Determinants of menstrual dysfunction in the female athlete triad: A cross-sectional study in Italian athletes.

BACKGROUND: In 1992 the American College of Sports Medicine first described the Female Athlete Triad. The Triad is a metabolic injury involving three distinct clinical traits: low energy availability, with possible eating disorder, low bone mineral density and menstrual dysfunction (MD). Although the estimated prevalence of the Triad is low (1.2 %), single factors are common in female athletes, at all competitive levels and ages. Even though the Triad was described over two decades ago, the interrelation of the three diagnostics components is still debated: additional evidence is required to improve the multidisciplinary treatment approach for this complex condition. MD is one of the first signs of energy impairment. The present study aims at investigating MD determinants and predictors in female athletes, to allow an early diagnosis of the Triad and to implement adequate preventive strategies. MATERIALS AND METHODS: An original structured questionnaire was composed to detect the presence of MD risk factors. Included participants were active female athletes within reproductive age range (15-40 years old). Anthropometric parameters and training-related factors, possibly affecting the regularity of the menstrual cycle, were investigated. RESULTS: Respondents were 288 female athletes. Among them, 73.3 % were under 25 years of age; 6.6 % resulted underweight; 30.6 % reported to follow a meal plan/diet and 13.9 % declared to be a smoker. Lean sports were practiced by 30.6 % of responders. Body-weight congruence was detected in in 79.9 % of participants, whereas overestimation of body image was found in 16.3 % of athletes. Irregular menstrual cycle, a possible MD predictor, was present in 33.0 % of athletes, with 41.1 % practicing some lean sport (p = 0.007). Also, overestimation of body image suggested an increased risk of menstrual irregularity (p = 0.001). BMI <18.5 or BMI >30 could also act as risk factor, although significance was not fully obtained (p = 0.053). Overall, practice of lean sports and overestimation of body image appeared good determinants of increased menstrual irregularity (AOR 2.02 and 3.83, respectively). CONCLUSIONS: Menstrual irregularity in female athletes can be considered an early predictor of MD: risk is further increased in athletes of lean sports and reporting an overestimation of self-perceived body image. Screenings and awareness programs should specifically address female athletes, because of their vulnerable-group profile. In order to define a standardized at-risk profile for Triad onset and sequelae likelihood, evaluation of menstrual regularity should especially be considered, in conjunction with the assessment of other indicators of energy availability (e.g. TEE, lean and fat mass, BMC). Testing for sport-derived stress and disordered eating attitudes is also recommended. Preventive strategy should involve the proactive engagement of sport clubs and periodic competitive sport medical assessment.

Female Athlete Triad: Lack of Awareness and Subsequent Consequences.

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An Assessment of the Early Symptoms of Energy Deficiency as a Female Athlete Triad Risk among the Polish National Kayaking Team Using LEAF-Q.

Background: Kayaking is a high intensity sport that demands high levels of aerobic and anaerobic capacity as well as a great deal of strength and endurance. The aim of this study was an assessment of the frequency of occurrence of early low energy availability symptoms using the Low Energy Availability in Females Questionnaire for women belonging to the Polish national kayaking team. Additionally, quantitative measurements of body composition and levels of calcium were performed. Methods: The study involved 33 women who were competitors in the Polish national kayaking team. Results: An analysis of the results in terms of disorders in the monthly cycle in the tested kayakers found that only five competitors, approximately 15% of the entire group, had this type of problem. Between the participants who had disorders of the menstrual cycle and those whose cycle was normal, there was only a statistically significant difference at the level of p < 0.001 in relation to the age of the kayakers. Conclusions: The Low Energy Availability in Females Questionnaire proved to be a useful screening tool, which allowed for the early detection of Female Athlete Triad symptoms in several young female kayakers from the Polish national team.

Nutritional Concerns among Female International Volunteers Based on the Income and Development Status of Their Country of Service.

This study aimed to determine the prevalence of female athlete triad risk factors among female international volunteers based on the development and income status of their country of service. A total of 2164 past volunteers completed a retrospective survey. Countries' income and development statuses were coded using the respective annual United Nations World Economic Situations and Prospects reports. Independent t-tests, ANOVAs, and Pearson's Chi-Squared tests were used to assess group differences; corresponding odds ratios were calculated. Volunteers in nondeveloped (OR = 2.25, CI = 1.85-2.75) and non-high-income (OR = 2.17, CI = 1.75-2.70) countries had over twice the odds of experiencing secondary amenorrhea. More volunteers who served in nondeveloped countries reported an increase in exercise while serving (p = 0.005). Those who served in a nondeveloped (OR = 1.52, CI = 1.16-1.98) or non-high-income (OR = 1.45, CI = 1.08-1.94) country had higher odds of weight loss. However, volunteers serving in nondeveloped (OR = 0.52, CI = 0.44-0.63) and non-high-income (OR = 0.50, CI = 0.4-0.61) countries were less likely to report food insecurity compared to those in developed and high-income countries. Bone mineral density was within the expected range regardless of income and development status. Female volunteers who served in nondeveloped and non-high-income countries experienced higher odds of secondary amenorrhea, which was likely influenced by an increase in exercise and higher odds of weight loss.

The Female Athlete Triad-the impact of running and type of diet on the regularity of the menstrual cycle assessed for recreational runners.

Background: The Female Athlete Triad (FAT) included three interrelated conditions including disordered eating, amenorrhea, and osteoporosis. The American College of Sports Medicine updated the definition of FAT to reflect the interdependence of low energy availability with or without eating disorders. The main aim of the study was to assess the impact of recreational running on potential disturbances in the regularity of women's menstrual cycles. Additionally, this work compared differences in the menstrual cycle between women runners and women who did not regularly practice sports. The respondents were also asked about the type of diet they consumed. Methods: A total of 360 women took part in the research. This group included 217 runners and 143 control. The authors' questionnaire was used in the research. Results: When compared to the control group, the runners had an increased frequency of menstrual cycles of <24 days (10.14% vs. 3.50%), fewer typical cycles of 25-31 days (75.58% vs. 86.71%), had fewer regular cycles per year (9.62 vs. 11.22), shorter duration of bleeding (4.79 vs. 5.27 days), and an increased frequency of painless menstruation (23.96% vs. 7.69%). A positive predictor of menstrual cycle disorders was the use of a 'special diet' (R:1.67; 95% C:0.47-2.87). Conclusions: The runners had shorter and less regular monthly cycles and shorter and more often painless menstrual bleeding when compared to the control group. The frequency of menstrual disorders in runners was increased by following a 'special diet'. The frequency of menstrual cycle disorders in runners, however, did not differ significantly from the control group.

Examination of the Prevalence of Female Athlete Triad Components among Competitive Cheerleaders.

The purpose of this study was to examine individual and combined Female Athlete Triad components within collegiate cheerleaders, an at-risk group. Cheerleaders (n = 19; age: 20.3 ± 1.2 years) completed anthropometric measurements, health history questionnaires, resting metabolic rate, the eating disorder inventory-3 and symptom checklist, blood sample, and DXA scan. Participants completed dietary and exercise logs for 7 days and used heart rate monitors to track daily and exercise energy expenditure. Proportions were calculated for low energy availability (LEA) risk, disordered eating risk, and pathogenic behaviors. Chi-square analysis was used to determine the difference between cheerleaders who experience low EA with or without disordered eating risk. All cheerleaders demonstrated LEA for the days they participated in cheerleading practice, 52.6% demonstrated LEA with eating disorder risk and 47.4% demonstrated LEA without eating disorder risk, 52.6% self-reported menstrual dysfunction, 14% experienced menstrual dysfunction via hormonal assessment, and 0% demonstrated low bone mineral density. Overall, 47.7% presented with one Triad component, 52.6% demonstrated two Triad components using self-reported menstrual data, and 10.5% demonstrated two Triad components using hormonal assessments. All cheerleaders displayed LEA. These findings support the need for increased education on the individual components of the Triad and their potential consequences by qualified personal.

The female athlete triad: review of current literature.

PURPOSE OF REVIEW: Adolescence and young adulthood are a critical period in the life of women for optimizing long-term bone health. Young athletes lead a demanding lifestyle with increased dietary requirements to meet the robust demands of energy expenditure to maintain a state of energy balance. During a time of fast paced changes and unpredictable societal demands on young athletes, it is important to review the severe consequences of energy deficiency and options for adequate management. RECENT FINDINGS: This review focuses on hormonal adaptations that occur in energy deficient female athletes that lead to menstrual irregularities and impaired bone health, increasing the risk for stress and other fractures. We also describe management strategies to mitigate the consequences of limited energy availability on bone and other outcomes. SUMMARY: These strategies should help guide the management of young female athletes to prevent irreversible changes to their bone health. Identifying current knowledge should help increase awareness among medical providers, which can then be communicated to the sports community, parents, and athletes.

Energy deficiency, menstrual disorders, and low bone mineral density in female athletes: a systematic review.

PURPOSE: Low energy availability (LEA) may lead to menstrual disorders and low bone mineral density, predisposing to the female athlete triad. The primary aim of the present review was to systematically investigate the impact of chronic strenuous exercise on the energy status of professional female athletes compared to sedentary, recreationally active controls as concerns their menstrual status and bone mineral density (BMD). A secondary aim was evaluation of the combined prevalence of the components of the female athlete triad in athletes as compared to non-athletes. METHODS: A systematic review was conducted from 2007 to February 2018. The inclusion and exclusion criteria of the studies were established in advance of the literature search according to the clinical inquiry and the study design. RESULTS: Four studies were included in this systematic review. The female athlete triad was more prevalent in professional athletes compared to non-athletes. The same results were obtained for both LEA and menstrual disorders. However, BMD and Z-scores showed high heterogeneity among the studies. CONCLUSION: Both female athletes and non-athletes are prone to LEA and subsequent menstrual disorders and low BMD or osteoporosis. Future studies are needed to examine energy availability in elite female athletes as well as in non-athletes.

Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States.

BACKGROUND: Menstrual irregularity (MI) is common in female athletes and is a component of the Female Athlete Triad (Triad). Many athletes with the Triad are started on hormonal contraceptives (HC) for MI, but this interferes with the ability to monitor menstrual cycle regularity and can mask other causes of MI. There are limited studies investigating the relationship between MI, HC use, and injury in female collegiate athletes. OBJECTIVE: To examine the prevalence of and relationship between HC use, MI, and bone stress injuries in female collegiate athletes in the United States. DESIGN: Cross-sectional study. SETTING: Online survey. PARTICIPANTS: 1020 U.S. female collegiate athletes (age ≥ 18 years). METHODS OR INTERVENTIONS: Assessment of risk factors for menstrual irregularity and bone stress injuries was conducted via a one-time survey. MAIN OUTCOME MEASURES: HC use, MI, history of stress fractures. RESULTS: Current HC use prevalence was 65% (95% confidence interval [CI], 61.9%, 67.8%). Of all athletes, 47% reported past MI. Of the athletes who were not currently using HCs, 32% had current MI. Compared with athletes without past MI, more athletes with past MI reported current HC use (73% vs. 57%) and indicated menstrual cycle consistency as the primary reason for use (24% vs. 4%) (P < .001). Additionally, 25% of athletes reported a history of stress fractures, which was associated with lean/aesthetic sports participation (odds ratio [95% CI]: 1.9 [1.4, 2.5]; P < .001) and less oral contraceptive pill (OCP) use (0.7 [0.5, 1.0]; P = .043). Compared with OCPs, injectable HCs were associated with greater odds of a history of stress fractures (4.5[1.6, 12.3]; P = .004). CONCLUSIONS: HC use was prevalent among this cohort of female collegiate athletes, and almost half of the athletes reported past MI. A goal of menstrual cycle regularity was cited by 24% of athletes as a primary reason to use HCs, which shows that more athlete education is needed to avoid masking MI and the Triad with HCs. Further studies elucidating the relationship between HC use, MI, and sports-related injury are warranted.

The Female Athlete Triad - What it is and Why it is Important in Primary Care.

The female athlete triad (FAT) is a disorder involving greater energy expenditure than energy consumption leading to 1) low energy availability (EA) with or without disordered eating 2) menstrual irregularities or amenorrhea and 3) low bone mineral density. Consequences of FAT include osteoporosis, stress fractures, increased cardiovascular risk, infertility, and negative psychological effects. The key risk factor for FAT is inadequate caloric intake when compared to the amount and intensity of exercise. All female athletes should be screened at least annually at pre-participation physicals or with signs of disordered eating, weight loss, abnormal growth or development, menstrual dysfunction, recent injuries, decreased athletic performance, or mood changes. Presence of one of the components of the triad necessitates further investigation. Treatment involves a multidisciplinary approach with increased energy intake and decreased exercise intensity being the primary goal of treatment. Understanding FAT is important for preventative medicine, as some consequences, such as infertility and loss of bone mineral density may not be reversible.

Exploring Health Demographics of Female Collegiate Rowers.

CONTEXT: Limited information exists about health patterns among female rowers at the collegiate level. Furthermore, the element of weight class (lightweights classified as <130 lb [59 kg]) as a factor in the physical and mental health of female collegiate athletes has not been investigated, despite weight requirements in sport being a risk factor for the female athlete triad. OBJECTIVE: To test the hypotheses that (1) components of the female athlete triad were more prevalent in lightweight than in openweight rowers; (2) perceived stress levels were greater in lightweight than in openweight rowers; and (3) rowers who were unable to row due to injury had greater perceived stress levels than uninjured athletes. DESIGN: Cross-sectional study. SETTING: Twelve collegiate women's rowing programs consisting of 6 National Collegiate Athletic Association Division I openweight and 6 Intercollegiate Rowing Association-level lightweight teams. PATIENTS OR OTHER PARTICIPANTS: A total of 158 female collegiate rowers (78 lightweight, 80 openweight). MAIN OUTCOME MEASURE(S): An electronic survey addressing injury history, diet and eating habits and body image (according to the triad screening questionnaire), stress levels (Perceived Stress Scale), and athlete identity (Athlete Identity Measurement Scale) was administered. RESULTS: Lightweight rowers reported limiting or carefully controlling foods more frequently than openweight rowers (41.9% to 29.9%, P = .013). A history of an eating disorder was more prevalent among lightweight than openweight rowers (25.7% to 13.0%, P = .048). Prevalences of stress fractures and menstrual irregularities did not differ between weight classes. Lightweight and openweight rowers' scores on the Perceived Stress Scale (16.0 ± 9.9 and 17.3 ± 6.4, respectively) were not different. Injured rowers scored higher on the Perceived Stress Scale (19.4 ± 7.2) than did uninjured rowers (16.6 ± 5.72). CONCLUSIONS: Weight class did not contribute to differences in the prevalence of female athlete triad components or perceived stress, although lightweight rowers were more likely to have a history of eating disorder. Injury may be a risk factor for increased stress in this population.

Hypogonadism in Exercising Males: Dysfunction or Adaptive-Regulatory Adjustment?

For decades researchers have reported men who engaged in intensive exercise training can develop low resting testosterone levels, alterations in their hypothalamic-pituitary-gonadal (HPG) axis, and display hypogonadism. Recently there is renewed interest in this topic since the International Olympic Committee (IOC) Medical Commission coined the term "Relative Energy Deficiency in Sports" (RED-S) as clinical terminology to address both the female-male occurrences of reproductive system health disruptions associated with exercise. This IOC Commission action attempted to move beyond the sex-specific terminology of the "Female Athlete Triad" (Triad) and heighten awareness/realization that some athletic men do have reproductive related physiologic disturbances such as lowered sex hormone levels, HPG regulatory axis alterations, and low bone mineral density similar to Triad women. There are elements in the development and symptomology of exercise-related male hypogonadism that mirror closely that of women experiencing the Triad/RED-S, but evidence also exists that dissimilarities exist between the sexes on this issue. Our research group postulates that the inconsistency and differences in the male findings in relation to women with Triad/RED-S are not just due to sex dimorphism, but that there are varying forms of exercise-related reproductive disruptions existing in athletic men resulting in them displaying a relative hypogonadism condition. Specifically, such conditions in men may derive acutely and be associated with low energy availability (Triad/RED-S) or excessive training load (overtraining) and appear transient in nature, and resolve with appropriate clinical interventions. However, manifestations of a more chronic based hypogonadism that persists on a more permanent basis (years) exist and is termed the "Exercise Hypogonadal Male Condition." This article presents an up-to-date overview of the various types of acute and chronic relative hypogonadism found in athletic, exercising men and proposes mechanistic models of how these various forms of exercise relative hypogonadism develop.

Common Medical Concerns of the Female Athlete.

Women are increasingly participating in more and more sporting activities. For years, women athletes have been treated as the "female" equivalent of male athletes, with similar medical approaches but this is changing. The concept that women are unique in their "athletic arena" is further underscored with emerging scientific evidence--from the physiologic details not visible to the eye, to the more overt biomechanical and anatomic differences. We review a handful of conditions active women potentially may encounter: pregnancy, the female athlete triad, patellofemoral pain, potential injuries to the anterior cruciate ligament, and anemia.

The Female Athlete Triad: A Comparison of Knowledge and Risk in Adolescent and Young Adult Figure Skaters, Dancers, and Runners.

STUDY OBJECTIVE: The female athlete triad is often found in sports that value leanness and aesthetics and can lead to adverse health effects. We aimed to compare knowledge and risk of the triad among adolescent figure skaters, dancers, and runners. DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES: We advertised our survey on social media platforms: sports-specific forums; Facebook; and Instagram. We received 928 responses. We included female figure skaters, dancers, and runners aged 25 years or younger (N = 712). We asked participants to name the triad components and dichotomized knowledge scores as high or low. We developed a 6-question triad risk scale and defined "at risk" if participants endorsed 3 or more questions. RESULTS: Of 712 participants: 60% were figure skaters; 28% dancers; 12% runners; 78% were adolescents (≤17 years of age); 22% young adults (18-25 years); 12% had heard of the triad. A higher proportion of runners than figure skaters and dancers had high knowledge of the triad (16% vs 6% vs 5%, P < .01). Overall 60% of athletes were "at risk" of the triad, 25% skipped a period for 3 or more months, and 34% had a history of stress fractures or shin splints. Young adults vs adolescents and dancers vs figure skaters and runners had nearly twice the odds of triad risk. CONCLUSION: Most athletes were at risk of the triad but few knew about it. Dancers were at higher risk compared with figure skaters and runners. Efforts should be made to raise awareness of the triad among athletes, parents, and coaches, with special attention paid to the dance community.

Female Athlete Triad.

The female athlete triad is a condition seen in physically active female athletes, consisting of low energy availability, menstrual dysfunction, and low bone mineral density. The condition should be viewed as a metabolic injury. It can have an impact on female athletes at any age or level. Activities at highest risk are those emphasizing leanness, aesthetics, and endurance. The cornerstone of treatment is improving mismatched energy balance. A multidisciplinary team, including health care providers, dieticians, and mental health professionals, is vital in caring for female athlete triad patients. Increased awareness and education are needed for medical as well as athletic communities.

Reduced energy availability: implications for bone health in physically active populations.

PURPOSE: The present review critically evaluates existing literature on the effects of short- and long-term low energy availability (EA) on bone metabolism and health in physically active individuals. METHODS: We reviewed the literature on the short-term effects of low EA on markers of bone metabolism and the long-term effects of low EA on outcomes relating to bone health (bone mass, microarchitecture and strength, bone metabolic markers and stress fracture injury risk) in physically active individuals. RESULTS: Available evidence indicates that short-term low EA may increase markers of bone resorption and decrease markers of bone formation in physically active women. Bone metabolic marker responses to low EA are less well known in physically active men. Cross-sectional studies investigating the effects of long-term low EA suggest that physically active individuals who have low EA present with lower bone mass, altered bone metabolism (favouring bone resorption), reduced bone strength and increased risk for stress fracture injuries. CONCLUSIONS: Reduced EA has a negative influence on bone in both the short- and long-term, and every effort should be made to reduce its occurrence in physically active individuals. Future interventions are needed to explore the effects of long-term reduced EA on bone health outcomes, while short-term low EA studies are also required to give insight into the pathophysiology of bone alterations.

Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes.

BACKGROUND: The female athlete triad (referred to as the triad) contributes to adverse health outcomes, including bone stress injuries (BSIs), in female athletes. Guidelines were published in 2014 for clinical management of athletes affected by the triad. PURPOSE: This study aimed to (1) classify athletes from a collegiate population of 16 sports into low-, moderate-, and high-risk categories using the Female Athlete Triad Cumulative Risk Assessment score and (2) evaluate the predictive value of the risk categories for subsequent BSIs. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 323 athletes completed both electronic preparticipation physical examination and dual-energy x-ray absorptiometry scans. Of these, 239 athletes with known oligomenorrhea/amenorrhea status were assigned to a low-, moderate-, or high-risk category. Chart review was used to identify athletes who sustained a subsequent BSI during collegiate sports participation; the injury required a physician diagnosis and imaging confirmation. RESULTS: Of 239 athletes, 61 (25.5%) were classified into moderate-risk and 9 (3.8%) into high-risk categories. Sports with the highest proportion of athletes assigned to the moderate- and high-risk categories included gymnastics (56.3%), lacrosse (50%), cross-country (48.9%), swimming/diving (42.9%), sailing (33%), and volleyball (33%). Twenty-five athletes (10.5%) assigned to risk categories sustained ≥1 BSI. Cross-country runners contributed the majority of BSIs (16; 64%). After adjusting for age and participation in cross-country, we found that moderate-risk athletes were twice as likely as low-risk athletes to sustain a BSI (risk ratio [RR], 2.6; 95% confidence interval [95% CI], 1.3-5.5) and high-risk athletes were nearly 4 times as likely (RR, 3.8; 95% CI, 1.8-8.0). When examining the 6 individual components of the triad risk assessment score, both the oligomenorrhea/amenorrhea score ( P = .0069) and the prior stress fracture/reaction score ( P = .0315) were identified as independent predictors for subsequent BSIs (after adjusting for cross-country participation and age). CONCLUSION: Using published guidelines, 29% of female collegiate athletes in this study were classified into moderate- or high-risk categories using the Female Athlete Triad Cumulative Risk Assessment Score. Moderate- and high-risk athletes were more likely to subsequently sustain a BSI; most BSIs were sustained by cross-country runners.

Knowledge, Attitude, and Skill of High School Coaches with Regard to the Female Athlete Triad.

STUDY OBJECTIVE: The purpose of this study was to investigate knowledge high school coaches have about the female athlete triad and to determine if gender differences in knowledge, attitudes, and behaviors exist. DESIGN: Cross-sectional survey. SETTING: Twenty-six high schools in and around the vicinity of Cleveland, Ohio. PARTICIPANTS: Two-hundred currently employed high school coaches. INTERVENTIONS: Participants completed a 30-question survey used to assess knowledge, attitudes, and behaviors coaches had about the female athlete triad. MAIN OUTCOME MEASURES: Descriptive statistics (means, SD, frequency) and gender differences in response to triad knowledge, attitude, and behavior questions. RESULTS: One hundred twenty-three high school coaches completed the survey. Survey respondents were between 25 and 35 years of age, coached for 6-10 years, and coached female athletes 75%-100% of the time. Twenty-four percent reported "having heard of the triad" and 14% (17 of 123) were able to correctly name all of its components. There were no significant differences between gender and the coach's ability to correctly name the 3 triad components (t = 1.47, P = .14). There was no correlation between coach gender (r = 0.13, P = .07), age (r = 0.07, P = .42), number of years of coaching (r = 0.014, P = .88), and coach's knowledge of the triad components, respectively. CONCLUSION: Female athletes might be at risk for developing the female athlete triad and high school coaches can be instrumental in identifying athletes who are at risk. This study showed that gaps in knowledge about the triad exist and that educating coaches about the condition could serve as an important means of prevention for the condition.