2009 May | Female Athlete Triad Coalition

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Health-related concerns of the Female Athlete: A lifespan approach

By Joy, E.A., Van Hala, S., and Cooper, L. (2009). American Family Physician March 79(6): 489-49

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.

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Prevalence of the Female Athlete Triad/Tetrad In Professional Ballet Dancers

By Anne Z. Hoch, FACSM¹, Paula Papanek, FACSM², Heather S. Havlik¹, William G. Raasch¹, Michael E. Widlansky¹, Jane E. Schimke¹, David D. Gutterman¹. ¹Medical College of Wisconsin, Milwaukee, WI.²Marquette University, Milwaukee, WI.
Email: azeni@mcw.edu

The prevalence of the female athlete triad in professional dancers in unknown. Futhermore, amenorrhea may increase the risk of endothelial dysfunction, a predictor of cardiovascular risk in this population.

PURPOSE: To determine the prevalence of disordered eating, menstrual dysfunction, reduced bone mineral density and endothelial dysfunction in professional ballet dancers.

METHODS: Twenty two professional ballet dancers volunteered for this study. Subjects completed a questionnaire in regards to disordered eating (EDE-Q). Whole serum blood was drawn to determine hormonal, TSH and prolactin levels. Subjects also completed a questionnaire about their menstrual history. Bone mineral density (BMD) and body composition were measured with a GE Lunar Prodigy DXA. Endothelial function was measured in the brachial artery by high resolution ultrasound employing standard methods for measuring brachial reactivity testing. An increase in brachial diameter < 5% to hyperemic flow stimulus was a priori defined as endothelial dysfunction.

RESULTS: Disordered eating. Thirty two percent had abnormal EDE-Q scores. Menstrual dysfunction. Eighteen percent reported a history primary amenorrhea, 27% currently had menstrual dysfunction and 9% were currently taking birth control. Bone mineral density. Thirty two percent had evidence of low bone density (Z score< 1.0).Cardiovascular. Sixty four percent of dancers had abnormal brachial artery flow mediated dilation (<5%).

CONCLUSIONS: Triad characteristics including endothelial dysfunction were common in this group. Eighteen percent had one component, 45% had two components, 18% had 3 components and 5% had all four components of the Triad (Tetrad).

FUNDING: This study was funded by a grant from the General Clinical Research Center, Grant #M01 RR00058, by the Clinical & Translational Science Institute Adult Translational Research Unit, Medical College of Wisconsin, and Recipient of Steve Cullen Healthy Heart Club Funding 2008.

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

By 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.