ACSM. (2009). Physicians lack knowledge of the Female Athlete Triad. Medscape Medical News:

Jordana Bieze Foster

Authors and Disclosures

 June 1, 2009 (Seattle, Washington) — Fewer than one third of physicians can correctly identify all 3 components of the female athlete triad, according to a study presented here at the American College of Sports Medicine (ACSM) 56th Annual Meeting, suggesting that a surprising number of at-risk female athletes might not be receiving the treatment they need.

“There are significant knowledge gaps in terms of both recognition and treatment. We believe these knowledge gaps are based on a lack of education,” Elizabeth Joy, MD, MPH, associate professor of family and preventive medicine at the University of Utah in Salt Lake City, told attendees at the meeting. “There are some real missed opportunities here to intervene before some serious health consequences develop.”

The Utah researchers assessed physicians’ knowledge of the triad using an Internet-based survey. The questionnaire was distributed to 207 physicians identified by researchers as likely to come in contact with female athletes experiencing 1 or more components of the triad: reduced energy availability, menstrual dysfunction, and low bone mineral density. A total of 128 physicians completed the survey, for a 67.7% response rate.

Only 28.6% of respondents correctly identified all 3 triad components. The greatest knowledge gap concerned reduced energy availability, which was identified by only 29.7% of respondents. Physicians were twice as likely to correctly identify menstrual dysfunction (pegged by 66.7%) and low bone mineral density (65.9%).

By comparison, a survey-based study, published in 2006 in the Wisconsin Medical Journal (WMJ. 2006;105:21-24), found that 48% of physicians were able to correctly identify all 3 triad components. However, since that survey was conducted, the American College of Sports Medicine revised its position statement on the triad, replacing “disordered eating” with the broader “reduced energy availability” to reflect that an athlete whose caloric intake does not match her caloric output can be at risk regardless of body image. The Utah survey results suggest that the revised definition, published in 2007 (Med Sci Sports Exerc. 2007;39:1867-1882), has not yet trickled down to the level of the treating physician.

“Reduced energy availability is the central component of the female athlete triad, yet was the least recognized,” Dr. Joy said. “The most striking finding was that only 35.9% of respondents knew that increasing energy intake is the best option for treatment of low bone density.”

More than half of the survey respondents (58.1%) said that they had received no education about the triad during residency, and more than three quarters (79.8%) said that the triad had not been part of their continuing medical education.

Limitations of the Utah study were its small sample size and the fact that it involved only a single institution. Another limitation was that the survey was not as detailed as the researchers would have liked because of the need to keep it a reasonable length to maximize the response rate.

Mitchell J. Rauh, PhD, PT, MPH, who presented a study during the same session on the association between triad symptoms and history of stress fracture in female high-school runners, said that he has observed similar practitioner knowledge gaps but was nonetheless surprised by the figures Dr. Joy reported.

“That 28.6% is a really low number,” said Dr. Rauh, associate professor at Rocky Mountain University of Health Professions in Provo, Utah, and adjunct research professor in the School of Exercise & Nutritional Sciences at San Diego State University in California. “That’s a lot of girls being missed. And these are things we can fix if physicians know about it and can get the girls the right treatment.”

The study did not receive commercial support. Dr. Joy and Dr. Rauh disclosed no relevant financial relationships.

American College of Sports Medicine (ACSM) 57th Annual Meeting: Abstract 793. Presented May 28, 2009.

Prevalence of the Female Athlete Triad/Tetrad

Exercise has recognized benefits for women of all ages in terms of health management and enhanced well-being. However, there is cause for concern that physically active girls and women may be at a greater risk of a variety of medical conditions over the course of the lifespan as a result of participation in exercise and sport. As the female athlete progresses from childhood to maturity, her physiology makes her more susceptible to development of these conditions. During childhood, approximately 4 to 10 years, young girls that participate in athletic training have an increased risk of injury, such as heat-related illness and overuse injuries. Less efficient thermoregulatory systems predispose children to dehydration and high body temperatures. The American Academy of Pediatrics, the American College of Sports Medicine, and other expert groups recommend frequent rest periods on hot, humid days; gradual acclimatization to warmer climates; adequate hydration before and during activity; and wearing light-colored, lightweight, absorbent clothing. Overuse injuries in children are a result of muscle imbalance, inflexibility, and the susceptibility of growth cartilage to repetitive stress. These particular injuries often involve the growth plate and it is at the growth plate that treatment should be targeted. Training programs (both aerobic and resistance in accordance with expert guidelines) should emphasize conditioning, flexibility and refraining from early sport specialization and excessive activity. Adolescent girls aged 11 to 17 years have some of the same concerns as children despite the benefit of lifelong fitness habits, as well as conditions and injuries associated with the adult population, such as overuse injuries, the female athlete triad, sacroiliac dysfunction, and anterior cruciate ligament (ACL). Preventative strategies include strength training, awareness of the pathology involved in the female athlete triad, and proprioceptive training, and exercises to improve jumping, landing, and cutting techniques. Women between the ages of 18 and 49 years are also affected by the aforementioned conditions occurring in adolescent girls. Additionally, specific consideration of published guidelines for exercise during pregnancy and regarding the incidence of pelvic floor dysfunction is important as women reach adulthood. Screening for the female athlete triad remains a fundamental preventative measure, especially in patients with a history of stress fractures. Older female athletes, 50 years and older, are more likely to suffer from chronic medical conditions and the use of exercise in disease prevention and management, as well as reducing the number of falls resulting in hip fractures and associated morbidity and mortality, must be underscored. In summary, engagement in exercise is recommended for girls and women throughout the lifespan to improve fitness and weight control and prevent and treat chronic diseases. The emphasis is placed on awareness of exercise contraindications associated with each age range to ensure positive and fulfilling physical activity participation.

APRIL 2009

Female Athlete Triad Studies

This prevalence study uses a cross-sectional analysis to assess the prevalence of the female athlete triad in adolescent elite women swimmers. The sample includes 78 female elite swimmers in the age range of 11-19 years from Rio de Janeiro, Brazil. The study examines the presence of disordered eating, menstrual dysfunctions, and bone dysfunctions as components of the Female Athlete Triad syndrome (referred to as the Triad). Disordered eating was examined using three questionnaires (Eating Attitudes Test, Bulimic Investigatory Test Edinburgh, and Body Shape Questionnaire). Menstrual dysfunction was measured using a validated questionnaire. Bone dysfunction was examined using an assessment of bone mineral density (BMD) by applying the method of dual-energy X-ray absorptiometry (DXA). Statistical analyses included a t test comparing the means; a chi-square test evaluating the association among categorical variable (P<0.05); Pearson’s coefficients of simple linear correlation between the variables of lean body mass and BMD at the spine (L1-L4) and overall in the body; and Kaplan-Meier survival curves estimating mean menarche age. The mean age at menarche of the athletes was 12.38±0.2 y. The presence of disordered eating, menstrual dysfunction, and low bone mass were found to be 44.9%, 19.2%, and 15.4% respectively in the group of swimmers. Among the athletes, 47.4% (37 of 78) met one criterion of the Triad, 15.4% (12 of 78) met two criteria, and 1.3% (1 of 78) met all three criteria, implying potential development of the Triad. Only 35.9% (28 of 78) of the athletes did not present with any of the components associated with the Triad. The prevalence of the Triad in this study population was low. However, the presence of one or two components of the Triad, especially disordered eating, was observed in the athletes and was described as demonstrating the incidence of partial status in these adolescent elite women swimmers. The present study underscores the importance of monitoring these components and their causes in order to generate preventative measures that will reverse or avoid the development of the Triad thus improving the health of the athletes.

Biomechanics

Franklyn M, Oakes BW, Field B, Wells P, D. M. (2008). Section modulus is the optimum geometric predictor for stress fractures and medial tibial stress syndrome in both male and female athletes. Am J Sports Med 36:1179-1189

Areal bone mineral density (aBMD) as measured by dual energy x-ray absorptiometry (DXA) is not a good predictor of stress fracture risk. Previous studies have shown that aBMD can be higher, similar or lower in fractured athletes as compared to non-fractured peers. Investigations by x-ray and computed tomography (CT) suggested that geometrical parameters (e.g. bone diameter, cortical cross-sectional area), could better discriminate athletes with and without stress fracture. This study examined tibial bone geometry in 88 subjects (43 men) including sedentary controls, active controls, athletes with stress fracture and athletes with medial tibial stress syndrome (MTTS, commonly known as shin splints). Using x-ray and CT, athletes with stress fracture were found to have a lower section modulus than uninjured counterparts (without stress fracture). Section modulus reflects the distribution of bone mass away from the maximum principal axis of the bone’s cross-section, normalised by bone size. A small section modulus means that the most extreme point on the cross-section (the furthest from the centroid) is submitted to the highest stress under bending. The authors also found that subjects with MTSS had smaller tibial cross-sectional dimensions than did uninjured athletes. Most studies on stress fracture risk have been performed in military recruits, who are not necessarily very active prior to basic training, which partly explains the high incidence of stress fractures in this population. The present study indicates that stress fracture risk in athletes also seems associated with bone geometry. The major limitation of the study is the sample size, with only 5 men and 6 women with stress fractures. There were more participants with MTTS, based on the consideration by some clinicians that MTSS represents the early stage of stress fracture. The strengths of this study were the bone imaging techniques that were used (x-ray and CT), the depth of the biomechanical analysis, the quality of the recruitment (only subjects with stress fracture at the junction between mid-third and distal third of the tibia were included), the documentation of stress fracture and MTTS diagnosis, and the adjustment of the data to account for body size.

Nutrition – metabolism

Christo K, Prabhakaran R, Lamparello B, Cord J, Miller KK, Goldstein MA, Gupta N, Herzog DB, Klibanski A, Misra M (2008) Bone metabolism in adolescent athletes with amenorrhea, athletes with eumenorrhea, and control subjects. Pediatrics 121:1127-1136

Studies investigating the impact of amenorrhea on adolescent athletes’ bone health are scarce. Most studies have been performed in adults. This study compared dual energy x-ray absorptiometry (DXA)-derived areal bone mineral density (aBMD) and bone turnover markers between adolescent endurance athletes with amenorrhea (n=21), athletes with eumenorrhea (n=18), and control subjects (n=18), aged 12-18 years. Results are presented as Z-scores. The Z-score is a statistical measure of the distance (in standard deviations, SD) of an individual from the population mean of the same age (in contrast to the T-score, which is a comparison of an individual with the mean in young adults). For example, a Z-score of +1SD for aBMD means that the participant’s aBMD is 1 SD higher than the mean for his/her age. The study showed that aBMD and bone mineral apparent density (BMAD; an estimate of volumetric density) at the lumbar spine were lower in amenorrheic than eumenorrheic athletes and controls, with 38 % of amenorrheic athletes being osteopenic (Z-score<-1 SD). Hip aBMD Z-scores were also lower in amenorrheic athletes than eumenorrheic counterparts. Body mass index Z-scores, lean mass, IGF-I and menstrual status were independent predictors of Z-scores in aBMD. The authors also reported that levels of bone turnover markers (P1NP for bone formation and NTx for bone resorption) were lower in athletes with amenorrhea than in control subjects. The study confirmed that athletes with primary or secondary amenorrhea have lower aBMD than eumenorrheic athletes. At the spine, the amenorrheic athletes even had lower values than the control athletes. These findings suggest that the spine, which is rich in trabecular bone, is more sensitive to hypoestrogenism and/or benefits less from repetitive loading than the hip. Findings in bone turnover markers must still be considered with caution in adolescents, particularly in cross-sectional studies, as markers were shown to depend on sex, Tanner stage, height velocity, as well as skeletal mass and rate of bone mineral accrual. The study indicates that negative impact of amenorrhea on bone health can already be detected during adolescence, which is a crucial period for bone mass accrual and the attainment of peak bone mass in young adulthood.

Annals of the New York Academy of Sciences, June 2008, Vol. 1135,  ”The Menstrual Cycle and Adolescent Health”  Edited by, Catherine M. Gordon,  Corrine Welt,  Robert W. Rebar, Paula J.A. Hillard, Martin M. Matzuk, and Lawrence M. Nelson.

A group of basic scientists, clinicians, clinical investigators, psychologists, patient advocacy groups, and representatives from professional societies and governmental agencies met at the National Institutes of Health in October, 2007 with the long-term goal of having the menstrual cycle accepted and understood as a marker of general health in adolescent girls.

A compilation of this meeting is presented in this special issue, which is divided into five sections: 1) The Normal Adolescent Menstrual Cycle, 2) Disease Processes and the Adolescent Menstrual Cycle, 3) Bridging Normal and Abnormal Menstrual Cycle Processes,4)  Modern Dilemmas and the Adolescent Menstrual Cycle, and 5) Conclusions and Reflections for Future Research in this Area. 

Of specific interest are the following chapters:

• - Menstruation in adolescents: what’s normal, what’s not? By Paula J. Adams Hillard
• - The pathophysiology of amenorrhea in the adolescent, by Neville H. Golden and Jennifer L. Carlson
• - Long-term skeletal effects of eating disorders with onset in adolescence, by Madhusmita Misra
• - Exercise-induced amenorrhea and bone health in the adolescent athletes, by Michelle P. Warren and Abigail T. Chua
• - Reflections on future research in adolescent reproductive health, by Catherine M. Gordon, D. Lynn Loriaux, Melvin M. Grumbach, Alan D. Rogol, Lawrence M. Nelson

Nutrition

Lappe JM, Cullen D, Haynatzki G et al. Calcium and vitamin D supplementation decreases incidence of stress fractures in female navy recruits. J Bone Miner Res 2008; 23(5):741-749.

This randomised double-blind placebo-controlled study investigated the effect of 2000 mg calcium and 800 IU vitamin D of daily supplementation on the incidence of stress fractures in 5,201 female military recruits. Supplementation was initiated at the beginning of the 8-week basic training program. A total of 3,700 recruits completed the study and stress fracture incidence was 21% lower in the treated group (6.8% vs. 8.6% in the placebo group, p=0.02). Most of the fractures were at the tibia or fibula. Unfortunately vitamin D levels could not be measured. The recruits had a median dairy intake <1 serving/day, which provides ~300 mg of calcium. This could partly explain why the supplementation was so efficient. During training 2,786 subjects reported having no menstrual periods. The risk of fracture in those with amenorrhea was 91% higher than those with one or more menstrual periods during training (RR, 1.91, 95% CI = 1.47-2.47, p<0.0001). The only factor that was protective of fracture was history of exercise. Although the outcomes of the study – and the sample size – are impressive, the mechanisms by which the supplementation helped to prevent stress fractures are still unclear. 

Bone Health

Bredella MA, Misra M, Miller KK et al. Distal radius in adolescent girls with anorexia nervosa: trabecular structure analysis with high-resolution flat-panel volume CT. Radiol 2008; 249(3):938-946.

This study investigated the microarchitecture of the trabecular bone network in adolescents with mild anorexia nervosa (body weight>80% ideal weight for age). Trabecular bone is found in vertebral bodies and extremities of long bones. It is composed of a complex network of trabeculae and looks like a sponge -hence the term ‘spongious bone’ to describe trabecular bone. The trabecular bone microarchitecture has been relatively less well studied than cortical bone due to the limitations of bone imaging techniques in vivo. The size of the trabeculae varies between 50 to 300 µm, which explains why techniques such as DXA or pQCT cannot be used to analyze the trabecular network. The authors used flat panel volume computed tomography which provides a resolution of 150µm³. The authors demonstrated that trabecular bone microarchitecture was affected in girls with mild anorexia nervosa despite normal BMD (as measured by DXA), and that the anorectic girls had thinner trabeculae with larger spaces between the trabeculae than normal-weight girls. These adaptations are similar to what is observed after menopause, leading to increased skeletal fragility. This study showed that trabecular bone microarchitecture was affected before a decrease in BMD could be detected by DXA. Given that the subjects suffered from mild anorexia nervosa, these findings are of great concern for adolescents who suffer from more severe forms of the disease.