FEMALE ATHLETE TRIAD Dr Willa Fornetti DO MS

FEMALE ATHLETE TRIAD Dr. Willa Fornetti, DO, MS Primary Care Sports Medicine Non Operative Orthopedics

Female Athlete Case • 15 year old female cross country runner • Complains of left lateral knee pain • 6 weeks ago gradual onset with running when her season started • Height 5 ft. , 6 in, Weight 110 lbs. , BMI is 18 • Prior bilateral knee pain, shin splints, Achilles pain in the pas • She doesn’t know how often she gets her menses but “not every month”

Female Athlete Triad Overview • • • History of Women in Sports Benefits of Exercise Female Athlete Triad Risk factors Prevalence Health consequences Screening and diagnosis Treatment Summary

Women in Sports • In 1972, Title IX significantly changed women’s participation in sports. • Educational amendment meant to provide more educational opportunities for women. • Created equal opportunity for sports • Schools had to offer scholarships and provide the same access to coaching, equipment and facilities “No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving federal financial assistance. ”

Women in Sports • High School Athletes – Before Title IX, fewer than 300, 000 high school girls (1 in 27) played sports – Now there is 3 million high school girls (1 in 2) play sports • Collegiate Athletes – Mid 1970 s fewer than 32, 000 women competing in intercollegiate sports – In 2010 -2011 there were 191, 000 (through the NCAA)

Benefits of Exercise • Many health benefits! • Female athletes do better in school and have a higher graduation rate • More likely to obtain advanced degrees • More likely to hold leadership roles • Decreased high risk behavior – Less likely to smoke or use drugs – Less teen age pregnancies

Women in Sports • Sports are a great way for women to build strong healthy bodies, self esteem and a life-love of physical activity. • For some exercise becomes pathologic and detrimental to a woman’s health. • Female athlete triad is a serious health concern that has been identified among athletes.

Female Athlete Triad Defined • In the 90 s: – disordered eating – amenorrhea – osteoporosis • 2007 and today: – low energy availability (with or without eating disorder) – menstrual dysfunction – altered bone mineral density

The Female Athlete Triad Defined

Female Athlete Triad Defined Energy Availability Disordered Eating Menstrual Function Bone Mineral Density (BMD)

Female Athlete Triad Energy Availability • Defined as dietary energy intake minus exercise energy expenditure • Energy availability is the amount of dietary energy remaining for other body functions after exercise. • Food In – Activity Out = “left over” energy used for physiologic function

Female Athlete Triad Energy Availability • Athletes who are not aware of nutritional needs for their body – Intake is inadvertently restricted – Intake doesn’t match expenditure – Inadequate education regarding energy requirements • Eating Disorders – Anorexia – Bulimia – Eating disorder NOS

Female Athlete Triad Criteria for Anorexia Nervosa • Refusal to maintain body weight at or above a minimally normal weight for age and height (body weight less than 85% of that expected). • 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 postmenarcheal females, amenorrhea, i. e. , the absence of at least three consecutive menstrual cycles.

Female Athlete Triad Anorexia Nervosa • Patients are usually between the age of 12 yrs and the mid-thirties • 90 to 95 % female • Majority are Caucasian, middleclass or upper-middle class families. • The mortality associated with anorexia has been reported to be as high as 9 percent – secondary to cardiac arrhythmia due to electrolyte abnormalities – and/or diminished heart muscle mass • Suicide has also been more common (2 to 5%) in patients with anorexia nervosa.

Female Athlete Triad Criteria for Bulimia Nervosa • Recurrent episodes of binge eating. • Eating larger amounts in a 24 hour period that is larger than most people. • Sense of lack of control over eating during the binge episodes. • Recurrent inappropriate compensatory behavior in order to prevent weight gain – Purging- self induced vomiting, misuse of laxatives, diuretics and enemas – Non Purging- fasting, 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

Female Athlete Triad Eating Disorder NOS • For disorders of eating that do not meet the criteria for any specific eating disorder: – Criteria for Anorexia Nervosa are met except that the individual has regular menses – Criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual’s current weight is in the normal range – Criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency less than twice a week or for a duration of less than 3 months – Regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food – Repeatedly chewing and spitting out, but not swallowing, large amounts of food – Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa

Female Athlete Triad

Female Athlete Triad Normal Menses

Female Athlete Triad Menstrual Dysfunction • When you do not eat enough calories, hormones from the hypothalamus and pituitary will not be released • These hormones normally signal the ovaries to make estrogen and progesterone and menstrual cycles occur • Estrogen is necessary for bones to grow stronger http: //www. endotext. org/female 5/female 5. htm

Female Athlete Triad Menstrual Dysfunction • Amenorrhea- absence of menses > 3 months – Primary- delay in age of menarche – Secondary- occurs after onset of menarche (most common, important to rule out pregnancy) • • • Oligomenorrhea- cycles greater than 35 days Anovulation- menses without ovulation Luteal phase suppression Delayed menarche often occurs in athletes Cause of exercise induced menstrual dysfunction is due to decreased energy input

Female Athlete Triad Menstrual Dysfunction • Menstrual dysfunction may be the first detectable problem • Not having menstrual cycles is NOT NORMAL • They should see their primary care physician or OB/GYN for diagnostic evaluation • Contact their physician with your concerns

Female Athlete Triad

Female Athlete Triad Bone Health

Female Athlete Triad Bone Mineral Density (BMD) • BMD is measured by DEXA • Post menopausal women – Hip and lumbar spine measured – Use T scores • > -1 normal • -1 to -2. 5 osteopenia • < - 2. 5 osteoporosis • Young athletes – Whole body scans – Use Z scores

Female Athlete Triad Determinants of Bone Mineral Density • Genetics (60 -80%) • Exercise and physical activity • Hormones • Nutrition • Smoking, drugs and alcohol

Female Athlete Triad Bone Mineral Density • Peak Bone Mass is achieved between 18 -25 yrs

Female Athlete Triad Bone Mineral Density • Bone is a living, dynamic tissue that is constantly remodeling • Loaded bone remodels to become stronger • Athletes in weight bearing sports usually have a 5 -15% higher BMD than non athletes • Bone strength and fracture risk depend on density and quality of bone

Female Athlete Triad Bone Mineral Density Mudd LM, Fornetti W, Pivarnik JM. Bone mineral density in collegiate female athletes: comparisons among sports. J Athl Train 2007; 42: 403 -8.

Female Athlete Triad Bone Health Consequences • Peak bone mass is achieved between 18 -25 yrs • After age 25 years women loss bone mass at 0. 3 -0. 5% annually • Lose approximately 2% of BMD per year of amenorrhea or oligomenorrhea instead of gaining the typical 2 -4% of bone mass • Loss of BMD may not be reversible • Relative risk for stress fractures 2 -4 x greater in amenorrheic than eumenorrheic athletes

Female Athlete Triad Bone Mineral Density • Peak Bone Mass is achieved between 18 -25 yrs.

Female Athlete Triad

Female Athlete Triad Risk Factors • • Thin build body type sports Restrictive dietary intact Exercise excessively Vegetarian Limit types of food Low self esteem Family dysfunction Abuse

Female Athlete Triad Prevalence of Low Energy Availability • Prevalence of low energy availability with or without eating disorders is unknown • Disordered Eating NOS – 28 -65% prevalence of dietary restriction, binge eating and/or purging behaviors among thinbuild athletes • Eating disorders – 25 -31% prevalence among athletes in thin-build sports – 5 -9% in the general population

Female Athlete Triad Prevalence of Exercise Menstrual Dysfunction • Depending on the type of sport and competition level, the incidence varies • Secondary Amenorrhea – 24% to 26% in female athletes – 2 -5% in the general population • Greatest incidence for sports that favor a low body weight physique – ballet (6 -69%) – runners (24 -65%)

Female Athlete Triad Prevalence of Decreased Bone Mineral Density • Higher prevalence reported among athletes with disordered eating and/or amenorrhea • Osteopenia (T score -1 to 2. 5) – 22 -50% prevalence among female athletes – 12% in the general population • Osteoporosis (T score less than -2. 5) – 0 -13% prevalence reported among female athletes – 2. 3% in the general population • Many studies have been using T score and not the recommended Z score

Female Athlete Triad Prevalence • Studies have shown that prevalence of all three components of the triad is small – 1% to 4% • You do not need all 3 components to have adverse health effects • If one component detected then screen for the rest

Female Athlete Triad Health Consequences • Negative consequences to current • Increased risk of future osteoporosis and fractures and future bone health – Stress Fractures • Impaired future fertility – Delayed healing of fractures • Cardiac Arrhythmias • Gastrointestinal disorders • Death • Nutrient deficiencies • Excessive Fatigue • Increased Recovery Time • Decreased Training Responses or Adaptations • Decreased or Impaired Performance

Female Athlete Triad Screening and Diagnosis • Screening can occur any time an athlete is evaluated • History– – – Past medical Past surgical Medications Menstrual Psychological • Nutritional assessment • Exercise History – Exercise patterns – Training intensity – Additional exercise outside training – History of injuries

Female Athlete Triad Physical Exam Signs of Anorexia • • • Bradycardia Hypotension Lanugo Hypothermia Cold intolerance Yellow Skin Dry hair and skin Alopecia Pruritus

Female Athlete Triad Physical Exam Signs for Bulimia • • • Fatigue Abdominal pain Chest pain Swollen parotid Sore throat/esophagitis • • • Erosion of tooth enamel Knuckle scars/callus Constipation Bloodshot eyes Petechiae of sclera

Female Athlete Triad Lab Tests and Imaging Studies • Electrolytes, Complete blood count, Sed rate, Thyroid function, Liver function, Urinalysis • Plain radiographs • 3 -phase bone scan or MRI for stress fractures • DEXA scan – If amenorrheic for >1 year – BMI less than 18 – History of a stress fracture. • If abnormal pituitary function, MRI of head • Pelvic ultrasound • EKG if resting heart rate is less than 50

Female Athlete Triad Treatment Team • Athletic Trainer • Primary Care Sports Medicine Physician • Sports Psychologist • Nutritionist • Family • Coaches

Female Athlete Triad Treatment • Treatment for acute orthopedic and medical problems • Counseling, Therapy • Rehabilitation • Lifestyle Modifications • Restoring Energy Deficit

Female Athlete Triad Treatment • CORRECTION OF ENGERY DEFICIT!!! • Decreasing intensity of exercise and increasing nutritional intake – Weight gain of 2. 5 to 5 lbs – 10% decrease in exercise load (duration or intensity) • Birth control pills are no longer recommended • Bisphonates not advised for young women • Antidepressants for bulimia, anorexia, depression and anxiety disorders

Female Athlete Triad Return to Play Can continue to play while in treatment Activity modifications with close monitoring Restrict private workouts Withdrawal from activity should not be used as a form of punishment for noncompliance • Difficult cases, resumption of physical activity when the athlete is 10 -15% of ideal body weight. • •

Case Revisited • She’s been told she is “too thin” – She has seen a gynecologist for irregular menses – She denies any abnormal eating behaviors • Counseling and Education • Contacted her primary care physician • Physical therapy for ITB syndrome • She gained 6 lbs in our 8 week f/u visit

Female Athlete Triad Summary • Watch for components of the triad – low energy availability (with or without eating disorder) – menstrual dysfunction – altered bone mineral density • Occurs across a spectrum • Energy availability is key • Menstrual dysfunction may be more easily detectable

Female Athlete Triad Summary • Certain sports have a higher incidence of problems • Early Intervention • Treatment with a medical team approach • Comprehensive evaluation with close monitoring • Education and Prevention

Female Athlete Triad References • ACSM Information Brochure: http: //www. acsm. org/docs/brochures/the-female-athlete-triad. pdf • Female Athlete Issues for the Team Physician: A Consensus Statement. MSSE 2003; 1785 -1791. • http: //www. endotext. org/female 5/female 5. htm • http: //www. femaleathletetriad. org/ • Mudd LM, Fornetti W, Pivarnik JM. Bone mineral density in collegiate female athletes: comparisons among sports. J Athl Train 2007; 42: 403 -8. • Nutrition and Athletic Performance: http: //journals. lww. com/acsm-msse/toc/2009/03000 pages 709 -731 • The benefits of physical activity. Centers for Disease Control and Prevention. http: //www. cdc. gov/physicalactivity/everyone/health/index. html • The Female Athlete Triad Position Statement: http: //journals. lww. com/acsmmsse/toc/2007/10000 pages 1867 -1882

Female Athlete Triad Questions? ? ?