Should you suspect the female athlete triad?

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Applied Evidence

Should you suspect the female athlete triad?

J Fam Pract. 2014 April;63(4):187-192

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References

1. Nattiv A, Loucks AB, Manore MM, et al; American College of Sports Medicine. American College of Sports Medicine position stand on the female athlete triad. Med Sci Sports Exerc. 2007;39:1867-1882.

2. Nattiv A, Agostini R, Drinkwater B, et al. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med. 1994;13:405-418.

3. Nichols JF, Rauh MJ, Lawson MJ, et al. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160:137-142.

4. Torstveit MK, Sungot-Borgen J. The female athlete triad exists in both athletes and controls. Med Sci Sports Exerc. 2005; 37:1449-1459.

5. Byrne S, McLean N. Elite athletes: effects of the pressure to be thin. J Sci Med Sport. 2002;5:80-94.

6. Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med. 2004;14:25-32.

7. Beals KA, Manore MM. Disorders of the female athlete triad among collegiate athletes. Int J Sport Nutr Exerc Metab. 2002;12:281-293.

8. De Souza MJ, Miller BE, Loucks AB, et al. High frequency of luteal phase deficiency and anovulation in recreational women runners: blunted elevation in follicle-stimulating hormone observed during luteal-follicular transition. J Clin Endocrinol Metab. 1998;83:4220-4232.

9. Khan KM, Liu-Ambrose T, Sran MM, et al. New criteria for the female athlete triad syndrome? As osteoporosis is rare, should osteopenia be among the criteria for defining the female athlete triad syndrome? Br J Sports Med. 2002;36:10-13.

10. Loucks AB. Effects of exercise training on the menstrual cycle: existence and mechanisms. Med Sci Sports Exerc. 1990;22:275-280.

11. Loucks AB, Verdun M, Heath EM. Low energy availability, not the stress of exercise, alters LH pulsatility in exercising women. J Appl Physiol (1985). 1998;84:37-46.

12. Mendelsohn FA, Warren MP. Anorexia, bulimia, and the female athlete triad: evaluation and management. Endocrinol Metab Clin N Am. 2010;39:155-167.

13. Misra M, Miller KK, Tsai P, et al. Elevated peptide YY levels in adolescent girls with anorexia nervosa. J Clin Endocrinol Metab. 2006;91:1027-1033.

14. Lawson EA, Klibanski A. Endocrine abnormalities in anorexia nervosa. Nat Clin Pract Endocrinol Metab. 2008;4:407-414.

15. Brancaccio P, Maffulli N, Buonauro R, et al. Serum enzyme monitoring in sports medicine. Clin Sports Med. 2008;27:1-18, vii.

16. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285:785-795.

17. 2007 ISCD Official Positions–Pediatric. The International Society for Clinical Densitometry Web site. Available at: http://www.iscd.org/official-positions/2007-iscd-official-positions-pediatric. Accessed February 26, 2014.

18. 2013 ISCD Official Positions–Adult. The International Society for Clinical Densitometry Web site. Available at: http://www.iscd.org/official-positions/2013-iscd-official-positions-adult. Accessed February 26, 2014.

19. Position stand on the female athlete triad. The Internal Olympic Committee Web site. Available at: http://www.olympic.org/Documents/Reports/EN/en_report_917.pdf. Accessed February 3, 2014.

20. The Female Athlete Triad Coalition Web site. Available at: http://www.femaleathletetriad.org. Accessed February 3, 2014.

21. Eating disorders. National Institute of Mental Health Web site. Available at: http://www.nimh.nih.gov/health/publications/eating-disorders/index.shtml. Accessed February 26, 2014.

22. Synthetic Calcitonin (Salmon) nasal spray (ns)—market withdrawal of all products, effective October 1st, 2013—for health professionals. Government of Canada Health Canadians Web site. Available at: http://healthycanadians.gc.ca/recall-alertrappel-avis/hc-sc/2013/34783a-eng.php. Accessed February 13, 2014.

23. Greer FR, Krebs NF; American Academy of Pediatrics Committee on Nutrition. Optimizing bone health and calcium intakes of infants, children, and adolescents. Pediatrics. 2006;117:578-585.

Tx: First, restore sufficient nutrition

When treating a patient with the triad, consider consulting with a sports medicine specialist because these physicians typically are trained in diagnosing and treating this condition. Because low energy availability is the cornerstone of the triad, the priority in treating an affected athlete is to restore sufficient nutrition for caloric needs. Referral to a registered dietitian for full nutritional assessment and meal planning is recommended. If your athlete is unwilling or unable to follow dietary recommendations, refer her to an eating disorder specialist team. Ideally, this specialist team would consist of a registered sport nutritionist, a physician, and a psychologist or psychiatrist who specializes in eating disorders.

Drugs that can augment your efforts

Although they play a small role in treating the triad, pharmacologic therapies may be used to augment nutrition counseling. The selective serotonin reuptake inhibitor fluoxetine is the only medication approved by the US Food and Drug Administration for treating patients with bulimia; it is not approved for those with anorexia nervosa._²¹

Oral contraceptives may help women return to monthly menses, but they do not normalize the metabolic factors that impair bone formation and bone health. They can be used as a last measure in athletes who will not follow dietary or exercise recommendations, or those who, despite following recommendations, do not have a return to normal menses after 6 months.

Nasal calcitonin may be used to treat low BMD; order a follow-up DXA scan in 12 months to monitor improvement. However, prolonged use of nasal calcitonin may increase the risk for cancer, and in October 2013 nasal calcitonin was withdrawn from the Canadian market.²² For amenorrheic athletes, recommend oral calcium, 1000 to 1300 mg/d, and vitamin D, 400 to 800 IU/d. Ideally, patients should receive these levels of nutrients via dietary intake, but if that is not realistic, supplements may be considered.^1,23 Bisphosphonates and selective estrogen receptor modulators are contraindicated for premenopausal athletes.¹⁹

Can the patient return to play?

The athlete will need to be medically and psychologically cleared before being allowed to return to play (RTP). If she has menstrual dysfunction or low BMD, these conditions should be addressed as a prerequisite for RTP. If the treating physician, nutritionist, and/or eating disorder specialist team recommends specific treatments or other interventions, the athlete should agree to the treatment plan in order to RTP. The physician or assessment team should determine the time frame for RTP on an individual basis. Athletes who do not comply with treatment regimens should, for their health and safety, be prohibited from return to sports participation.

Athletes who do not comply with treatment regimens should be prohibited from return to sports participation.Focus on prevention

Primary prevention should focus on educating female (and male) athletes about regarding food as fuel, discouraging unhealthy weight loss, and enlisting the support of coaches and governing bodies. An athlete’s coaches may be the first to notice symptoms of the triad as changes in performance or behavior, but coaches should not encourage athletes to lose weight or be involved in determining an athlete’s weight.¹⁹

CORRESPONDENCE
Jennifer Payne, MD, Family Medicine Residency Program, Lancaster General Hospital, 555 N Duke Street, Lancaster, PA 17604; jpayne2@lghealth.org