12-months of increased dietary intake does not exacerbate disordered eating-related attitudes, stress, or depressive symptoms in women with exercise-associated menstrual disturbances: The REFUEL randomized controlled trial.

Disordered eating-related attitudes are a leading cause of energy deficiency and menstrual disturbances in exercising women. Although treatment recommendations include psychological counseling with increases in dietary intake, a key concern is whether increased dietary intake may exacerbate negative eating behaviors. OBJECTIVE: To determine the effects of a 12-month nutritional intervention on eating-related attitudes and psychological characteristics in exercising women with oligomenorrhea/amenorrhea (Oligo/Amen). METHODS: Intent-to-treat analysis of the REFUEL randomized controlled trial (#NCT00392873) in 113 exercising women (age [mean±SEM]:] 21.9 ± 0.4 yrs; BMI: 20.9 ± 0.2 kg/m2). Women were randomized to increase energy intake 20-40% above baseline energy needs (Oligo/Amen+Cal, n = 40) or maintain energy intake (Oligo/Amen Control, n = 36) while maintaining their exercise behaviors. A reference group of ovulatory women (OVref, n = 37) maintained diet and exercise behaviors. Body composition, eating attitudes, stress, and depressive symptoms were assessed at baseline and every 3 months. RESULTS: At baseline, the Oligo/Amen groups had higher drive for thinness, cognitive restraint, and eating disorder risk than OVref group (p < 0.001). Increased energy intake led to increases in percent body fat and fat mass (p < 0.010), but not psychobehavioral outcomes, in the Oligo/Amen+Cal compared to Oligo/Amen Control group. Independent of group, cognitive restraint decreased (p < 0.001) and resilient coping increased (p < 0.007) over 12-months, while perceived stress (p = 0.143) and depressive symptoms (p = 0.344) were unchanged. DISCUSSION: Long-term nutritional intervention consisting of modest increases in dietary intake with guidance from a registered dietician and a psychologist increases body and fat mass without increasing disordered eating-related attitudes, stress, or depressive symptoms in exercising women with Oligo/Amen.

Bone mineral density in response to increased energy intake in exercising women with oligomenorrhea/amenorrhea: the REFUEL randomized controlled trial.

BACKGROUND: Energy deficiency can result in menstrual disturbances and compromised bone health in women, a condition known as the Female Athlete Triad. OBJECTIVES: The REFUEL randomized controlled trial assessed the impact of increased energy intake on bone health and menstrual function in exercising women with menstrual disturbances. METHODS: Exercising women with oligomenorrhea/amenorrhea (Oligo/Amen) were randomly assigned to an intervention group (Oligo/Amen + Cal, n = 40, mean ± SEM age: 21.3 ± 0.5 y; weight: 55.0 ± 1.0 kg; BMI: 20.4 ± 0.3 kg/m2) who increased energy intake 20%-40% above baseline energy needs for 12 mo or a control group (Oligo/Amen Control, n = 36; mean ± SEM age: 20.7 ± 0.5 y; weight: 59.1 ± 1.3 kg; BMI: 21.3 ± 0.4 kg/m2). Energy intake and expenditure, metabolic and reproductive hormones, body composition, and areal bone mineral density (aBMD) were assessed. RESULTS: Oligo/Amen + Cal improved energy status [increased body mass (2.6 ± 0.4 kg), BMI (0.9 ± 0.2 kg/m2), fat mass (2.0 ± 0.3 kg), body fat percentage (2.7% ± 0.4%), and insulin-like growth factor 1 (37.4 ± 14.6 ng/mL)] compared with Oligo/Amen Control and experienced a greater likelihood of menses (P < 0.05). Total body and spine aBMD remained unchanged (P > 0.05). Both groups demonstrated decreased femoral neck aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.0002 g/cm2 ; time main effect P = 0.043) and month 12 (-0.011 g/cm2; 95% CI: -0.021, -0.001 g/cm2; time main effect P = 0.023). Both groups demonstrated a decrease in total hip aBMD at month 6 (-0.006 g/cm2; 95% CI: -0.011, -0.002 g/cm2; time main effect P = 0.004). CONCLUSIONS: Although higher dietary energy intake increased weight, body fat, and menstrual frequency, bone mineral density was not improved, compared with the control group. The 12-mo intervention may have been too short and the increase in energy intake (∼352 kcal/d), although sufficient to increase menstrual frequency, was insufficient to increase estrogen or improve aBMD. Future research should refine the optimal nutritional and/or pharmacological interventions for the recovery of bone health in athletes and exercising women with Oligo/Amen.This trial was registered at clinicaltrials.gov as NCT00392873.

Randomised controlled trial of the effects of increased energy intake on menstrual recovery in exercising women with menstrual disturbances: the 'REFUEL' study.

STUDY QUESTION: Does increased daily energy intake lead to menstrual recovery in exercising women with oligomenorrhoea (Oligo) or amenorrhoea (Amen)? SUMMARY ANSWER: A modest increase in daily energy intake (330 ± 65 kcal/day; 18 ± 4%) is sufficient to induce menstrual recovery in exercising women with Oligo/Amen. WHAT IS KNOWN ALREADY: Optimal energy availability is critical for normal reproductive function, but the magnitude of increased energy intake necessary for menstrual recovery in exercising women, along with the associated metabolic changes, is not known. STUDY DESIGN, SIZE, DURATION: The REFUEL study (trial # NCT00392873) is the first randomised controlled trial to assess the effectiveness of 12 months of increased energy intake on menstrual function in 76 exercising women with menstrual disturbances. Participants were randomised (block method) to increase energy intake 20-40% above baseline energy needs (Oligo/Amen + Cal, n = 40) or maintain energy intake (Oligo/Amen Control, n = 36). The study was performed from 2006 to 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were Amen and Oligo exercising women (age = 21.0 ± 0.3 years, BMI = 20.8 ± 0.2 kg/m2, body fat = 24.7 ± 0.6%) recruited from two universities. Detailed assessment of menstrual function was performed using logs and measures of daily urinary ovarian steroids. Body composition and metabolic outcomes were assessed every 3 months. MAIN RESULTS AND THE ROLE OF CHANCE: Using an intent-to-treat analysis, the Oligo/Amen + Cal group was more likely to experience menses during the intervention than the Oligo/Amen Control group (P = 0.002; hazard ratio [CI] = 1.91 [1.27, 2.89]). In the intent-to-treat analysis, the Oligo/Amen + Cal group demonstrated a greater increase in energy intake, body weight, percent body fat and total triiodothyronine (TT3) compared to the Oligo/Amen Control group (P < 0.05). In a subgroup analysis where n = 22 participants were excluded (ambiguous baseline menstrual cycle, insufficient time in intervention for menstrual recovery classification), 64% of the Oligo/Amen + Cal group exhibited improved menstrual function compared with 19% in the Oligo/Amen Control group (χ2, P = 0.001). LIMITATIONS, REASONS FOR CAUTION: While we had a greater than expected dropout rate for the 12-month intervention, it was comparable to other shorter interventions of 3-6 months in duration. Menstrual recovery defined herein does not account for quality of recovery. WIDER IMPLICATIONS OF THE FINDINGS: Expanding upon findings in shorter, non-randomised studies, a modest increase in daily energy intake (330 ± 65 kcal/day; 18 ± 4%) is sufficient to induce menstrual recovery in exercising women with Oligo/Amen. Improved metabolism, as demonstrated by a modest increase in body weight (4.9%), percent body fat (13%) and TT3 (16%), was associated with menstrual recovery. STUDY FUNDING/COMPETING INTEREST(S): This research was supported by the U.S. Department of Defense: U.S. Army Medical Research and Material Command (Grant PR054531). Additional research assistance provided by the Penn State Clinical Research Center was supported by the National Center for Advancing Translation Sciences, National Institutes of Health, through Grant UL1 TR002014. M.P.O. was supported in part by the Loretta Anne Rogers Chair in Eating Disorders at University of Toronto and University Health Network. All authors report no conflict of interest. TRIAL REGISTRATION NUMBER: NCT00392873. TRIAL REGISTRATION DATE: October 2006. DATE OF FIRST PATIENT'S ENROLMENT: September 2006.

Characterizing the resting metabolic rate ratio in ovulatory exercising women over 12 months.

PURPOSE: A reduced resting metabolic rate (RMR) ratio and suppressed total triiodothyronine (TT3 ) have been demonstrated to reflect metabolic compensation to chronic energy deficiency. However, it is unknown whether the relationship between RMR ratio and TT3 remains constant over time. OBJECTIVE: To examine the relationship between RMR ratio and TT3 in free-living exercising, ovulatory, weight-stable women (n = 14) for a 12-month observational period. METHODS: Dual-energy X-ray absorptiometry (DXA) and indirect calorimetry provided data on anthropometrics and energy expenditure. Harris-Benedict, DXA, and Cunningham (1980 and 1991) equations estimated RMR and RMR ratio (measured RMR/predicted RMR). Repeated measures analysis assessed changes over time (ANOVA and Friedman). Generalized linear modeling tested whether RMR ratio threshold predicted TT3  > 73.2 ng/dL or TT3  > 80 ng/dL over 12-months. RESULTS: Women were 25.9 ± 5.4 years, weighed 59.6 ± 5.2 kg with BMI 22.3 ± 1.4 kg/m2 at baseline, which remained constant throughout the study (weight: P = .523; BMI: P = .511). There was no significant effect of time for RMR (P = .886), TT3 (P = .890), energy availability (P = .212), and RMR ratio (Harris-Benedict: P = .852; DXA: P = .607; Cunningham1980 : P = .754; Cunningham1991 : P = .739). When TT3  > 73.2 ng/dL, each RMR ratio threshold (Harris-Benedict: P = .021; DXA: P = .019; Cunningham1980 : P = .019; Cunningham1991 : P = .016) significantly predicted participants as energy replete; however, when using a more lenient clinical TT3 threshold of >80 ng/dL, only the DXA ratio threshold yielded a significant prediction of TT3 (P < .001). CONCLUSIONS: The relationship between RMR ratio and TT3 remains significant and consistent over time in free-living exercising women, validating the use of RMR ratio for the longitudinal characterization of energetic status in this population (ie, prospective serial monitoring).

Geometric and "True" Densitometric Characteristics of Bones in Athletes with Stress Fracture and Menstrual Disturbances: A Systematic Review.

BACKGROUND: Stress fractures can lead to short- and long-term consequences, impacting participation in sport and general health. Recognizing which skeletal characteristics render bones susceptible to stress fracture may aid stress-fracture prevention. Menstrual disturbances among exercising women are a known risk factor for stress fracture; therefore, assessing skeletal commonalities between women with stress fractures and women with menstrual disturbances may increase our understanding of why menstrual disturbances put athletes at greater risk for stress fracture. Three-dimensional (3D) bone imaging tools provide detailed information about volumetric bone mineral density (vBMD) and bone structure that cannot be obtained using traditional two-dimensional (2D) techniques. OBJECTIVES: This systematic review serves to: (1) evaluate the current literature available on vBMD, bone geometry, and bone structure in exercising women with menstrual disturbances and exercising women with stress fractures, and (2) assess the common skeletal characteristics between both conditions. Our aim is to reveal bone properties beyond 2D areal BMD that may indicate increased susceptibility to stress fracture among exercising women with menstrual disturbances. SEARCH METHODS: A search of the PubMed/Medline database was completed in May 2018. ELIGIBILITY CRITERIA: Eligible articles included those that reported vBMD, bone geometry, or bone structure obtained from 3D imaging techniques or estimated from 2D imaging techniques. Only studies conducted in premenopausal exercising women and girls who had a stress fracture, a menstrual disturbance, or both were included. RESULTS: Twenty-four articles met the inclusion criteria. Bone area and cortical thickness at the tibia were identified as altered both in women with menstrual disturbances and in women with stress fractures; however, there was inconsistency in the results observed for all bone parameters. The majority of skeletal parameters of the lower extremities were not significantly different between exercising women with and without stress fractures and between those with and without menstrual disturbances. DISCUSSION: Most studies were moderate or low quality based on study design, and only one article combined both conditions to explore vBMD and bone geometry in athletes with menstrual disturbances and a history of stress fracture. These findings highlight the need for more skeletal research on the intersection of these health conditions in exercising women. The lack of observed differences in skeletal parameters suggests that risk factors other than bone geometry and structure may be the primary causes of stress fracture in these women.

Energy Deficiency Suppresses Bone Turnover in Exercising Women With Menstrual Disturbances.

CONTEXT: In exercising women, energy deficiency can disrupt the balance of bone formation and resorption, resulting in bone loss and an altered rate of bone turnover, which may influence future bone mineral density and fracture risk. OBJECTIVE: To assess the effects of energy status and estrogen status on bone turnover. DESIGN: Cross-sectional. SETTING: The Women's Health and Exercise Laboratory at Pennsylvania State University. PARTICIPANTS: Exercising women (n = 109) operationally defined as energy deficient or replete based on total triiodothyronine concentration and as estrogen deficient or replete based on menstrual cycle history and reproductive hormone metabolites. MAIN OUTCOME MEASURES: Bone formation index [procollagen type I N-terminal propeptide (P1NP) concentration corrected for average P1NP concentration in healthy reference group, i.e., [P1NP]i/median [P1NP]ref], bone resorption index [serum C-terminal telopeptide (sCTx) concentration corrected for average sCTx concentration in healthy reference group, i.e., [sCTx]i/median [sCTx]ref], bone balance (ratio of bone formation index to bone resorption index to indicate which process predominates), and bone turnover rate (collective magnitude of bone formation index and bone resorption index to indicate overall amount of bone turnover). RESULTS: The combination of energy and estrogen deficiency resulted in less bone formation and a lower rate of bone turnover compared with women who were estrogen deficient but energy replete. Regardless of estrogen status, energy deficiency was associated with decreased bone resorption as well. No main effects of estrogen status were observed. CONCLUSIONS: The results highlight the critical role that adequate energy plays in the regulation of bone turnover, especially bone formation, in exercising women with menstrual disturbances.

Rationale and study design of an intervention of increased energy intake in women with exercise-associated menstrual disturbances to improve menstrual function and bone health: The REFUEL study.

PURPOSE: Exercising women who consume inadequate energy relative to expenditure are at risk for downstream health consequences, such as menstrual cycle disturbances and poor bone health. Collectively, these conditions are known as the Female Athlete Triad (Triad). Clinicians often prescribe hormonal contraceptives to address this issue; however, the recommended treatment is reversal of the energy deficit. This paper describes the design of the REFUEL study, a randomized controlled trial (RCT) that explored the effectiveness of a 12-month intervention of increased energy intake on the reversal of an unhealthy energetic status and menstrual dysfunction and subsequent improvements in bone health in exercising women with severe menstrual cycle disturbances. METHODS: Women between the ages of 18-35 years and participating in at least 2 h/week of purposeful exercise were recruited. Those who reported irregular or absent menstrual cycles and were determined to have an exercise-associated menstrual disturbance (EAMD) were randomized into either the treatment group (EAMD + Cal), which was instructed to increase caloric intake throughout the intervention, or a control group (EAMD Control). Women who reported eumenorrhea were eligible for the ovulatory (OV) Control group. Repeated measures of energetic and metabolic status, reproductive status, and skeletal health were obtained. DISCUSSION: The REFUEL study is the first RCT to explore a non-pharmacological treatment approach among exercising women with the Triad. 118 women were randomized, and 55 women completed the entire study. The findings of this study have the potential to inform and alter clinical practice for exercising young women who present with this condition.

Low resting metabolic rate in exercise-associated amenorrhea is not due to a reduced proportion of highly active metabolic tissue compartments.

Exercising women with menstrual disturbances frequently display a low resting metabolic rate (RMR) when RMR is expressed relative to body size or lean mass. However, normalizing RMR for body size or lean mass does not account for potential differences in the size of tissue compartments with varying metabolic activities. To explore whether the apparent RMR suppression in women with exercise-associated amenorrhea is a consequence of a lower proportion of highly active metabolic tissue compartments or the result of metabolic adaptations related to energy conservation at the tissue level, RMR and metabolic tissue compartments were compared among exercising women with amenorrhea (AMEN; n = 42) and exercising women with eumenorrheic, ovulatory menstrual cycles (OV; n = 37). RMR was measured using indirect calorimetry and predicted from the size of metabolic tissue compartments as measured by dual-energy X-ray absorptiometry (DEXA). Measured RMR was lower than DEXA-predicted RMR in AMEN (1,215 ± 31 vs. 1,327 ± 18 kcal/day, P < 0.001) but not in OV (1,284 ± 24 vs. 1,252 ± 17, P = 0.16), resulting in a lower ratio of measured to DEXA-predicted RMR in AMEN (91 ± 2%) vs. OV (103 ± 2%, P < 0.001). AMEN displayed proportionally more residual mass (P < 0.001) and less adipose tissue (P = 0.003) compared with OV. A lower ratio of measured to DXA-predicted RMR was associated with lower serum total triiodothyronine (ρ = 0.38, P < 0.001) and leptin (ρ = 0.32, P = 0.004). Our findings suggest that RMR suppression in this population is not the result of a reduced size of highly active metabolic tissue compartments but is due to metabolic and endocrine adaptations at the tissue level that are indicative of energy conservation.

Current and past menstrual status is an important determinant of femoral neck geometry in exercising women.

UNLABELLED: Menstrual status, both past and current, has been established as an important determinant of bone mineral density (BMD) in young exercising women. However, little is known regarding the association between the cumulative effect of menstrual status and indices of bone health beyond BMD, such as bone geometry and estimated bone strength. PURPOSE: This study explores the association between cumulative menstrual status and indices of bone health assessed using dual-energy x-ray absorptiometry (DXA), including femoral neck geometry and strength and areal BMD (aBMD), in exercising women. METHODS: 101 exercising women (22.0±0.4years, BMI 21.0±0.2kg/m(2), 520±40min/week of self-reported exercise) participated in this cross-sectional study. Women were divided into three groups as follows based on their self-reported current and past menstrual status: 1) current and past regular menstrual cycles (C+P-R) (n=23), 2) current and past irregular menstrual cycles (C+P-IR) (n=56), 3) and current or past irregular cycles (C/P-RIR) (n=22). Current menstrual status was confirmed using daily urinary metabolites of reproductive hormones. DXA was used to assess estimates of femoral neck geometry and strength from hip strength analysis (HSA), aBMD, and body composition. Cross-sectional moment of inertia (CSMI), cross-sectional area (CSA), strength index (SI), diameter, and section modulus (Z) were calculated at the femoral neck. Low CSMI, CSA, SI, diameter, and Z were operationally defined as values below the median. Areal BMD (g/cm(2)) and Z-scores were determined at the lumbar spine, femoral neck, and total hip. Low BMD was defined as a Z-score<-1.0. Chi-square tests and multivariable logistic regression were performed to compare the prevalence and determine the odds, respectively, of low bone geometry, strength, and aBMD among groups. RESULTS: Cumulative menstrual status was identified as a significant predictor of low femoral neck CSMI (p=0.005), CSA (p≤0.024), and diameter (p=0.042) after controlling for confounding variables. C+P-IR or C/P-RIR were four to eight times more likely to exhibit low femoral neck CSMI or CSA when compared with C+P-R. Lumbar spine aBMD and Z-score were lower in C+P-IR when compared with C+P-R (p≤0.003). A significant association between menstrual group and low aBMD was observed at the lumbar spine (p=0.006) but not at the femoral neck or total hip (p>0.05). However, after controlling for confounding variables, cumulative menstrual status was not a significant predictor of low aBMD. CONCLUSION: In exercising women, the cumulative effect of current and past menstrual irregularity appears to be an important predictor of lower estimates of femoral neck geometry, as observed by smaller CSMI and CSA, which may serve as an another means, beyond BMD, by which menstrual irregularity compromises bone strength. As such, evaluation of both current and past menstrual status is recommended to determine potential risk for relatively small bone geometry at the femoral neck.

Energy availability discriminates clinical menstrual status in exercising women.

BACKGROUND: Conditions of low energy availability (EA) (<30 kcal/kgLBM) have been associated with suppressed metabolic hormones and reductions in LH pulsatility in previously sedentary women during short-term manipulations of energy intake (EI) and exercise energy expenditure (EEE) in a controlled laboratory setting. The purpose of this study was to examine if EA, defined as EA = (EI-EEE)/kgLBM, is associated with disruptions in ovarian function in exercising women. METHODS: Menstrual status was confirmed with daily measures of urinary reproductive metabolites across 1-3 menstrual cycles or 28-day monitoring periods. EA was calculated for exercise days using EI from 3-day diet logs, EEE from heart-rate monitors and/or exercise logs for a 7-day period, and body composition from DXA. Resting energy expenditure (REE) was measured by indirect calorimetry. Total triiodothyronine (TT3) was measured from a fasting blood sample. RESULTS: 91 exercising women (23.1 ± 0.5 years) were categorized clinically as either exercising amenorrheic (ExAmen, n = 30), exercising oligomenorrheic (ExOligo, n = 20) or exercising eumenorrheic (ExEumen, n = 41). The eumenorrheic group was further divided into more specific subclinical groups as either exercising ovulatory (ExOv, n = 20), exercising inconsistent (ExIncon, n = 13), or exercising anovulatory (ExAnov, n = 8). An EA threshold of 30 kcal/kgLBM did not distinguish subclinical menstrual status (χ (2) = 0.557, p = 0.46) nor did EA differ across subclinical disturbance groups (p > 0.05). EA was lower in the ExAmen vs. ExEumen (30.9 ± 2.4 vs. 36.9 ± 1.7 kcal/kgLBM, p = 0.04). The ratio of REE/predicted REE was lower in the ExAmen vs. ExEumen (0.85 ± 0.02 vs. 0.92 ± 0.01, p = 0.001) as was TT3 (79.6 ± 4.1 vs. 95.3 ± 2.9 ng/mL, p = 0.002). CONCLUSIONS: EA did not differ among subclinical forms of menstrual disturbances in a large sample of exercising women, but EA did discriminate clinical menstrual status, i.e., amenorrhea from eumenorrhea.

Reductions in urinary collection frequency for assessment of reproductive hormones provide physiologically representative exposure and mean concentrations when compared with daily collection.

OBJECTIVE: To determine if reducing the frequency of urinary sample collection from daily to 5, 3, or 2 days per week during a menstrual cycle or 28-day amenorrheic monitoring period provide accurate representations of the reproductive hormone metabolites estrone-1-glucuronide (E1G) and pregnanediol glucuronide (PdG) exposure and mean concentrations. METHODS: Exercising women presenting with eumenorrhea or exercise-associated menstrual disturbances collected daily urine samples for the assessment of E1G and PdG concentrations. After enzyme immunoassay analysis of the daily samples, E1G and PdG data were systematically removed from each menstrual cycle or amenorrheic monitoring period to mimic three reduced collection frequencies, representing 5, 3, and 2 days per week. Exposure and mean concentration were calculated for both hormones and all four urinary collection frequencies. RESULTS: E1G and PdG exposure and mean cycle concentrations derived from reduced collection frequencies were not different from daily collection (P > 0.05), independent of whether menstrual cycles and monitoring periods were analyzed together or separately. Bland-Altman analysis indicated acceptable agreement between each reduced collection frequency and daily collection. CONCLUSIONS: Compared with daily urinary collection, a reduced collection frequency of 5, 3, or 2 days each week provides accurate E1G and PdG profiles of collection periods of various lengths and types of menstrual function. Reduction of urinary sample collection frequency may enable researchers to reduce participant burden and costs, increase compliance, and study a wider range of study populations.

2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad.

The female athlete triad is a medical condition often observed in physically active girls and women and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement presents a set of recommendations developed following the first (San Francisco, CA) and second (Indianapolis, IN) International Symposia on the Female Athlete Triad. This consensus statement was intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the female athlete triad and to provide clear recommendations for return to play. The expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts.

Current perspectives on the etiology and manifestation of the "silent" component of the Female Athlete Triad.

The Female Athlete Triad (Triad) represents a syndrome of three interrelated conditions that originate from chronically inadequate energy intake to compensate for energy expenditure; this environment results in insufficient stored energy to maintain physiological processes, a condition known as low energy availability. The physiological adaptations associated with low energy availability, in turn, contribute to menstrual cycle disturbances. The downstream effects of both low energy availability and suppressed estrogen concentrations synergistically impair bone health, leading to low bone mineral density, compromised bone structure and microarchitecture, and ultimately, a decrease in bone strength. Unlike the other components of the Triad, poor bone health often does not have overt symptoms, and therefore develops silently, unbeknownst to the athlete. Compromised bone health among female athletes increases the risk of fracture throughout the lifespan, highlighting the long-term health consequences of the Triad. The purpose of this review is to examine the current state of Triad research related to the third component of the Triad, ie, poor bone health, in an effort to summarize what we know, what we are learning, and what remains unknown.

2014 Female Athlete Triad Coalition consensus statement on treatment and return to play of the female athlete triad: 1st International Conference held in San Francisco, CA, May 2012, and 2nd International Conference held in Indianapolis, IN, May 2013.

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves 3 components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with 1 or more of the 3 Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhea, and osteoporosis. This consensus statement represents a set of recommendations developed following the first (San Francisco, California) and second (Indianapolis, Indianna) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad Expert Panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance, and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team, and implementation of treatment contracts. This consensus paper has been endorsed by The Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians, and other health care professionals, the American College of Sports Medicine, and the American Medical Society for Sports Medicine.

2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013.

The Female Athlete Triad is a medical condition often observed in physically active girls and women, and involves three components: (1) low energy availability with or without disordered eating, (2) menstrual dysfunction and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and an early intervention is essential to prevent its progression to serious endpoints that include clinical eating disorders, amenorrhoea and osteoporosis. This consensus statement represents a set of recommendations developed following the 1st (San Francisco, California, USA) and 2nd (Indianapolis, Indiana, USA) International Symposia on the Female Athlete Triad. It is intended to provide clinical guidelines for physicians, athletic trainers and other healthcare providers for the screening, diagnosis and treatment of the Female Athlete Triad and to provide clear recommendations for return to play. The 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad expert panel has proposed a risk stratification point system that takes into account magnitude of risk to assist the physician in decision-making regarding sport participation, clearance and return to play. Guidelines are offered for clearance categories, management by a multidisciplinary team and implementation of treatment contracts. This consensus paper has been endorsed by the Female Athlete Triad Coalition, an International Consortium of leading Triad researchers, physicians and other healthcare professionals, the American College of Sports Medicine and the American Medical Society for Sports Medicine.

Effect of high dietary restraint on energy availability and menstrual status.

INTRODUCTION: Dietary restraint (DR) is a key eating behavior associated with menstrual disturbances (MD) in exercising women. However, the association between DR and energy availability (EA) has not been examined. PURPOSES: The objective of this study is 1) to compare EA in women when categorized by DR score, to include an evaluation of the frequency of women with low EA, and 2) to compare the distribution of subclinical and clinical MD between DR groups. METHODS: Exercising women (23 ± 4 yr; body mass index, 21.1 ± 1.9 kg·m; and exercise volume, 333 ± 198 min·wk) were retrospectively categorized by DR score into two groups: 1) women with high DR (n = 30) and 2) women with normal DR (n = 56). DR scores were obtained from the Three-Factor Eating Questionnaire. High DR score was defined as ≥13. Body composition was measured using dual-energy x-ray absorptiometry. EA was defined as energy intake - exercise energy expenditure per kilogram lean body mass (LBM). Low EA was defined as <30 kcal·kg LBM. Menstrual status was determined using daily urinary samples assayed for reproductive hormones. RESULTS: EA was lower in the high DR versus the normal DR group (35.0 ± 12.9 vs 42.0 ± 12.9 kcal·kg LBM, P = 0.018). There was no difference (P = 0.866) in frequency of low EA between DR groups. There was a greater frequency of MD (amenorrhea, oligomenorrhea, anovulation, or luteal phase defect) in the high DR group (21/28, 75.0%) versus the normal DR group (24/47, 51.1%) (χ = 4.2, P = 0.041). CONCLUSION: Our findings demonstrate that exercising women with high DR exhibited lower EA and a greater frequency of MD (subclinical and clinical) compared with women with normal DR. However, high DR was not associated with low EA in exercising women.

A case report of recovery of menstrual function following a nutritional intervention in two exercising women with amenorrhea of varying duration.

Increasing caloric intake is a promising treatment for exercise-associated amenorrhea, but strategies have not been fully explored. The purpose of this case report was to compare and contrast the responses of two exercising women with amenorrhea of varying duration to an intervention of increased energy intake. Two exercising women with amenorrhea of short (3 months) and long (11 months) duration were chosen to demonstrate the impact of increased caloric intake on recovery of menstrual function and bone health. Repeated measures of dietary intake, eating behavior, body weight, body composition, bone mineral density, resting energy expenditure, exercise volume, serum metabolic hormones and markers of bone turnover, and daily urinary metabolites were obtained. Participant 1 was 19 years old and had a body mass index (BMI) of 20.4 kg/m(2) at baseline. She increased caloric intake by 276 kcal/day (1,155 kJ/day, 13%), on average, during the intervention, and her body mass increased by 4.2 kg (8%). Participant 2 was 24 years old and had a BMI of 19.7 kg/m(2). She increased caloric intake by 1,881 kcal/day (7,870 kJ/day, 27%) and increased body mass by 2.8 kg (5%). Resting energy expenditure, triiodothyronine, and leptin increased; whereas, ghrelin decreased in both women. Resumption of menses occurred 23 and 74 days into the intervention for the women with short-term and long-term amenorrhea, respectively. The onset of ovulation and regular cycles corresponded with changes in body weight. Recovery of menses coincided closely with increases in caloric intake, weight gain, and improvements in the metabolic environment; however, the nature of restoration of menstrual function differed between the women with short-term versus long-term amenorrhea.

Body composition and reproductive function exert unique influences on indices of bone health in exercising women.

Reproductive function, metabolic hormones, and lean mass have been observed to influence bone metabolism and bone mass. It is unclear, however, if reproductive, metabolic and body composition factors play unique roles in the clinical measures of areal bone mineral density (aBMD) and bone geometry in exercising women. This study compares lumbar spine bone mineral apparent density (BMAD) and estimates of femoral neck cross-sectional moment of inertia (CSMI) and cross-sectional area (CSA) between exercising ovulatory (Ov) and amenorrheic (Amen) women. It also explores the respective roles of reproductive function, metabolic status, and body composition on aBMD, lumbar spine BMAD and femoral neck CSMI and CSA, which are surrogate measures of bone strength. Among exercising women aged 18-30 years, body composition, aBMD, and estimates of femoral neck CSMI and CSA were assessed by dual-energy x-ray absorptiometry. Lumbar spine BMAD was calculated from bone mineral content and area. Estrone-1-glucuronide (E1G) and pregnanediol glucuronide were measured in daily urine samples collected for one cycle or monitoring period. Fasting blood samples were collected for measurement of leptin and total triiodothyronine. Ov (n = 37) and Amen (n = 45) women aged 22.3 ± 0.5 years did not differ in body mass, body mass index, and lean mass; however, Ov women had significantly higher percent body fat than Amen women. Lumbar spine aBMD and BMAD were significantly lower in Amen women compared to Ov women (p < 0.001); however, femoral neck CSA and CSMI were not different between groups. E1G cycle mean and age of menarche were the strongest predictors of lumbar spine aBMD and BMAD, together explaining 25.5% and 22.7% of the variance, respectively. Lean mass was the strongest predictor of total hip and femoral neck aBMD as well as femoral neck CSMI and CSA, explaining 8.5-34.8% of the variance. Upon consideration of several potential osteogenic stimuli, reproductive function appears to play a key role in bone mass at a site composed of primarily trabecular bone. However, lean mass is one of the most influential predictors of bone mass and bone geometry at weight-bearing sites, such as the hip.