1. 2015 Sports Medicine for the Primary Care Physician

2. Female Athlete Triad
Christina Nisonger Murphy, MD

3. Disclosure Slide
No financial disclosures.

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

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

7. Spectrum of Female Athlet Triad

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

9. 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)

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

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

12. 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%

13. - 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%

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

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

16. 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%

17. - 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%

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

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

20. 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%

21. Spectrum of Female Athlete Triad

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

23. 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

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

25. Hypogonadotropic hypogonadism
Low energy availability
Pituitary tumors

26. Spectrum of Female Athlete Triad

27. 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

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

29. 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)

30. Who needs bone density testing?
≥ 2 ‘Moderate risk’ Triad Risk Factors
Current or history of disordered eating for ≥ 6 months
BMI between , <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)

31. 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

32. 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

33. 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%

34. 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

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

36. 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

37. 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

38. 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 kcal/day
Target ≥ 45kcal/kg FFM if possible
Team-based approach
Physician, sports dietician, (if needed) mental health provider

39. 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

40. 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

41. 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

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

43. 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

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

45. 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

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

47. 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

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

49. 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

50. Identifying at Risk Athletes

51. 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)?

52. Cumulative Risk Assessment

53. Cumulative Risk Assessment

54. 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

55. References
De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, Gibbs JC, Olmsted M, Goolsby M, Matheson G 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.

56. 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.