Female athlete triad links low energy, missed periods and weak bones
In female athletes, low energy availability is crucial to menstrual function and bone health. This 2012 narrative review covers the female athlete triad in young women in sport. The triad joins missed periods, low energy intake, and low bone density. The authors say treatment takes a team and aims for periods to return naturally.
Key Findings
Among women in leanness-focused or appearance-focused sports such as ballet and running, secondary amenorrhea can affect as many as 69%. The general population figure is 2% to 5%.
One study of female athletes found all 3 triad components in 4.3% of athletes and 3.4% of healthy controls. Two components ranged from 5.4% to 26.6%.
Compared with eumenorrheic athletes, amenorrheic athletes had 10% to 20% less lumbar spine BMD and a 2 to 4 times greater risk of stress fracture.
Some studies found an oral contraceptive pill improved BMD in this group, and other research showed no significant effect. No specific drug has consistently improved BMD.
Among female elite athletes, clinical eating disorders were reported at rates from 16% to 47%.
Interpretation
The paper is a narrative review of PubMed articles from 1981 onward. Each figure comes from a separate study, and the figures vary with sport, age, and screening method. Lower bone density in amenorrheic athletes is an association reported in those studies. The authors call the data on oral contraceptive pills for bone density unresolved. Research on transdermal estrogen comes mainly from postmenopausal women. The authors survey earlier research and run no trial of their own.
RRM Context
The review notes that an oral contraceptive pill can restart bleeding while energy availability stays low. Restorative reproductive medicine looks for the cause of a missing cycle. It treats the natural return of the cycle as the sign of recovery. Suppressive medications can produce bleeding without that sign.
Our editorial summary of this paper, not the article's abstract.
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.
Reproductive Endocrinology › Ovarian Hormones › Estrogen · Bone Health › Bone Mineral Density › Peak Bone Mass · Lifestyle and Environment › Nutrition and Metabolic Health › Eating Disorders and Underfueling
Taraneh Gharib Nazem, Kathryn E Ackerman
T Nazem, Kathy Ackerman, Kate Ackerman, K Ackerman
PMID 23016101 23016101 DOI 10.1177/1941738112439685 10.1177/1941738112439685 Nazem et al. 2012, Nazem 2012
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