Is the Pill the Answer for Patients with the Female Athlete Triad?

April 2012
Elizabeth Joy, MD, MPH, FACSM

Invited Commentary, Current Sports Medicine Reports, 2012, 11(2): 54-55.

Dr. Elizabeth Joy provided an insightful commentary in Current Sports Medicine Reports in April 2012 on the prescription of oral contraceptives in female athletes with amenorrhea. This article addresses concerns of using oral contraceptives as a treatment strategy in women affected by the Female Athlete Triad, particularly because oral contraceptives act to replace estrogen and progesterone not the hormones associated with low energy availability, such as low triiodothyronine, leptin, and insulin-like growth factor to name a few. Joy outlined a two-step approach in treating an athlete with the Female Athlete Triad to include: (1) a comprehensive history and physical examination to confirm diagnoses and (2) the engagement of a multi-disciplinary team (physician, sports dietician, and mental health professional) to promote the athlete’s recovery. Joy does identify certain instances wherein oral contraceptives may be used for clinical management of the Female Athlete Triad. Examples include those athletes unwilling to comply with changes to dietary intake or exercise training volume or in those athletes, in spite of efforts to fulfill nutritional and exercise training recommendations, are nonetheless unsuccessful in resuming a healthy menstrual cycle. To this end, there are inter-individual differences for clinical management of the Female Athlete Triad and for some, oral contraceptives may be a beneficial approach following efforts to accommodate steps one and two. In conclusion, findings from randomized control trials and epidemiologic studies on the effectiveness of oral contraceptives in treating amenorrhea and related health consequences (i.e., low bone mineral density) are inconclusive and further research is required to establish the role of oral contraceptives on clinical outcomes in women presenting with the Female Athlete Triad.

Energy Deficiency, Menstrual Disturbances and Low Bone Mass: What Do Exercising Australian Women Know About The Female Athlete Triad?

March 2012
Stephanie M. Miller, Sonja Kukuljan, Anne I. Turner, Paige can der Pligt and Gaele Ducher
International Journal of Sports Nutrition and Exercise Metabolism, 2012, 22, 131-138.

Miller and colleagues (2012) recently published a report in the International Journal of Sports Nutrition and Exercise Metabolism that examined the knowledge, attitudes and behaviors of premenopausal exercising women in Australia with respect to eating patterns, menstrual health and bone health. Female exercisers (n=191) aged 18-40yr completed a survey (11 were later excluded for incomplete answers) and were categorized into lean-build (n=82), non-lean-build (n=94) or gym/fitness activity groups (n=4). Of those assessed, only 10% of respondents correctly identified the 3 components of the Female Athlete Triad (energy deficiency, menstrual dysfunction, and low bone mass) independent of sport type, age, level of competition and personal experience with Female Athlete Triad-related clinical outcomes. Interestingly, participants who presented with a history of menstrual dysfunction demonstrated a greater likelihood of correctly describing the signs of an energy deficiency (i.e., rapid weight loss, absent menses and stress fractures). In the lean-build group, 22% of respondents stated that they would not take action if they presented with amenorrhea compared to 3% of non-lean-build athletes. The factors associated with not taking effective action for amenorrhea were: (1) participation in lean-build sports, (2) history of amenorrhea and (3) history of stress fracture. Furthermore, 1 in 2 athletes competing at the international level deemed amenorrhea normal in exercising women regardless of sport type (lean-build vs. non-lean-build). As such, the majority of participants believed that amenorrhea was a natural outcome of intense exercise training and not a serious clinical problem. In conclusion, this publication underscores that a significant proportion of Australian exercising women are not aware of the magnitude or severity of the Female Athlete Triad medical conditions, particularly the effect of amenorrhea on bone health. Also, the majority of these exercising women do not associate amenorrhea with serious clinical consequences which is notably worrisome. Alternatively, participants demonstrated sufficient knowledge of the risk factors for poor bone health. Overall, these findings raise concern and highlight that in spite of presenting with signs of energy deficiency or amenorrhea, a significant amount of exercising women may not appropriately take action. Educational programs and future investigation on the Female Athlete Triad is necessary to advance knowledge surrounding this syndrome and its prevention and treatment strategies.

Movaseghi S, Dadgostar H, Dahaghin S, Chimeh N, Alenabi T, Dadgostar E, Davatchi F.

Medicine & Science in Sports Exercise. 2011

Previously, no study had reported prevalence of the Female Athlete Triad in Asian or Islamic countries. The purpose of this study was to evaluate clinical manifestations of the Triad among elite female athletes in Iran. The study was conducted in three phases. Phase I included a total of 786 (94%) athletes with a mean age of 21.2 ± 4.5 years who completed a detailed questionnaire which contained questions relating to participants’ demographic characteristics, athletic history, history of injuries, and menstrual pattern. Athletes diagnosed with functional hypothalamic menstrual disorder or stress fracture in addition to those using weight-loss drugs participated in phases I and II. Bone-mineral density (BMD) was assessed using dual energy X-ray absorptiometry (DXA) during phase II of the study. Phase III consisted of clinical interviews to diagnose eating disorders. A total of 72(9.2%) athletes reported menstrual irregularities (MI) while 17(2%) reported stress fracture. Athletes participating in high-risk activities had significantly more stress fractures than those involved in low-risk sports. Only 3(0.4%) athletes manifested all three common clinical manifestations of the Triad which include eating disorder, menstrual irregularity, and low BMD. Since the design study was based on the 1997 ACSM position, the methods did not assess low-energy availability or sub-clinical menstrual disorders. For this reason, the study most likely underestimated the prevalence of the Triad among elite Iranian athletes. Future investigators should utilize objective methods to identify and evaluate cases of low energy availability and subclinical menstrual disorders.

Rauh MJ, Nichols JF, Barrack MT.

School of Exercise & Nutritional Sciences, San Diego State University, CA, USA. mrauh@rmuohp.edu

J Athl Train. 2010 May-Jun;45(3):243-52.

In this prospective study by Rauh and colleagues, the relationship among disordered eating, menstrual dysfunction, and low bone mineral density (BMD) and musculoskeletal injury among girls in high school sports was evaluated. 163 female athletes from 8 sports completed daily injury reports, the Eating Disorder Examination Questionnaire (EDE-Q) that assessed disordered eating attitudes and behaviors, a dual-energy x-ray absorptiometry (DXA) scan that measured BMD and lean tissue mass, anthropometric measurements, and a questionnaire on menstrual history and demographic characteristics. 90 injuries occurred in 61 athletes (37.4%). Using a model with z score ≤ -1 SD, a history of oligomenorrhea/amenorrhea in the past year and low BMD were associated with the occurrence of musculoskeletal injury. Disordered eating (Eating Disorder Examination Questionnaire score ≥ 4.0), a history of oligomenorrhea/amenorrhea during the past year, and a low BMD were associated with musculoskeletal injury occurrence when using a z-score of of ≤ -2 SDs. This study further proves that this unhealthy Triad increased one’s risk of injury. This information can be used to further promote screening, prevention, and adequate treatment in at-risk female athletes.

Doyle-Lucas AF, Davy BM.

Department of Dance, The Ohio State University, Columbus, Ohio, USA.

J Dance Med Sci. 2011;15(2):65-75.

Prevention is the best treatment for the Triad and disordered eating. This purpose of this study by Doyle-Lucas and Davy was to develop, implement, and evaluate a theoretically based nutritional education intervention through a DVD lecture series (three 30-minute classes) in summer intensive programs for pre-professional, adolescent ballet dancers. The goals were to increase knowledge of basic sports nutrition principles and the Female Athlete Triad and promote self-efficacy for adopting healthier dietary habits. Dancers ranging from 13 to 18 years old who were attending summer intensive programs affiliated with professional ballet companies were recruited. Group One (n = 231) participated in the nutrition education program, while Group Two the control participants (n = 90) did not. Assessments of the participants’ dietary status consisted of a demographic questionnaire, a Sports Nutrition Knowledge and Behavior Questionnaire, and a Food Frequency Questionnaire. The intervention group was assessed at baseline, immediately post-program, and at six weeks post-program. The control group was assessed at baseline and at six weeks post-baseline. The intervention program was effective at increasing nutrition knowledge, perceived susceptibility to the Female Athlete Triad, and self-efficacy constructs. Improvements in dietary intake were also observed among intervention group participants, which makes this a very promising educational tool. To improve overall health and performance nutrition education should be incorporated into the training regimens of adolescent dancers. This potentially replicable DVD-based program may be an effective, low-cost mechanism for doing that.

Becker CB, McDaniel L, Bull S, Powell M, McIntyre K.

Department of Psychology, Trinity University, One Trinity Place, San Antonio, TX 78212-7200, United States.

This study was done to further investigate a crucial issue in the female athlete triad-that of education. Becker and colleagues evaluated whether two peer-led interventions could have a positive effect on athletes eating disorder (ED) risk factors. Athletes were randomly assigned to athlete-modified dissonance prevention or healthy weight intervention (AM-HWI). ED risk factors were assessed pre/post-treatment, and 6-week and 1-year follow-up. Results (analyzed sample, N=157) indicated that both interventions reduced thin-ideal internalization, dietary restraint, bulimic pathology, shape and weight concern, and negative affect at 6 weeks, and bulimic pathology, shape concern, and negative affect at 1 year. Unexpectedly we observed an increase in students spontaneously seeking medical consultation for the triad. Qualitative results suggested that AM-HWI may be more preferred by athletes.

By Kathryn E. Ackerman, Taraneh Nazem, Dorota Chapko, Melissa Russell, Nara Mendes, Alexander P. Taylor, Mary L. Bouxsein, and Madhusmita Misra in J Clin Endocrinol Metab, 2011.

In a recent cross-sectional study published in the Journal of Clinical Endocrinology and Metabolism, Ackerman and colleagues from Massachusetts General Hospital and Harvard Medical School examined the bone mineral density (BMD) and bone microarchitecture in 34 young (15-21yr) amenorrheic (AA) and eumenorrheic athletes (EA) compared to 16 age-matched nonathletes (NAC). BMD was measured using dual energy x-ray absorptiometry (DXA) and bone microarchitecture was determined using high-resolution peripheral quantitative computed tomography (pQCT). The purpose of the study was to determine whether impaired bone microarchitecture is an independent determinant of fracture risk in AA, which to date has not been evaluated. There were no significant differences between groups for chronological age, bone age, BMI, or vitamin D levels. Age of menarche did not differ between athletic groups, but was significantly higher in the AA compared to the NAC (14.2±2.5yr vs. 12.1±1.7yr, p=0.006). Lean body mass was significantly higher in the EA vs NAC (46.7±15.5kg vs. 39.8±4.5, p=0.009); whereas, percent body fat was significantly lower in AA vs. NAC (21.4±4.5% vs. 25.6±4.9%, p=0.03). Estradiol was significantly suppressed in AA to confirm amenorrheic status. The EA group demonstrated significantly greater femoral neck and hip BMD Z-scores (0.21±1.14 and 0.80±1.09 respectively); whereas, lumbar BMD and bone mineral apparent density (BMAD) Z-scores were higher in EA and NAC vs. AA (-0.62±1.05 vs. -0.36±1.26 vs. -1.66±1.10). Both athletic groups had significantly greater total area, trabecular area, and cortical perimeter at the tibia compared to NAC. Cortical density was lower in AA vs. NAC. After controlling for bone age, both athletic groups were significantly lower than NAC. Trabecular density was lower at the radius in AA compared to EA and NAC. Regression modeling demonstrated that later menarcheal age was an important determinant of impaired bone microarchitecture. After controlling for covariates, subject grouping explained 18-24% of the variance in tibial trabecular number and separation. In conclusion, amenorrhea was an important determinant of lower trabecular bone density of the radius, lower total density and greater trabecular separation at the tibia. Subject grouping explained the greatest amount of variance in trabecular number and separation at the tibia. Therefore, bone microarchitecture is a valuable bone health parameter to measure in amenorrheic athletes independent of bone mineral density and may represent important information relative fracture risk.

Jeanne F. Nichols, PhD; Mitchell J. Rauh, PhD, PT, MPH; Mandra J. Lawson, MS, RD; Ming Ji, PhD; Hava-Shoshana Barkai, MS. Arch Pediatr Adolesc Med. 2006; 160:137-142

As of recent years, most literature surrounding the female athlete triad subsisted solely in collegiate female athletes. Data regarding high school-aged athletic females was severely lacking. In 2006, Nichols et al performed an observational cross-sectional study to estimate the prevalence of the female athlete triad among high school athletes. One-hundred-seventy female athletes representing eight sports from six high schools in southern California were included in the analysis to determine prevalence of the three aspects of the triad: disordered eating, menstrual status and bone health. Disordered eating and menstrual status were determined by interviewer-assisted questionnaires. Bone mineral density was determined via dual-energy x-ray absorptiometry (DXA) at the spine (L1-L4), hip and total body. Among athletes, 18.2% met criteria for disordered eating, 23.5% met criteria for menstrual irregularity and 21.8% met criteria for low bone mass. Ten of the 170 girls studied (5.9%) met criteria for 2 of the 3 components of the triad and 2 girls (1.2%) met criteria for all 3. In comparison to eumenorrheic athletes (regular menstrual cycles), oligomenorrheic (cycle length of 36-90 days) and amenorrheic (no menses for ≥ 90 days) athletes presented with high dietary restraint (the ability to restrict food intake) and Eating Disorder Examination Questionnaire global scores. As well, in comparison to eumenorrheic athletes, and after controlling for age, age at menarche, BMI, race/ethnicity and sport type, athletes with oligomenorrhea/amenorrhea had lower bone mineral densities at the trochanter (hip). In conclusion, the prevalence of the female athlete triad in high school-aged female athletes showed to be substantial illustrating that these women are at risk for one or more of the components of the triad. Long-term health consequences may be associated with the disordered eating, menstrual irregularities and poor bone health seen in this population. Preparticipation screening to identify these components should be encouraged as a preventive approach to identify high-risk athletes.

September 2011

S. E. Tomten, A. T. Høstmark in Scand J Med Sci Sports 2006: 16:127–133

Exercising female athletes create an energy deficit with exercise for which they require an increase in energy intake to match expenditure and remain in a state of energy balance.  However, reported daily intake is often similar to, or even lower than sedentary women; which creates an energy deficit leading to menstrual dysfunction and related complications such as poor bone health.   In a study by Tomten and Hostmark, energy balance, nutritional intake, training activity and total energy expenditure were assessed in female athletes both with and without menstrual dysfunction.  Energy balance and nutritional adequacy were assessed in a group of runners with irregular menstrual function (IR, n=10) as well as a group of runners with normal menstrual function (R, n=10).   Daily training-related excess energy expenditure and total energy expenditure (TEE) were not different between groups.  Daily energy intake (EI) was, however, significantly lower in IR athletes than in the R athletes.  EI and TEE were in balance in R athletes; however, a significant negative energy balance was observed in IR athletes. The energy deficit observed in the IR athletes was corroborated by significantly lower levels of free thyroxine in IR athletes, which may indicate a depressed BMR in IR athletes.  Mean intakes of carbohydrates and protein were close to recommended guidelines and were not significantly different between groups. The key difference in macronutrient intake was observed in dietary fat that was significantly lower in the IR athletes.  Though all athletes were weight stable, an energy deficit was observed in IR athletes, and not in R athletes, primarily due to a lower intake of dietary fat.  Fear of gaining weight has been widely accepted as a probable cause for a sub-optimal EI in athletes who depend on a low body mass for success.  Decreasing dietary fat intake has been one method by which female athletes lower their EI to maintain low body weights.  They may be reluctant to increase food intake in fear of a possible weight gain, even though a higher EI may seem to improve the reproductive function, it may also increase body weight and fat mass.

By Noel Pollock, Claire Grogan, Mark Perry, Charles Pedlar, Karl Cooke, Dylan Morrissey, and Lygeri Dimitriou in International Journal of Sports Nutrition and Exercise Metabolism, 2010, 20 419-426.

In a recent cross-sectional study by Pollock and colleagues, the associations between bone mineral density (BMD), menstrual status, disordered eating, and training volume were explored in 44 elite female endurance runners with a mean age of 22.9 years. Seven runners were followed longitudinally and this investigation represents one of the few studies with follow-up data in this subgroup of elite-level athletes. Bone density measurements were completed using DXA. Training and menstrual history were obtained using in-house questionnaires. The Three Factor Eating Questionnaire (TFEQ) was completed to assess eating behavior. For the longitudinal analysis, a follow-up DXA scan was completed 6-14 months from baseline. The investigators demonstrated that menstrual dysfunction, disordered eating, and low BMD were coexistent in 15.9% of the runners. However, there were no significant relationships (p>0.05) between BMD and menstrual status, disordered eating, and training volume, respectively. Interestingly, a significant positive association was found between a reduction in BMD at the lumbar spine and training volume (p=0.026). Therefore, these findings indicate that Triad-related complications exist in elite female endurance runners and furthermore, that low BMD and osteoporosis are prevalent. Pollock and colleagues also found that normal menstrual status did not significantly relate to normal BMD. To this end, it is notably imperative that female endurance athletes complete a DXA amongst their pre-participation screening. Furthermore, future research should investigate this association between high training volume, potential menstrual dysfunction, and reductions in lumbar BMD in larger populations of female endurance athletes. Based on these findings, it is indirectly suggested that a negative energy balance is a contributing factor to bone loss in these athletes.