2015 Sports Medicine for the Primary Care Physician

Female Athlete Triad Christina Nisonger Murphy, MD

Disclosure Slide No financial disclosures.

Objectives Define female athlete triad Components of female athlete triad Treatment of female athlete triad Screening tools

Female Athlete Triad Low energy availability with or without disordered eating Menstrual dysfunction Low bone mineral density

Spectrum of Female Athlet Triad

Low Energy Availability Does not require an eating disorder Inadequate caloric intake: Pathologic caloric restriction Expending more calories than are taken in

Calculating Energy Availability Normal > 45 kcal/kg Negative effects at ≤ 30 kcal/kg BMI < 17.5 suggests low energy availability Adolescents < 85% Estimated Body Weight Calories consumed – Calories expended Energy Availability = Lean Body Mass (kg)

EBW - McLaren Method 17 yoF 5’ 2”, 90 pound Track athlete Weight 50%ile Weight/Height %EBW = X 100

EBW - McLaren Method 17 yoF 5’ 2”, 90 pound Track athlete Weight 50%ile Weight/Height %EBW = X 100 102

EBW - McLaren Method 17 yoF 5’ 2”, 90 pound Track athlete Weight 50%ile Weight/Height %EBW = X 100 90 102 %EBW = X 100 102 %EBW = 88%

- cannot calculate EBW for: girls >163 cm (5’ 4”) EBW - McLaren Method 17 yoF 5’ 2”, 90 pound Track athlete Limitations: - cannot calculate EBW for: girls >163 cm (5’ 4”) boys >176 cm (5’ 9”) Weight 50%ile Weight/Height %EBW = X 100 90 102 %EBW = X 100 102 %EBW = 88%

EBW – Moore Method 17 yoF 5’ 2”, 90 pound Track athlete Weight Matched %ile Weight %EBW = X 100

EBW – Moore Method 17 yoF 5’ 2”, 90 pound Track athlete Weight Matched %ile Weight %EBW = X 100

EBW – Moore Method 17 yoF 5’ 2”, 90 pound Track athlete Weight Matched %ile Weight %EBW = X 100 90 108 %EBW = X 100 108 %EBW = 83%

- cannot easily be used for: >97th percentile < 3rd percentile EBW – Moore Method 17 yoF 5’ 2”, 90 pound Track athlete Limitations: - cannot easily be used for: >97th percentile < 3rd percentile Weight Matched %ile Weight %EBW = X 100 90 108 %EBW = X 100 108 %EBW = 83%

EBW – BMI Method 17 yoF 5’ 2”, 90 pound Track athlete BMI 16.5 BMI 50th Percentile BMI %EBW = X 100

EBW – BMI Method 17 yoF 5’ 2”, 90 pound Track athlete BMI 16.5 21 BMI 50th Percentile BMI %EBW = X 100

EBW – BMI Method 17 yoF 5’ 2”, 90 pound Track athlete BMI 16.5 BMI 50th Percentile BMI %EBW = X 100 21 16.5 21 %EBW = X 100 %EBW = 78%

Spectrum of Female Athlete Triad

Menstrual Dysfunction Primary amenorrhea Secondary amenorrhea Oligomenorrhea (<9 menses/12 months)

Secondary Amenorrea Secondary Amenorrhea Abnormal TSH TSH, Prolactin, beta-hCG Abnormal TSH Elevated Prolactin Normal Pregnancy Other testing to consider: -Estradiol -Total, free testosterone -DHEA, DHEA-S -Early morning 17-hydroxyprogesterone

Secondary Amenorrhea Gonadotrophins (LH/FSH) Low Normal Elevated Progestin Challenge Negative Positive Premature Ovarian Failure Functional Hypothalamic Amenorrhea Chronic Anovulation Hypothalamic-Pituitary Etiology

Hypogonadotropic hypogonadism Low energy availability Pituitary tumors

Spectrum of Female Athlete Triad

Low Bone Density -- Adolescents Requires presence of clinically significant fracture history AND low bone mineral density Clinically significant fracture: Long bone fracture of the lower extremity Vertebral compression fracture Two or more long bone fractures of the upper extremity Low BMD: Z-score ≤ -2.0 adjusted for age, gender, body size Weight bearing athletes: Low BMD <-1.0

Low Bone Density -- Premenopausal Low BMD – Z-score ≤ -2.0 Osteoporosis: Z-score ≤ -2.0 AND secondary cause of osteoporosis

Who needs bone density testing? ≥ 1 ‘High risk’ Triad Risk Factors History of DSM-V-diagnosed eating disorder BMI ≤ 17.5, <85% estimated body weight Recent weight loss of ≥ 10% in 1 month Menarche ≥ 16yo Current or history of < 6 menses over 12 months Two prior stress fractures One high risk stress fracture – femoral neck, pelvis, sacrum Low-energy non-traumatic fracture Prior Z-score of <-2.0 (at least 1 year ago)

Who needs bone density testing? ≥ 2 ‘Moderate risk’ Triad Risk Factors Current or history of disordered eating for ≥ 6 months BMI between 17.5-18.5, <90% estimated body weight Recent weight loss of 5-10% in 1 month Menarche between 15 and 16yo Current or history of 6-8 menses over 12 months One prior stress fracture Prior Z-score between -1.0 and -2.0 (at least 1 year ago)

Others to consider History of ≥ 1 non-peripheral or ≥ 2 peripheral long bone traumatic fractures (nonstress) AND One moderate- or high-risk Triad risk factors

Where to scan? Adolescents (<20yo) Adult women (≥ 20yo) Posteroanterior spine Whole body (less head if possible) Adjust for growth delay (with height or height-age) Adjust for maturation (bone-age) Use pediatric reference data Adult women (≥ 20yo) Weight-bearing sites Femoral neck Total Hip

Consequences of decreased BMD N = 259 female athletes (age 18 ± 0.3) Average BMI: 21.5 ± 0.2 65% exercise ≥ 12hrs/wk Stress injury in 28 participants (10.6%) BMI < 21 – 15.3% Oligo/amenorrhea – 10.9% Exercise ≥ 12hr/wk – 14.7% BMI < 21 Oligo/amenorrhea Exercise ≥ 12hr/wk 29.2%

Associations Between Disordered Eating, Menstrual Dysfunction and Musculoskeletal Injury Among High School Athletes N = 850 high school athletes Disordered Eating – 35.4% Menstrual Dysfunction – 18.8% MSK Injury – 65.6% Overuse Injury: Upper extremity – 27% Lower extremity – 43.1% Age: 15.4 ± 1.2 Average BMI: 21.1 ± 3.0

Associations Between Disordered Eating, Menstrual Dysfunction and Musculoskeletal Injury Among High School Athletes Increased risk of OU injury in aesthetic athletes – OR 5.0

Associations Between Disordered Eating, Menstrual Dysfunction and Musculoskeletal Injury Among High School Athletes MENSTRUAL Menstrual Dysfunction = < 9 periods/12 months or no menarche in athletes < 15yo

Treatment should focus on ‘restoration or normalization of body weight as the best strategy for successful resumption of menses and improved bone health.’ -- ACSM 2014 Consensus Statement

Low Energy Availability Weight gain leading to resumption of menses Typically 5 – 10% weight gain (1 – 4kg) Achieve a BMI of ≥ 18.5 kg/m2 or ≥ 90% predicted body weight Increase in caloric intake 250-500 kcal/day Target ≥ 45kcal/kg FFM if possible Team-based approach Physician, sports dietician, (if needed) mental health provider

Excluded N = 50 NCAA athletes with oligo/amenorrhea 12 amenorrhea, 38 oligomenorrhea ROM = Return Of Menses 5-year follow up with non-pharmacologic management with dietary and exercise interventions therapy 28% track and field/CC 22% gymnastics Excluded

Low BMD Weight gain and subsequent resumption of menses are key to prevent further loss of bone mass. Amenorrheic women women will lose ~2-3% of bone mass per year if untreated

Increased weight by 10% or to ≥ 85% ideal body weight N = 75 anorexic women Age: 24.4 ± 0.6 % Ideal Body Weight: 75.8 ± 0.8 PA Spine BMD Hip BMD Increased weight by 10% or to ≥ 85% ideal body weight

N = 75 anorexic women Age: 24.4 ± 0.6 % Ideal Body Weight: 75.8 ± 0.8 PA Spine BMD Hip BMD

Greatest improvement with weight gain and resumption of menses N = 75 anorexic women Age: 24.4 ± 0.6 % Ideal Body Weight: 75.8 ± 0.8 PA Spine BMD Hip BMD Greatest improvement with weight gain and resumption of menses

Pharmacologic Management Consider pharmacologic management if: Lack of response to nonpharmacologic treatment for ≥ 1 year New fractures occur during nonpharmacologic management

Pharmacologic Management Combined oral/non-oral contraceptives OCP therapy is NOT associated with consistent improvement in BMD and may further compromise bone health DO NOT RESTORE SPONTANOUES MENSES and provide a false sense of security

Increased bone density Mechanism Growth Hormone + IGF-I Increased bone density

Synthetic function inhibted Mechanism Growth Hormone + Synthetic function inhibted IGF-I IGF-I is already decreased in amenorrheic athletes Vaginal and transdermal estrogen gets around first pass metabolism First pass metabolism Estrogen

Hormonal Treatment Consider hormonal therapy if: Symptoms of estrogen deficiency Vaginal dryness Dyspareunia Impaired bone health despite implementation of non-pharmacologic therapy

Pharmacologic therapy Combined oral contraceptive 20-35μg ethinyl estradiol Transdermal estradiol with cyclic progesterone 100μg 17β-estradiol (unproven contraceptive efficacy) Bisphosphonates? Teriparatide? Refer to endocrinology OCP may MAINTAIN BMD in those with low BMD

Identifying at Risk Athletes

Screening Questions Have you ever had a menstrual period? How old were you when you had your first menstrual period? When was your most recent menstrual period? How many periods have you had in the last 12 months? Are you presently taking any female hormones(estrogen, progesterone, OCP)? Do you worry about your weight? Are you trying to or has anyone recommeneded that you gain or lose weight? Are you on a special diet or do you aovid certain types of foods or food groups? Have you ever had an eating disorder? Have you ever had a stress fracture? Have you ever been told you have low bone density (osteopenia or osteoporosis)?

Cumulative Risk Assessment

Cumulative Risk Assessment

Summary Low energy availability and body weight are the central factor in the triad and the focus of treatment Screening of athletes during PPE can help identify and treat at risk athletes early preventing poor outcomes

References De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, Gibbs JC, Olmsted M, Goolsby M, Matheson G. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad. Clinical Journal of Sports Medicine. March 2014; 24 (2). Le Grange D, Doyle P, Swanson S, Ludwig K, Glunz C, Kreipe R. Calculation of Expected Body Weight in Adolescents With Eating Disorders. Pediatrics. February 2006; 129 (2). Barrack MT, Gibbs JC, De Souza MJ, et al. Higher incidence of bone stress injury with increasing female athlete triad risk factors: a prospective multisite study of exercising girls and women. Am J Sports Med. April 2014; 42 (2). Thein-Nissenbaum JM, Rauh MJ, Carr KE, et al. Associations between disordered eating, menstrual dysfunction, and musculoskel- etal injury among high school athletes. J Orthop Sports Phys Ther. 2011;41:60–69.

References Arends JC, Cheung MY, Barrack MT, et al. Restoration of menses with nonpharmacologic therapy in college athletes with menstrual disturban- ces: a 5-year retrospective study. Int J Sport Nutr Exerc Metab. 2012; 22:98–108. Miller KK, Lee EE, Lawson EA, et al. Determinants of skeletal loss and recovery in anorexia nervosa. J Clin Endocrinol Metab. 2006;91: 2931–2937.