Female athlete triad
Female Athlete Triad is a syndrome in which eating disorders (or low energy availability)[1], amenorrhoea/oligomenorrhoea and decreased bone mineral density (osteoporosis and osteopenia) are present[2] Also know simply as the Triad, this condition is seen in females participating in sports that emphasize leanness or low body weight.[3] The Triad is a serious illness with lifelong health consequences and can potentially be fatal.[4]
Contents
Triad Components
Low Energy Availability
Energy availability is defined as energy intake minus energy expended. Energy is taken in through food consumption. Our bodies expend energy through normal functioning as well as through exercise. In the case of female athlete triad, low energy availability may be coupled with eating disorders, but not necessarily so. Athletes may experience low energy availability by exercising more without a concomitant change in eating habits, or they may increase their energy expenditure while also eating less.[2]
While most athletes do not meet the criteria to be diagnosed with an eating disorder such as anorexia nervosa or bulimia nervosa, many will exhibit disordered eating habits.[4] Some examples of disordered eating habits are fasting; binge-eating; purging; and the use of diet-pills, laxatives, diuretics, and enemas.[2] By restricting their diets, athletes worsen the problem of low energy availability.
Having low dietary energy from excessive exercise and/or dietary restrictions leaves too little energy for the body to carry out normal functions such as proceeding through a regular menstrual cycle or conducting bone maintenance.[2]
Amenorrhea
Amenorrhea, defined as the cessation of a woman’s menstrual cycle for more than three months, is the second disorder in the Triad. Weight fluctuations from dietary restrictions and/or excessive exercise affect the hypothalamus’s output of gonadotropic hormones. Gonadotropic hormones “stimulate growth of the gonads and the secretion of sex hormones.”[5] (e.g. gonadotropin-releasing hormone, lutenizing hormone and follicle stimulating hormone.) These gonadotropic hormones play a role in stimulating estrogen release from the ovaries. Without estrogen release, the menstrual cycle is disrupted.[6]
There are two types of amenorrhea. A woman who has been having her period and then stops menstruating for ninety days or more is said to have secondary amenorrhea. Primary amenorrhea is characterized by delayed menarche. Menarche is the onset of a girl’s first period. Delayed menarche may be associated with delay of the development of secondary sexual characteristics.[2]
Osteoporosis
Osteoporosis is defined by the National Institutes of Health as ‘‘a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.’’[7]
Immediate Effects of Low Bone Density. Patients with female athlete triad get osteoporosis due to hypoestrogenmia, or low estrogen levels which is part of amenorrhea. With estrogen deficiency, the osteoclasts live longer and are therefore able to resorb more bone. In response to the increased bone resorption, there is increased bone formation and a high-turnover state develops which leads to bone loss and perforation of the trabecular plates.[8] As osteoclasts break down bone, patients see a loss of bone mineral density. Low bone mineral density renders bones more brittle and hence susceptible to fracture. Because athletes are active and their bones must endure mechanical stress, the likelihood of experiencing bone fracture is particularly high.[2]
Additionally, because those suffering with female athlete triad are also restricting their diet, they may also not be consuming sufficient amounts vitamins and minerals which contribute to bone density; not getting enough calcium or vitamin D further exacerbates the problem of weak bones.[4]
Long Term Effects of Low Bone Density. Bone mass is now thought to peak between the ages of 18-25. Thus, behaviors which result in low bone density in youth could be detrimental to an athlete’s bone health throughout her life time.[4]
At Risk Populations
Gymnastics, figure skating, ballet, diving, swimming, and long distance running are examples of sports which emphasize low body weight. The Triad is seen more often in aesthetic sports such as these versus ball game sports. Women taking part in these sports may be at an increased risk for developing female athlete triad.[4]
Identification and Treatment
Symptoms of the Triad
Clinical symptoms of the Triad may include disordered eating, fatigue, hair loss, cold hands and feet, dry skin, noticeable weight loss, increased healing time from injuries, increased incidence of bone fracture and cessation of menses. Affected female may also struggle with low-self esteem and depression.[9]
Upon physical examination, a physician may also note the following symptoms: elevated carotene in the blood, anemia, orthostatic hypotension, electrolyte irregularities, hypoestrogenism, vaginal atrophy, and bradycardia.[2][4]
Treatment
Multidisciplinary Approach. Athletes diagnosed with female athlete triad should be treated using a multidisciplinary approach. Patients are recommended to work with a dietician who can monitor their nutritional status and help the patient work towards a healthy goal weight. Patients should also meet with a psychiatrist or psychologist to address the psychological aspects of the Triad. Finally, it is generally recommended that athletes reduce the amount of time they spend exercising by 10-12 percent. Therefore, it is important that trainers and coaches are made aware of the athlete’s condition and be part of her recovery.[4]
Pharmacologic Treatment. Patients are also sometimes treated pharmacologically. To both induce menses and improve bone density, doctors may prescribe cyclic estrogen or progesterone as is used to treat post-menopausal women. Patients may also be put on oral contraceptives to stimulate regular periods. In addition to hormone therapy, nutrition supplements may be recommended. Doctors may prescribe calcium supplements. Vitamin D supplements may be also used because this vitamin aids in calcium absorption. Bisphosphonates and calcitonin, used to treat adults with osteoporosis, may be prescribed, although their effectiveness in adolescents has not yet been established. Finally, if indicated by a psychiatric examination, the affected athlete may be prescribed anti-depressants and in some cases benzodiazepines to help in alleviating severe distress at mealtimes.[4]
See also
References
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