5.1 5.2 Bell, J. Female Athlete Triad and Relative Energy Deficiency in Sport. Plus, Course. 2023.
- ↑ Critchley HO, Maybin JA, Armstrong GM, Williams AR. Physiology of the endometrium and regulation of menstruation. Physiological reviews. 2020 Apr 29.
- ↑ Zero to Finals. Understanding the Menstrual Cycle. Available from: https://www.youtube.com/watch?v=3Lt9I5LrWZw[last accessed 25/04/2023]
- ↑ Riaz Y, Parekh U. Oligomenorrhea. InStatPearls [Internet] 2021 Dec 28. StatPearls Publishing.
- ↑ Gasner A, Rehman A. Primary Amenorrhea. InStatPearls [Internet] 2021 Sep 8. StatPearls Publishing.
- ↑ Gibson ME, Fleming N, Zuijdwijk C, Dumont T. Where have the periods gone? The evaluation and management of functional hypothalamic amenorrhea. Journal of clinical research in pediatric endocrinology. 2020 Jan;12(Suppl 1):18.
- ↑ Ulin M, Ali M, Chaudhry ZT, Al-Hendy A, Yang Q. Uterine fibroids in menopause and perimenopause. Menopause (New York, NY). 2020 Feb;27(2):238.
- ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 Talaulikar V. Menopause transition: Physiology and symptoms. Best practice & research Clinical obstetrics & gynaecology. 2022 Mar 16.
- ↑ 13.0 13.1 Ambikairajah A, Walsh E, Cherbuin N. A review of menopause nomenclature. Reproductive health. 2022 Dec;19(1):1-5.
- ↑ Hyvärinen M, Juppi HK, Taskinen S, Karppinen JE, Karvinen S, Tammelin TH, Kovanen V, Aukee P, Kujala UM, Rantalainen T, Sipilä S. Metabolic health, menopause, and physical activity—a 4-year follow-up study. International Journal of Obesity. 2022 Mar;46(3):544-54.
- ↑ 15.0 15.1 Davis SR, Baber RJ. Treating menopause—MHT and beyond. Nature Reviews Endocrinology. 2022 Aug;18(8):490-502.
- ↑ National Institute of Aging. What is Menopause? Available from:https://www.youtube.com/watch?v=af-356SbCkY [last accessed 28/4/2023]
- ↑ National Institute of Aging. What are the Signs and Symptoms of Menopause? Available from: https://www.youtube.com/watch?v=_nMdn6EI6WA [last accessed 28/04/2023]