The Female Athlete Triad Continuum The ACSM Position Stand

1. The Female Athlete Triad ContinuumThe ACSM Position Stand Lauren Stephenson, MA, ATC Sports Medicine Update June 14, 2013

2. Female Athlete Triad • Recognized 1992 • American College of Sports Medicine (ACSM) • Association between: • Disordered Eating • Amenorrhea • Osteoporosis • Prevalent in activities that emphasize lean physique

3. Prevalence of Female Athlete Triad • Disordered Eating • 25-31% in sport that emphasizes leanness • 5.5-9% in control • Bone Mineral Density • Osteopenia 22-50% • 12% Control • Osteoporosis 0-13% • 2.3% Control • Primary Amenorrhea • >22% Cheerleading, Diving, & Gymnastics • Secondary Amenorrhea • 69% Dancers • 65% Distance Runners • 2-5% Control

4. Female Athlete Triad Continuum Optimal Energy Availability Reduced Energy Availability with or without an Eating Disorder Eumenorrhea Optimal Bone Health Low Energy Availability with or without an Eating Disorder Subclinical Menstrual Disorder Low BMD Healthy Unhealthy Functional Hypothalamic Amenorrhea Osteoporosis (ACSM, 2007)

5. Healthy Female Athlete

6. Healthy Female Athlete • Adjusts energy intake to reflect energy expenditure • Energy aids in bone health & development by preserving eumenorrhea • Estrogen restrains bone resorption • High Bone Mineral Density Optimal Energy Availability Optimal Bone Health Eumenorrhea

7. Unhealthy Female Athlete

8. Unhealthy Female Athlete Low Energy Availability With or Without Eating Disorder • Exercises for prolonged periods • Does not increase energy intake • Restrict diet • Clinical eating disorders • Limits bone development by inducing amenorrhea • Less estrogen leads to increased bone resorption • Low bone mineral density Osteoporosis Amenorrhea

9. Three Interrelated Spectrums • Energy Availability • With or Without Eating Disorders • Menstrual Function • Bone Health

10. Female Athlete Triad Continuum Optimal Energy Availability Reduced Energy Availability with or without an Eating Disorder Eumenorrhea Optimal Bone Health Low Energy Availability with or without an Eating Disorder Subclinical Menstrual Disorder Low BMD Healthy Unhealthy Functional Hypothalamic Amenorrhea Osteoporosis (ACSM, 2007)

11. Energy Availability Energy Availability = Energy Intake – Exercise Energy Expenditure Amount of dietary energy left for body functions after exercise

12. Menstrual Function

13. Bone Mineral Density (BMD) • Osteoporosis • A skeletal disorder characterized by compromised bone strength predisposing an individual to increased risk of fracture • International Society for Clinical Densitometry recommendation: BMD scores less than Z= -1.0 compared to age/sex matched athletes (5-15% higher BMD) should be investigated further

14. BMD Z-Scores

15. Associated Health Issues • Depression • Anxiety • Cardiovascular Issues • Renal Issues • Infertility • Decreased muscle perfusion • Impaired skeletal muscle metabolism • Elevated LDL • Stress fractures • Gastrointestinal Issues • Endocrine Issues • CNS Issues • Inability to reach peak BMD potential • Death

16. Prevention & Treatment

17. Prevention Strategies • Education • Optimize energy availability • Maximize bone mineral gains • Nutritional counseling • Calcium & vitamin D • Benefits of weight bearing exercise • Policies & procedures for harmful weight loss practices

18. NATA Recommended Prevention Strategies • De-emphasize weight • Emphasis on weight or thinness/leanness will likely increase the risk of disordered eating. • De-emphasis will likely have the converse effect. • Recognize individual differences in athletes • By focusing on the athlete's individual differences, the likelihood of enhanced performance for each athlete can be increased • Education • Education should be made available to everyone involved • Coaches remain instrumental in the detection of the triad, therefore education is key. • Involvement by Sport Governing Bodies

19. Nonpharmacological Treatment • Increase dietary energy intake to 3,000-4,500 calories • Nutrition & Psychological Counseling • Increase Calcium & Vitamin D • Increase Protein • Those with disordered eating must meet participation criteria • Comply with all treatment strategies • Maintain close monitoring by health-care professionals • Precedence of treatment of training & competition • Modify type, duration & intensity of training

20. Pharmacological Treatment • Antidepressants • No significant benefit in those with continued decrease in BMI with • Hormone Replacement Therapy (HRT) • Oral Contraceptive Pill (OCP) • May restore menstrual cycle • Does not normalize factors that effect bone formation • Should not use biophosphates (used to treat osteoporosis in postmenopausal women) • No proven efficiency in women of child-bearing age • Potential harm to developing fetus

21. Conclusion Optimal Energy Availability Reduced Energy Availability with or without an Eating Disorder Eumenorrhea Optimal Bone Health Low Energy Availability with or without an Eating Disorder Subclinical Menstrual Disorder Low BMD Healthy Unhealthy Functional Hypothalamic Amenorrhea Osteoporosis (ACSM, 2007)