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The Female Athlete Triad: Health Pitfalls for Adolescents

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World Pediatric Bone and Joint Day

Drawing attention to important diseases in children and adolescents

October 19, 2014

The Female Athlete Triad: Health Pitfalls for Adolescents

By Vineeta T. Swaroop, MD, Assistant Professor of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 
 
Sophie* is a 15 year old adolescent with a history of a metatarsal (foot) stress fracture and medial tibial stress syndrome (“shin splints”) who is an avid cross country runner.  Often she does not eat prior to her workouts but otherwise eats 3 meals per day.  Recently she has felt very fatigued and weak during her races, reporting that her legs felt heavy and she would sometimes feel dizzy or disoriented.  She has been running seven days a week, averaging 40-50 miles a week, and has lost 18 pounds in the past year.  At times she feels that running has become a compulsion.  She previously had normal monthly periods but has not menstruated in the past 5 months.  Sophie’s tests showed low bone mineral density and low iron and vitamin D levels. 

In this representative case extreme dieting and exercising have already had detrimental effects on Sophie’s athletic performance and her overall health.  The lack of normal menstrual cycles and proper nutrition to balance her level of exercise are affecting her body’s bone-building and repairing processes and weakening her skeleton.  These problems are manifesting as her stress fracture and shin splints which prevent her from participating in her sport. 

Maintaining a healthy level of activity through sports and exercise is important for girls and women of all ages.  Occasionally, a female athlete may become overly focused on their diet and how much they exercise which can have a negative effect on not only athletic performance, but overall health.  “The Female Athlete Triad” is a medical condition often observed in active girls and women. It involves one or more of the following: low energy (calorie) availability, menstrual dysfunction, and low bone mineral density. Early identification and intervention is essential for preventing the Triad from progressing to serious conditions such as clinical eating disorders, amenorrhea, and osteoporosis,” said Dr. Cynthia Labella of Ann and Robert H. Lurie Children’s Hospital in Chicago, Illinois.  Although female athletes may appear to have a healthy diet, those with this condition typically are not consuming enough calories, especially those contained in fat, to support the amount of exercise in which they participate.  Hence the number of calories they take in does not balance the calories that they use.  This can lead to the bones not receiving enough calories to maintain their normal function and repair small injuries sustained during exercises and day-to-day activities.
 
While females in any sport can develop female athlete triad, certain sports are higher risk.  This includes sports that stress a thin appearance such as figure skating and gymnastics, and sports in which being thin is thought to improve performance such as distance running or rowing.  Adolescent females who have symptoms of the female athlete triad may have low self-esteem or depression, or may feel pressure to lose weight or improve their performance from coaches or parents.
The female athlete triad is composed of three interrelated conditions, which each occur on a spectrum of severity.  The prevalence of the components of the female athlete triad, based on two studies evaluating female adolescent athletes, ranges from 18-35% for disordered eating, 19-54% for menstrual dysfunction, and 13-22% for low bone mineral density.  These rates are much higher than those seen among women and girls in general.

Low energy availability can result from purposeful or unintentional disordered eating.  Affected females may become preoccupied with body shape or weight and demonstrate poor nutritional intake.  Disordered eating can occur in many forms including some who starve themselves (anorexia nervosa) or others who alternate between overeating and purging (bulimia).  Some may also misuse diet pills, diuretics, or laxatives.  However, the athlete’s diet may appear to be adequate, until the number of calories consumed by training is considered.  Low energy availability in an athlete can cause many problems including dehydration, muscle fatigue, erratic heartbeat, damage to the kidney or other serious conditions. 

In addition, inadequate nutrition can lead to bone loss.  This is particularly important in an adolescent because this is the time when your body should be at its peak of developing bone.
Menstrual dysfunction occurs when inadequate nutrition, low calorie intake, high-energy demands, or physical and emotional stress lead to hormonal changes causing you to miss more than three periods in a row, and is cause for concern.  During normal menstruation, the body produces a hormone called estrogen that helps to keep bones strong.  Without a normal menstrual cycle, there may be insufficient estrogen which can lead to more bone loss.  Having low bone mineral density puts an adolescent athlete at higher risk for fractures and other skeletal injuries which can prevent sports participation. 

Recognizing the female athlete triad is the first step in treatment.  Your doctor will ask a number of questions about your diet, exercise level, history of sports injuries or fractures, your menstrual history, changes in your weight, medications, family history, and factors causing stress in your life.  In addition to a physical exam, laboratory tests may be ordered to check for underlying medical conditions.  In some cases a bone density test, called a DEXA scan, may be recommended.  The successful treatment of female athlete triad relies on a team approach including orthopaedic and pediatric specialists.  Members of the treatment team may include your pediatrician, gynecologist, coach, athletic trainer, nutritionist, and psychological counselor.  However, you and your family are the most important members of this team.  Education geared toward promoting healthy behaviors and optimizing bone mass is necessary in order to restore regular physical activity and sports participation, as well as protecting your bones for the future.

“Exercise is vital for women of all ages to build and maintain healthy bones.  When the female athlete triad happens young women can still win the battle by working with their families, coaches and a health care team,” said Ellen M. Raney, MD, FAAP, Affiliate Professor, Oregon Health Sciences University, Shriners Hospitals for Children, Portland, and chair, Pediatric Specialty Group of the U.S. Bone and Joint Initiative.

In Sophie’s case, her treatment team included not only her pediatrician and orthopedic specialist, but also a physical therapist to help treat her orthopaedic injuries, a dietician to educate her about healthy eating, and a psychologist to help her address the factors affecting her mood.  As a result, she reported that running became less of a compulsion to her.  With a comprehensive treatment program, she began gaining weight slowly and her regular monthly periods returned.  With supplementation, her iron and vitamin D levels returned to normal.  Not only was Sophie able to resume running four days a week without further injuries, she even participated in cross country as a collegiate athlete.

The Adolescent Female Athlete Triad is the theme of the 2014 World Pediatric Bone and Joint (PB&J) Day. The day offers an opportunity for the Pediatric Specialty Group of the United States Bone and Joint Initiative to raise awareness about diseases in children and adolescents. In past years the group has drawn attention to diseases that can stem from obesity, and to Kids and Vitamin D deficiency. This year the group turns its attention to the adolescent female athlete triad.

For more information about the Adolescent Female Athlete Triad, visit the website for the American Academy of Pediatrics, or Your Orthopaedic Connection. This story is brought to you by the United States Bone and Joint Initiative as part of World Pediatric Bone and Joint (PB&J) Day, celebrated on October 19, which is part of Bone and Joint National Action Week (Oct. 12-20).

*Name changed to protect privacy 

References:
Barrack MT, Ackerman KE, Gibbs JC.  Update on the female athlete triad.  Curr Rev Musculoskelet Med 2013;6(2):195-204.
 
Other sources of information on sports injuries: 
American Medical Society for Sports Medicine (AMSSM)
American Physical Therapy Associaton (APTA)
Pediatric Orthopaedic Society of North America (POSNA)