The female athlete triad consists of
the combination of disordered eating, amenorrhea, and osteoporosis.
Each factor is interdependent and the normal precursor is
frequent and intense athletic participation.
Disordered Eating
Anorexia Nervosa and Bulimia are the most
known forms of eating disorders because of their severity,
but there’s a range which starts simply with a preoccupation
with food or body image.
In our society it’s nearly impossible
to objectively examine nutritional habits and caloric intake
due to our over-emphasis on "thinness." Sports with
subjective judging are usually most correlated with female
nutritional problems, for example dancing, figure skating,
diving, and gymnastics. Although, sometimes these women starve
themselves, often times they are encouraged by their parents
or coaches to strive for a body built (stereotypically) exact
for their specific sport.
The prevalence of eating disorders ranges
from 15% to 62% depending on the sport. Athletes in sports
with weight classifications tend to be more prone to eating
disorders, for example martial arts and rowing. For maximum
performance the major factor is lean body mass, not percentage
body fat, and what often happens is during extreme dieting
muscle mass gets lost along with fat, resulting in hampered
performances.
Lots of times coaches and trainers advise
athletes on ideal body fat percentage by using underwater weighing
techniques, which is the traditional way to calculate body
composition, but based on a standard value for bone density.
The problem is that with women with amenorrhea and decreased
bone density these formulae with over-estimate the percentages
of body fat, forcing them to want to lose yet more weight.
0.5% to 1% of adolescent and young adult women have anorexia
nervosa, and 2% to 4% of them have bulimia. Over 90% of athletes
with anorexia or bulimia are adolescent girls and women. Anorexia
Nervosa was first described in the late 19th century and bulimia
was first defined in 1976.
Diagnostic Criteria For Anorexia
Nervosa
-
Refusal to maintain body weight at
or above a minimally normal weight for age and height.
-
Intense fear of gaining weight or
becoming fat, even though underweight.
-
Disturbance in the way in which one’s
body weight or shape is experienced, undue influence
of body weight or shape on self-evaluation, or denial
of the seriousness of the current low body weight.
-
In post-menarcheal females, amenorrhea,
ie, the absence of at least three consecutive menstrual
cycles.
Diagnostic Criteria For Bulimia Nervosa
-
Recurrent episodes of binge eating.
An episode of binge eating is characterized by both of
the following: 1. Eating, in a discrete period of time
(e.g., within any 2-hour period) an amount of food that
is definitely larger than most people would eat during
a similar period of time and under similar circumstances.
2. A sense of lack of control over eating during the
episode (e.g.. a feeling that one cannot stop eating
or control what or how much one is eating).
-
Recurrent inappropriate compensatory
behavior in order to prevent weight gain, such as self-induced
vomiting; misuse of laxatives, diuretics, enemas, or
other medications; fasting; or excessive exercise.
-
The binge eating and inappropriate
compensatory behaviors both occur, on average, at least
twice a week for 3 months.
-
Self-evaluation is unduly influenced
by body shape and weight.
-
The disturbance does not occur exclusively
during episodes of anorexia nervosa.
The consequences of eating disorders can
be from impaired performance to death. Women with untreated
anorexia and bulimia may die, 10% to 18% of these women may
die from suicide, blood chemical abnormalities, and cardiac
problems. Also, insufficient caloric intake can lead to menstrual
disturbances and subsequent osteopenia.
Athletic Amenorrhea
Excluding pregnant women amenorrhea is
present in up to 5% of the general population, and 10% to 20%
of intensely exercising women. The prevalence may reach upwards
of 50% for elite runners and professional ballet dancers. Normal
ovulatory function is directly correlated with the stress of
intense training.
Amenorrheic athletes are extremely likely
to have begun earlier than normally menstruating athletes.
Body fat used to be thought of as the sole reason for Amenorrhea,
but it is now known that body fat does play a role, but the
stress of training and nutritional status are equally important.
Amenorrhea is classified in two categories,
primary amenorrhea which is defined as no pubertal changes,
such as breast buds, by 14 years of age, or no menstrual bleeding
by the age of 16 years. Secondary amenorrhea is defined as
no menstrual cycles in a 6-month period in a woman who has
had at least one episode of menstrual bleeding.
Athletic amenorrhea is thought to be a
form of hypothalamic amenorrhea in which pulsatile gonadotropin
releasing hormone is deficient, absent, or inappropriately
secreted. Even without weight gain or change in body fat some
athletes have return of menses during intervals of rest. Normal
menstrual cycles may take months or years after stress is relieved
to be restored, and prolonged amenorrhea can cause osteoporosis.
Osteoporosis
In 1984, the loss of bone mineral in the
spines of young amenorrheic athletes was first described by
Cann and associates. During adolescence if a young female athlete
is amenorrheic and doesn’t lay down a normal amount of
bone at this time, she may always have decreased bone mass.
Restoration of normal menses may retard the rate of further
bone loss, but the bone already lost is not replaced, and as
a result these women are at risk for future hip and spine fractures.
As a result even in the present when a young female athlete
presents with a stress fracture, a consideration must be the
possibility of early osteoporosis related to amenorrhea.
History and Physical Examination
Body weight history, nutritional history,
and menstrual history are all essential when treating young
female athletes. The age of menarche, frequency and duration
of menstrual periods are things that needed to be questioned
when inquiring about menstrual history. Also, the date of the
last menstrual period and the use of hormonal therapy should
be questioned. Nutritional history should include a 24 hour
recall of food intake, the usual number of meals and a list
of forbidden foods. Lastly, body weight history should include
the highest and lowest weight ever of the athlete.
Treatment
Treating the female athlete triad is very
difficult and requires a group or team approach. Treatment
often consists of physicians, a nutrition specialist, and either
a psychologist or a psychiatrist. When the athlete is in high
school or college, the athletic trainer, team doctor, and coach
should also participate in treatment. The team physician is
in ideal position to screen for any eating disorders and abnormal
menses during pre-participation physicals.
The orthopaedic surgeon should be very
aware of the athletic triad when dealing with stress fractures
and there’s no history of overuse. Counseling and nutritional
assessment should be given from someone who understands athletics
and caloric requirements. An adequate diet is more than just
the appropriate amount of caloric intake, but also 1,500mg
of calcium per day. Depending on the athlete a physician may
need to regulate when it is safe to get back to participating
in sports.
Psychological help and counseling may be
needed as well, especially if there’s a true eating disorder,
such as anorexia or bulimia. Counseling is really beneficial
because stress reduction techniques are particularly useful
in the competitive athlete because it often helps relieve performance
anxiety.
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