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2015 Sports Medicine for the Primary Care Physician

This presentation discusses the female athlete triad, focusing on low energy availability, menstrual dysfunction, and low bone density. It covers components of the triad, screening tools, and treatment options for healthcare providers. The spectrum of the female athlete triad is explored, detailing how low energy availability impacts athletes' health. It also delves into the various diagnostic methods like the McLaren Method, Moore Method, and BMI Method for assessing energy availability in athletes. The presentation further examines menstrual dysfunction, including primary and secondary amenorrhea, and highlights the importance of bone density testing in high and moderate-risk individuals. With a detailed overview of the triad, this resource equips primary care physicians with valuable insights into managing female athletes' health effectively.

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2015 Sports Medicine for the Primary Care Physician

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  1. 2015 Sports Medicine for the Primary Care Physician

  2. Female Athlete Triad Christina Nisonger Murphy, MD

  3. Disclosure Slide • No financial disclosures.

  4. Objectives • Define female athlete triad • Components of female athlete triad • Treatment of female athlete triad • Screening tools

  5. Female Athlete Triad • Low energy availability with or without disordered eating • Menstrual dysfunction • Low bone mineral density

  6. Spectrum of Female Athlet Triad

  7. Low Energy Availability • Does not require an eating disorder • Inadequate caloric intake: • Pathologic caloric restriction • Expending more calories than are taken in

  8. Calculating Energy Availability • Normal > 45 kcal/kg • Negative effects at ≤ 30 kcal/kg • BMI < 17.5 suggests low energy availability • Adolescents < 85% Estimated Body Weight Calories consumed – Calories expended Energy Availability = Lean Body Mass (kg)

  9. EBW - McLaren Method • 17 yoF 5’ 2”, 90 pound Track athlete Weight 50%ile Weight/Height %EBW = X 100

  10. EBW - McLaren Method • 17 yoF 5’ 2”, 90 pound Track athlete Weight 50%ile Weight/Height %EBW = X 100 102

  11. EBW - McLaren Method • 17 yoF 5’ 2”, 90 pound Track athlete Weight 50%ile Weight/Height %EBW = X 100 90 102 %EBW = X 100 102 %EBW = 88%

  12. EBW - McLaren Method • 17 yoF 5’ 2”, 90 pound Track athlete Limitations: - cannot calculate EBW for: girls >163 cm (5’ 4”) boys >176 cm (5’ 9”) Weight 50%ile Weight/Height %EBW = X 100 90 102 %EBW = X 100 102 %EBW = 88%

  13. EBW – Moore Method • 17 yoF 5’ 2”, 90 pound Track athlete Weight Matched %ile Weight %EBW = X 100

  14. EBW – Moore Method • 17 yoF 5’ 2”, 90 pound Track athlete Weight Matched %ile Weight %EBW = X 100

  15. EBW – Moore Method • 17 yoF 5’ 2”, 90 pound Track athlete Weight Matched %ile Weight %EBW = X 100 90 108 %EBW = X 100 108 %EBW = 83%

  16. EBW – Moore Method • 17 yoF 5’ 2”, 90 pound Track athlete Limitations: - cannot easily be used for: >97th percentile < 3rd percentile Weight Matched %ile Weight %EBW = X 100 90 108 %EBW = X 100 108 %EBW = 83%

  17. EBW – BMI Method • 17 yoF 5’ 2”, 90 pound Track athlete • BMI 16.5 BMI 50th Percentile BMI %EBW = X 100

  18. EBW – BMI Method • 17 yoF 5’ 2”, 90 pound Track athlete • BMI 16.5 21 BMI 50th Percentile BMI %EBW = X 100

  19. EBW – BMI Method • 17 yoF 5’ 2”, 90 pound Track athlete • BMI 16.5 BMI 50th Percentile BMI %EBW = X 100 21 16.5 21 %EBW = X 100 %EBW = 78%

  20. Spectrum of Female Athlete Triad

  21. Menstrual Dysfunction • Primary amenorrhea • Secondary amenorrhea • Oligomenorrhea (<9 menses/12 months)

  22. Secondary Amenorrea Secondary Amenorrhea TSH, Prolactin, beta-hCG Abnormal TSH Elevated Prolactin Normal Pregnancy Other testing to consider: -Estradiol -Total, free testosterone -DHEA, DHEA-S -Early morning 17-hydroxyprogesterone

  23. Secondary Amenorrhea Gonadotrophins (LH/FSH) Low Normal Elevated Progestin Challenge Premature Ovarian Failure Negative Positive Chronic Anovulation Functional Hypothalamic Amenorrhea Hypothalamic-Pituitary Etiology

  24. Hypogonadotropichypogonadism • Low energy availability • Pituitary tumors

  25. Spectrum of Female Athlete Triad

  26. Low Bone Density -- Adolescents • Requires presence of clinically significant fracture history AND low bone mineral density • Clinically significant fracture: • Long bone fracture of the lower extremity • Vertebral compression fracture • Two or more long bone fractures of the upper extremity • Low BMD: Z-score ≤ -2.0 adjusted for age, gender, body size • Weight bearing athletes: Low BMD <-1.0

  27. Low Bone Density -- Premenopausal • Low BMD – Z-score ≤ -2.0 • Osteoporosis: • Z-score ≤ -2.0 • AND secondary cause of osteoporosis

  28. Who needs bone density testing? • ≥ 1 ‘High risk’ Triad Risk Factors • History of DSM-V-diagnosed eating disorder • BMI ≤ 17.5, <85% estimated body weight • Recent weight loss of ≥ 10% in 1 month • Menarche ≥ 16yo • Current or history of < 6 menses over 12 months • Two prior stress fractures • One high risk stress fracture – femoral neck, pelvis, sacrum • Low-energy non-traumatic fracture • Prior Z-score of <-2.0 (at least 1 year ago)

  29. Who needs bone density testing? • ≥ 2 ‘Moderate risk’ Triad Risk Factors • Current or history of disordered eating for ≥ 6 months • BMI between 17.5-18.5, <90% estimated body weight • Recent weight loss of 5-10% in 1 month • Menarche between 15 and 16yo • Current or history of 6-8 menses over 12 months • One prior stress fracture • Prior Z-score between -1.0 and -2.0 (at least 1 year ago)

  30. Others to consider • History of ≥ 1 non-peripheral or ≥ 2 peripheral long bone traumatic fractures (nonstress) AND • One moderate- or high-risk Triad risk factors

  31. Where to scan? • Adolescents (<20yo) • Posteroanterior spine • Whole body (less head if possible) • Adjust for growth delay (with height or height-age) • Adjust for maturation (bone-age) • Use pediatric reference data • Adult women (≥ 20yo) • Weight-bearing sites • Posteroanterior spine • Femoral neck • Total Hip

  32. Consequences of decreased BMD N = 259 female athletes (age 18 ± 0.3) Average BMI: 21.5 ± 0.2 65% exercise ≥ 12hrs/wk Stress injury in 28 participants (10.6%) BMI < 21 – 15.3% Oligo/amenorrhea – 10.9% Exercise ≥ 12hr/wk – 14.7% BMI < 21 Oligo/amenorrhea Exercise ≥ 12hr/wk 29.2%

  33. Associations Between Disordered Eating, Menstrual Dysfunction and Musculoskeletal Injury Among High School Athletes N = 850 high school athletes Disordered Eating – 35.4% Menstrual Dysfunction – 18.8% MSK Injury – 65.6% Overuse Injury: Upper extremity – 27% Lower extremity – 43.1% Age: 15.4 ± 1.2 Average BMI: 21.1 ± 3.0

  34. Associations Between Disordered Eating, Menstrual Dysfunction and Musculoskeletal Injury Among High School Athletes

  35. Associations Between Disordered Eating, Menstrual Dysfunction and Musculoskeletal Injury Among High School Athletes MENSTRUAL Menstrual Dysfunction = < 9 periods/12 months or no menarche in athletes < 15yo

  36. Treatment should focus on ‘restoration or normalization of body weight as the best strategy for successful resumption of menses and improved bone health.’ -- ACSM 2014 Consensus Statement

  37. Low Energy Availability • Weight gain leading to resumption of menses • Typically 5 – 10% weight gain (1 – 4kg) • Achieve a BMI of ≥ 18.5 kg/m2 or ≥ 90% predicted body weight • Increase in caloric intake 250-500 kcal/day • Target ≥ 45kcal/kg FFM if possible • Team-based approach • Physician, sports dietician, (if needed) mental health provider

  38. N = 50 NCAA athletes with oligo/amenorrhea 12 amenorrhea, 38 oligomenorrhea ROM = Return Of Menses 5-year follow up with non-pharmacologic management with dietary and exercise interventions therapy Excluded

  39. Low BMD • Weight gain and subsequent resumption of menses are key to prevent further loss of bone mass. • Amenorrheic women women will lose ~2-3% of bone mass per year if untreated

  40. N = 75 anorexic women Age: 24.4 ± 0.6 % Ideal Body Weight: 75.8 ± 0.8 PA Spine BMD Hip BMD Increased weight by 10% or to ≥ 85% ideal body weight

  41. N = 75 anorexic women Age: 24.4 ± 0.6 % Ideal Body Weight: 75.8 ± 0.8 PA Spine BMD Hip BMD

  42. N = 75 anorexic women Age: 24.4 ± 0.6 % Ideal Body Weight: 75.8 ± 0.8 PA Spine BMD Hip BMD Greatest improvement with weight gain and resumption of menses

  43. Pharmacologic Management • Consider pharmacologic management if: • Lack of response to nonpharmacologic treatment for ≥ 1 year • New fractures occur during nonpharmacologic management

  44. Pharmacologic Management • Combined oral/non-oral contraceptives • OCP therapy is NOT associated with consistent improvement in BMD and may further compromise bone health DO NOT RESTORE SPONTANOUES MENSES and provide a false sense of security

  45. Mechanism Growth Hormone + IGF-I Increased bone density

  46. Mechanism Growth Hormone + Synthetic function inhibted IGF-I IGF-I is already decreased in amenorrheic athletes First pass metabolism Estrogen

  47. Hormonal Treatment • Consider hormonal therapy if: • Symptoms of estrogen deficiency • Vaginal dryness • Dyspareunia • Impaired bone health despite implementation of non-pharmacologic therapy

  48. Pharmacologic therapy • Combined oral contraceptive • 20-35μg ethinyl estradiol • Transdermal estradiol with cyclic progesterone • 100μg 17β-estradiol • (unproven contraceptive efficacy) • Bisphosphonates? • Teriparatide? • Refer to endocrinology

  49. Identifying at Risk Athletes

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