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      The Female Athlete Triad

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          Abstract

          Context:

          The female athlete triad (the triad) is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density; it is relatively common among young women participating in sports. Diagnosis and treatment of this potentially serious condition is complicated and often requires an interdisciplinary team.

          Evidence Acquisition:

          Articles from 1981 to present found on PubMed were selected for review of major components of the female athlete triad as well as strategies for diagnosis and treatment of the conditions.

          Results:

          The main goal in treatment of young female athletes with the triad is a natural return of menses as well as enhancement of bone mineral density. While no specific drug intervention has been shown to consistently improve bone mineral density in this patient population, maximizing energy availability and optimizing vitamin D and calcium intake are recommended.

          Conclusions:

          Treatment requires a multidisciplinary approach involving health care professionals as well as coaches and family members. Prevention of this condition is important to minimize complications of the female athlete triad.

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          Most cited references118

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          A reference standard for the description of osteoporosis.

          John Kanis, Eugene McCloskey, Helena Morales Johansson … (2008)
          In 1994, the World Health Organization published diagnostic criteria for osteoporosis. Since then, many new technologies have been developed for the measurement of bone mineral at multiple skeletal sites. The information provided by each assessment will describe the clinical characteristics, fracture risk and epidemiology of osteoporosis differently. Against this background, there is a need for a reference standard for describing osteoporosis. In the absence of a true gold standard, this paper proposes that the reference standard should be based on bone mineral density (BMD) measurement made at the femoral neck with dual-energy X-ray absorptiometry (DXA). This site has been the most extensively validated, and provides a gradient of fracture risk as high as or higher than that of many other techniques. The recommended reference range is the NHANES III reference database for femoral neck measurements in women aged 20-29 years. A similar cut-off value for femoral neck BMD that is used to define osteoporosis in women can be used for the diagnosis of osteoporosis in men - namely, a value for BMD 2.5 SD or more below the average for young adult women. The adoption of DXA as a reference standard provides a platform on which the performance characteristics of less well established and new methodologies can be compared.
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            Prevalence of vitamin D deficiency among healthy adolescents.

            E. Grace, Kerrin DePeter, Stuart Gordon … (2004)
            Although vitamin D deficiency has been documented as a frequent problem in studies of young adults, elderly persons, and children in other countries, there are limited data on the prevalence of this nutritional deficiency among healthy US teenagers. To determine the prevalence of vitamin D deficiency in healthy adolescents presenting for primary care. A cross-sectional clinic-based sample. An urban hospital in Boston. Three hundred seven adolescents recruited at an annual physical examination to undergo a blood test and nutritional and activity assessments. Serum levels of 25-hydroxyvitamin D (25OHD) and parathyroid hormone, anthropometric data, nutritional intake, and weekly physical activity and lifestyle variables that were potential risk factors for hypovitaminosis D. Seventy-four patients (24.1%) were vitamin D deficient (serum 25OHD level,
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              Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women.

              E. Loucks, J Thuma (2002)
              To investigate the dependence of LH pulsatility on energy availability (dietary energy intake minus exercise energy expenditure), we measured LH pulsatility after manipulating the energy availability of 29 regularly menstruating, habitually sedentary, young women of normal body composition for 5 d in the early follicular phase. Subjects expended 15 kcal/kg of lean body mass (LBM) per day in supervised exercise at 70% of aerobic capacity while consuming a clinical dietary product to set energy availability at 45 and either 10, 20, or 30 kcal/kg LBM.d in two randomized trials separated by at least 2 months. Blood was sampled daily during treatments and at 10-min intervals for the next 24 h. Samples were assayed for LH, FSH, estradiol (E2), glucose, beta-hydroxybutyrate, insulin, cortisol, GH, IGF-I, IGF-I binding protein (IGFBP)-1, IGFBP-3, leptin, and T3. LH pulsatility was unaffected by an energy availability of 30 kcal/kg LBM.d (P > 0.3), but below this threshold LH pulse frequency decreased, whereas LH pulse amplitude increased (all P < 0.04). This disruption was more extreme in women with short luteal phases (P < 0.01). These incremental effects most closely resembled the effects of energy availability on plasma glucose, beta-hydroxybutyrate, GH, and cortisol and contrasted with the dependencies displayed by the other metabolic hormones (simultaneously P < 0.05). These results demonstrate that LH pulsatility is disrupted only below a threshold of energy availability deep into negative energy balance and suggest priorities for future investigations into the mechanism that mediates the nonlinear dependence of LH pulsatility on energy availability.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Sports Health
                Journal ID (iso-abbrev): Sports Health
                Journal ID (publisher-id): SPH
                Journal ID (hwp): spsph
                Title: Sports Health
                Publisher: SAGE Publications (Sage CA: Los Angeles, CA )
                ISSN (Print): 1941-7381
                ISSN (Electronic): 1941-0921
                Publication date (Print and electronic): July 2012
                Publication date (Print): July 2012
                Volume: 4
                Issue: 4
                Pages: 302-311
                Affiliations
                [* ]Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
                [† ]Division of Sports Medicine, Children’s Hospital Boston and Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts
                Author notes
                [*] [‡ ]Address correspondence to Kathryn E. Ackerman, MD MPH Division of Sports Medicine Children’s Hospital Boston 319 Longwood Avenue, Boston, MA 02115 (e-mail: Kathryn.ackerman@ 123456childrens.harvard.edu ).
                Article
                Publisher ID: 10.1177_1941738112439685
                DOI: 10.1177/1941738112439685
                PMC ID: 3435916
                PubMed ID: 23016101
                SO-VID: 4d775830-8df8-4b80-bc96-af74d3873b5d
                Copyright © © 2012 The Author(s)
                History
                Categories
                Subject: Athletic Training
                Subject: 2
                Subject: 111
                Subject: 115
                Custom metadata
                cover-date July/August 2012

                ScienceOpen disciplines: Sports medicine
                Keywords: female athlete triad,disordered eating,amenorrhea,bone mineral density
                Data availability:
                ScienceOpen disciplines: Sports medicine
                Keywords: female athlete triad, disordered eating, amenorrhea, bone mineral density

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