Special concerns:

    Making weight- e.g.- gymnasts, wrestlers; The "right way":

        need 6-8 wks, maintain +/- 5% target weight (can dehyrate to 5%    relatively safely w/o affecting performance)

        many small meals/recovery snacks, balanced activity schedule, avoid dehydration >5%, HIP/CCHO/LOF/MVIM

    "The wrong way": weight cycling, decreased calories/dehydration:

        IMPAIR PERFORMANCE

        DECREASE LBW

        PSYCH EFFECTS

        ...FEMALE TRIAD

Weight gain/maintain training needs: (100 cal/mile, 300-500 cal/hr)

        500-1,000 extra cal/day

        Fruit juices, nuts/seeds, added CHO

        Avoid fast-food- vit ADC defic, folate/fiber defic, high fat

Char: caloric restriction +/- compulsive overeating

FOOD RESTRICTION AND BINGEING

Examples: weight class sports, figure skaters, runners, cheerleaders, divers, gymnasts, dancers, etc.

Gymnasts today weigh 20# less than those 20 yrs ago!

Incidence: <=1% young adult women AN, 2-4% BN; 90% AN/BN females

Anorexia nervosa: severe restriction of calories, distorted body image, fear of weight gain, weight < 85% age/height, amenorrhea

Thin/bony, fine baby hair, cold intolerance (low temp), brittle hair/nails, cold/discolored (yellow) skin/H/F, low HR, OBP, constip/bloating; anemia, alb, elect, ECG

Mortality to 14% (hosp): Suicide, GI, ELECT, CV, TEMP, ENDO, SKEL

Bulemia nervosa: Binge-purge cycling (exercise, diur/lax, vomiting)

Binge 2x/wk for 3 mos, loss control around eating, purging, abnl body image

May be normal or even over weight

Chipmunk cheeks, sore throat, deenamel back teeth, Russel’s sign, C/D, CP, abd pain, fatigue, bloodshot eyes, facial/extremity edema

Disordered eating: less extreme but disruptive and unhealthy versions

    Athletic implications:

        Decreased endurance, speed, concentration Rx time

        Fluid and electrolyte disturbance

            CV, GI, Thermoreg probs

        ...FEMALE TRIAD

Frequent and intense athletic involvement +/- caloric restriction

15-62% incidence!

Performance "tied" to image/habitus

"A perfectionist with high goals"...self-critical..."low self-esteem"

"...emphasis on maintenance of an ‘ideal body weight’ or optimal body fat is also common."

"Most of these patients are dedicated athletes...very motivated...strong work ethic...ignore or minimize minor injuries..."

"Coaches tend to admire these traits, so affected athletes often elude detection."

Mood swings, irritability; DEPRESSION, poor concentration, memory, attention

Obsession with calories

Young HS/college athlete

PCP: "...first present with...dramatic weight loss...stress fx."

Orthopedic surgeon: stress fxs without training change, recurrent stress fxs

PREVENTION BETTER THAN TREATMENT

Caloric restrict- hormonal disturbance (estrogen)- loss bone density

Initial loss fat, later loss LBM

Paradoxically, loss performance

Increased risk of stress fxs and osteoporosis

Can affect long-term physical and mental health

Need team Rx: nutrition/ psych/ endocrinol/ orthoped/ ATC

Athletic amenorrhea: 1 (14pub change/16bleed) vs 2 (6 mos after 1)

Cessation of menses for 3-6 mos, or < 3 cycles /yr

CONSIDER PREGNANCY (MOST COMMON CAUSE OF AMENORRHEA)

Causes: anat, endo (hypoth-pit-ovaries), tumors, stress

Excluding pregnant women: 5% female population, 10-20% vigorously exercising women; 40-50% elite women athletes (dancers and runners)

Causative factors:

Early age exercise/training

Weight loss +/- psychologic factors

Caloric insufficiency, body fat

Training stresses

COMPLEX:

Lo cal- lo body fat- amen

Lo cal- nl body fat- amen

"Hypothalamic amenorrhea" defic GnRH

Endog opioids, cortisol, melatonin, dopamine

All increased in athletic/endurance activities

Decrease freq and amplitude of GnRH secretion

Decreased fatty estrogen feedback

Rest can reverse even w/o wt gain

Osteoporosis: 1984: spines of young amen athletes

BONE DENSITY DEPENDS UPON "ESTROGEN EXPOSURE"

Mimics post-menopausal osteoporosis

May see localized increased density at exercise specific sites, but overall DECREASED whole body bone density

60-70% women’s peak bone mass acquired before age 20, max at age 28 early loss bone usually trabecular- this OPPORTUNITY IS LOST IN YOUNG AMENORRHEIC ATHLETE!

This mineral cannot be restored!

Resumption of menses can only retard future loss

Other risk factors: FH, smoking, low Ca++ intake, HPTH, corticosteroids, dilantin, thyroid supplements, etc.

CONSIDER RISK OF LATER SPINE AND HIP FXS, to say nothing of present risk of stress fxs, athletic and otherwise

Screening:

Orthopedic hx-

       Stress fxs, bone/muscle/tendon pain

       "Lingering" injuries, overuse injuries

       Training hx

        Amenorrheic runners have 4.5X risk stress fx

        Exercise as weight control

        ?Rest days

Menstrual hx, BW hx, nutritional hx

        24 hr food intake

        Dietary perspectives

        Protein intake (with fat- restricted)

        Forbidden food list

        Hi/low wts

        "Ideal wt"

        Wt control

        Diet pills, diuretics/laxatives in the past

        Exercise as wt control mechanism

 Recognition/Work-up/Rx:

RECOGNIZE THOSE AT RISK! BE SUSPICIOUS and COMPASSIONATE!

            School Nurse

            HCP

Orthopedic surgeon- Rx fxs, PPPE, training tips

PCP- "the whole pt." PPPE; CBC, SMA-20

OB/gyn consult- pregnancy, etc.; oral contraceptives

Endocrinologist- thyroid/pituit eval (E, FSH, TSH, bHCG, etc.)

        Estrogen level <20 pg/ml (= postmenopausal)

        Hormonal replacement (oral contraceptives)

Bone density eval- DEXA (dual energy X-ray absorptiometry)

        20-30’ MOE 1-2% $200

        Exposure: 3-10mrem; CXR 20-60; dental 300

        < 1SD below mean; osteopenia (1-2.5), osteoporosis (>2.5)

        Baseline and assessment of Rx

Nutritionist- dietary eval/assistance

        Cal, Ca++ (1500mg/day), Vit D (400-800IU), etc.

Psychologist/psychiatrist- components AN/BN/ED

Coaches- recognition, expectations, counseling

***ATC- recognition, expectations, counseling***

Factors: training habits, equipment, environment, alignment

    Mild exercise- maintain, but not increase bone density

    Moderate Exercise- increase bone mass, diameter, and strength

    Extreme exercise- caloric deficiency, hormonal imbalance (amenorrhea)-  loss bone mineral

Hx: insidious pain, increased with loading

Diff Dx- ST inflammation, infection, CCS, tumor

Usual sites-

    Lower extremity- weight-bearing sites:

    Spine, pelvis, hip, knee, tibia, ankle, foot

Special sites- women: 

    wider pelvis- Pubic ramus: (track) overstriding (flexion) and cross-over style (adduction)

    Ribs: (rowing and golf) PL rib pull by SA, RH, TRAP- periscap or ant rad pain

Dx- CLIN, X-rays, bone sans, MRI

Rx- AVOID IMPACT: "downshift activity"

OR: fem neck, tarsal navic, ant tib cortex

NSAID’s ??healing problems?? Tylenol prob better

Return to Sports: no pain and non-tender,

    Walk, water, return to land at 1/3 injury level 3X/wk increase 10-15%/wk

    Attend to contributing factors:

        training schedule- X-train

        biomechanics- shoes, alignment

...CONSIDER THE FEMALE TRIAD!

Exercise 30 min/day 5-7 days/week: walking, jogging, light weight training (high rep low resistance)

Ca++: women: 11-24 1200-1500mg/day, 25-50 1000mg/day,

                    50-65 +estrogen 1000mg/day, >50 -estrogen 1500 mg/day

Ca++ Foods:

Yogurt 1c 400mg, skim milk 1c 300mg, cheese 1oz 200+mg, turnip/mustard greens 1/2c cooked 180mg, baked beans 1c 150mg, collards 1/2c cooked 150mg, cottage cheese 1c 135mg, kale/tofu/almonds, broccoli <= 130mg

References:

Orthopedic Knowledge Update Sports Medicine 2; Arendt, EA Ed.; AAOS, Rosemont, IL 1999, 65-78.

The Female Athlete; Teitz, CC Ed.; AAOS, Rosemont, IL 1999, 75-85.

Erickson, SM, Sevier, TL, Osteoporosis in active women. The Physician and Sportsmedicine. November, 1997: 61-74.

Joy, E, et al. Team management of the female athlete triad. The Physician and Sportsmedicine. March 1997: 95-110.

1- The Female Athletic Triad is not rare. It is composed of disordered eating, amenorrhea (missed menstrual periods), and osteoporosis (loss of bone density). It is most often seen in achievement-focused athletes, participating in sports where weight and body image are traditionally tied to performance: running, dance, gymnastics, figure skating, diving, cheerleading, weight calss sports, etc.

2- Simply, the Triad is caused by inadequate caloric intake and/or caloric consumption for the needs of athletic activity, training and competition. This causes a shutdown of normal female endocrine function and reduced estrogen production, in part through the decline of body fat, and hence, a loss of ovulation and menstrual function. Loss of estrogen reduces bone mineralization.

3- The incidence of severe eating disorders (anorexia and bulemia) in the general female population in the U.S. is 3-5%, but much higher in athletic women (as high as 15 to 62%). Females make up 90% of those with eating disorders, which means that 10% are males (e.g.- wrestlers).

4- A definition of an eating disorder includes: caloric restriction or elimination +/- compulsive overeating behaviors (dieting, bingeing, purging, and exercising) stemming from an abnormal focus on performance, body image and body weight.

5- The implications of loss of menstrual function, even temporarily, before age 30 are very serious. The loss of estrogen causes a permanent and life-long loss of bone mineral which cannot be replaced. Remember, 60-70% of female skeletal calcium is stored before age 28. Athletic amenorrhea (loss of menses)= loss of estrogen= loss of bone. One cannot regain this lost bone, only reduce the rate of further loss! The bone that is not deposited before age 30 cannot be deposited later in a catch-up fashion! Athletic amenorrhea is essentially a pre-menopausal menopause!

6- The weakened skeleton is prone to fracture (especially stress fracture). This may be the first sign of the Female Athletic Triad. Stress fractures that occur without obvious training errors and/or mechanical problems signal the possibility of the Female Athletic Triad. The bone of those affected is 4.5x more likely to fracture than those without this condition.

7- Recurrent soft tissue and overuse injuries also may suggest eating disorders, as one can view excessive or compulsive exercise (to the extent of injury) as an extreme method of weight control.

8- Symptoms and signs of the Triad, apart from loss of menstrual function and orthopedic injury include: excessive focus on body weight/image/dieting despite thin/normal habitus, bingeing/purging,use of diuretics/laxatives, poor physical/mental and athletic performance, loss of attention/concentration, depression, fatique, cold intolerance, fainting/dizziness, brittle nails/hair, sore throat, bloodshot eyes, abdominal pain/constipation/bloating, swollen face or extremities, etc.

9- It is very doubtful the those affected with this condition will overcome the denial that often accompanies the Triad, and ask for help, especially if positively reinforced by athletic success. Suspicion and compassion on the part of family, friends, teammates, coaches, athletic trainers, teachers, and health care professionals is necessary, coupled with the willingness to assist in getting help for this individual. Rememeber, anorexia is fatal in 14%! Get help and enlist a team approach: ask your trainer, nurse, primary care provider, orthopedic surgeon, nutritionist, or gynecologist.

10- The most common cause of amenorrhea is pregnancy.

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