Female Athlete Triad

Original Editors - Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - James Chad Cissell, Michelle Walsh, Ethan Adams, Aarti Sareen, Lucinda hampton, Wanda van Niekerk, Regan Haley, Kim Jackson, Nicole Hills, Elaine Lonnemann, 127.0.0.1, Oyemi Sillo, WikiSysop, Adam Vallely Farrell, Claire Knott and Rishika Babburu  

Introduction

Ballet dancers at risk

The female athlete triad comprises three medical conditions, and is seen commonly in active teen girls:

• Energy imbalance with or without an eating disorder
• Menstrual disturbances
• Decreased bone mineral density with or without osteoporosis

The components of the female athlete triad are interconnected:

• Disordered eating leads to inadequate nutrition.
• Inadequate nutrition affects the production of hormones such as estrogen.
• Estrogen has an important role in bone development, low levels of estrogen leads to weakened bones and increasing the risk of injury.

The below 2 minute video gives a good overview of the condition.

Epidemiology

Studies suggest that between 15-62% of the female athletic population exhibit disordered eating behaviours. Amenorrhea among female athletes range between 3-66%, depending on the definition that is used.

Gymnasts: risk group

Risk Factors

Those at greatest risk are girls involved in sports in which performance is scored subjectively, a low bodyweight is a focus, figure hugging clothing is required for competition, weight categories are used for participation and an immature body is seen as better for performance.

• Categories of athletes at risk include: runner, dancers, gymnastics, figure skaters.
• At greater risk are highly competitive athletes.
• Younger individuals are greatly impacted by the non-reversible, long-term consequences of this syndrome. In fact, a study on animals found that low energy availability can decrease growth and hinder sexual development.

Mechanisms

Becoming aware of how each component can develop and present itself will aid healthcare providers and other stakeholders in sport in the early recognition of the female athlete triad. The Three components comprise:

Low Energy Availability With or Without an Eating Disorder. A low energy availability (EA) can be due to decreased dietary energy intake and/or increased energy expended during exercise and, when EA is low, this leads to less energy available for body functions.

• Some athletes may participate in restrictive diets or use pills or laxatives.
• Other athletes may have a diagnosis of an eating disorder (eg Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder) e Eating disorders can cause many problems, including dehydration, muscle fatigue and weakness, an erratic heartbeat, kidney damage, osteoporosis and hormone imbalances.

Menstrual Dysfunction: include:

1. Primary amenorrhea: pre-adolescent who hasn’t had a menstrual period by the age of 16 or has gone two years following the development of secondary sex characteristics without menarche. Eating disorders may be the cause.
2. Secondary amenorrhea: menstruation ceases for three months or longer in a woman who has previously had normal menstruation. An integral part of anorexia nervosa.
3. Oligomenorrhea: menstrual cycle occurs at irregular intervals.

Low Bone Mineral Density: Bone is a dynamic structure, constantly being remodelled by osteoclasts and osteoblasts. Female athletes, functioning at a low estrogen state, have less osteoblastic activity. Athletes require 5% to 15% higher bone mineral density than age-matched nonathlete, with reduced bone mineral density increases bone fragility and increase the risk of fractures. Stress fractures occurence is greater in amenorrheic athletes, and bone density has been shown to progressively decrease as the number of menstrual cycles missed since menarche increases.

Manifestations (including systemic involvement)

• Weight loss
• Absent or irregular menstrual cycles (includes primary and secondary amenorrhea, as well as oligomenorrhea)
• Chronic fatigue
• Fractures without significant trauma (low force cause); most common location is the tibia
• Compulsive exercise
• Increased infections and illnesses
• Decreased ability to recovery from injuries (slower tissue repair)
• Anxiety and depression
• Nutrient deficits
• Esophagitis and oesophageal perforation if self-induced vomiting
• Constipation
• Changes in thyroid function, appetite, decrease in insulin, increase in cortisol, and resistance to growth hormones
• Increased cardiovascular risk (including atherosclerosis) due to increase in bad lipids and endothelial dysfunction
• Decreased resting metabolic rate and slowed growth
• Impaired athletic performance and reduced muscle mass
• Vaginal dryness

Screening

The 2014 Female Athlete Triad Coalition Consensus (Triad Coalition) Statement on Treatment and Return to Play of the Female Athlete Triad, by De Souza and colleagues (2014), identified the following 9 questions that adolescent females should be asked as part of the PPE to screen for the Triad:  

• "Have you ever had a menstrual period?"
• "How old were you when you had your first menstrual period?"
• "When was your most recent menstrual period?"
• "How many periods have you had in the past 12 months?"
• "Are you presently taking any female hormones (estrogen, progesterone, birth control pills)?"
• "Do you worry about your weight?"
• "Are you trying to or has anyone recommended that you gain or lose weight?"
• "Are you on a special diet or do you avoid certain types of foods or food groups?"
• "Have you ever had an eating disorder?"
• "Have you ever had a stress fracture?"
• "Have you ever been told you have low bone density (Osteopenia or Osteoporosis)?"

Management

When approaching the Triad with an affected athlete it is important to recognize this may be a sensitive topic. Treatment requires a multidisciplinary approach. The team may be comprised of various healthcare providers including a physician, registered dietitian, mental health practitioner, physiotherapist (and/or athletic trainer or exercise physiologist), and coach. While interventions can have both pharmacological and non-pharmacological components, non-pharmacological treatment methods are to be the initial course of action. Pharmacological interventions should be considered if there is no improvement after a year of non-pharmacological intervention and/or the athlete has a relevant history of fractures.

Pharmacological interventions: may include oral contraceptives, gonadal steroids (estrogen, progesterone, and testosterone), other bone restorative medications, recombinant parathyroid hormone, antidepressants. However pharmacological interventions should not be a first-line therapy. There is a lack of evidence to support them.

Non-pharmacological interventions. Low energy availability (EA) is generally directly related to menstrual dysfunction and low bone mineral density (BMD) so it is addressed first and foremost. Depending on the cause of low EA, the athlete should be referred to a sports dietitian for nutritional education and counselling. If there is suspicion of a clinical eating disorder, the athlete should be referred to a mental health professional for psychological treatment. Depending on the severity, inpatient treatment may be needed. Energy expenditure may also need to be altered by reducing or ceasing exercise. It is believed that normalizing body weight will promote the return of menses and improve bone health. When it comes to low BMD, addressing low EA, increasing body weight, having a regular menstrual cycle, and ensuring adequate calcium and vitamin D are recommended.

Role for Physical Therapy in Management

A study by Pantano (2009) involved 205 physiotherapists and found that 61% self-reported having knowledge of the triad and all 3 of its components. However, when actively assessed, only 21% knew the spectrum. Pantano (2009) concluded that physiotherapists need to play a larger role in the prevention of the triad. Physiotherapists possess the knowledge and skills to help prevent a condition from happening in the first place or increasing in severity. They also help maintain and restore function in those dealing with particular conditions. 

Through presentations and discussions, physiotherapists can educate stakeholders in sport on the importance of adopting healthy behaviours and the role physiotherapy plays in preventing and treating the triad. As mentioned earlier on this page, screening athletes is very important. If there is suspicion of any triad component, the athlete should be referred onwards to a physician, dietitian, and/or mental health professional for further investigations. This may require the physiotherapist to advocate for their patients. 

Physiotherapists can play a role in assessing, modifying and monitoring an athlete’s activity, such that they can help place less focus on cardiovascular training. Case studies have shown improvements in bone health after athletes with amenorrhea gained some weight, but it is not likely that this will restore BMD by itself. Resistance exercises, including weight-training, should also be incorporated 2-3 days a week. While simple low-impact weight-bearing exercise has been shown to increase BMD during menopause, it is likely not enough for younger athletes. Additionally, high-impact sports, including running, may increase an athlete’s risk of developing stress fractures if they do not have adequate BMD to withstand the repeated forces. Lastly, it is also important to note that physiotherapists have the knowledge and skills to recognize and manage stress fractures and osteoporosis. See American College of Sports Medicine Position Stand: Physical Activity and Bone Health. 

As part of a multidisciplinary team, physiotherapists will work closely with others to determine an athlete’s readiness to return-to-play. If the athlete is not ready to fully return-to-play it is recommended athletes receive a written contract from the physician. The physician will work with each multidisciplinary team member to develop treatment goals and a plan that will allow the athlete to progress. Prior to 2014, there were no guidelines on clearing an athlete, but something like the Clearance and Return-to-Play Guidelines by Medical Risk Stratification, or the Decision-Based Return-to-Play model could be incorporated. Click here to access the article and resources for return-to-play.

Prevention

Preventing the triad requires proper education. Coaches, athletic trainers, parents and athletes need to be informed about the female athlete triad.

• Mandate annual screening of the triad for female athletes/dancers
• Mandate preseason education
• Mandate education for parents of athletes who are 18 years of age or younger
• Mandate education for coaches and athletic trainers
• Promote healthy stress-management behaviors and tactics
• Promote community awareness of the triad through educational programs