Issues Unique to the Female Athlete
18.1 Exercise-Associated Amenorrhea
Med Clin N Amer 1994;78:345
Cause: Multifactorial including excessive training, low body wt/low body fat, emotional stress, physical stress of training—all of which lead to suppression of the HPA axis.
Epidem:
2-5% of general population.
3.4-66% of athletic women, depending on chosen sport.
Most common in endurance sports (running, XC skiing, triathlon), dancers, gymnasts.
Pathophys:
Exercise-associated amenorrhea related to suppression of GnRH from hypothalamus resulting in reduced LH, estradiol, prolactin, and cortisol release. Should consider other causes (luteal phase dysfunction, polycystic ovarian syndrome, anovulatory amenorrhea).
Primary amenorrhea: failure to reach menarche by 16 y/o.
Secondary amenorrhea: Loss of regular cycle for 3-6 mo after establishing a normal menstrual cycle.
Sx:
Irregular or absent menstrual cycle for 3-6 mo.
Failure to reach menarche by 16 y/o.
Diet and wt history usually reveals below IBW, history of significant wt loss.
Si:
Body fat assessment: <10-15% concerning although not definitive.
Pelvic exam: enlarged uterus, ovaries, or adnexal masses.
Should conduct PAP smear and STD w/u as indicated by history.
X-ray:
Heel ultrasound: Screening study for bone loss in long-standing amenorrhea.
DEXA scan: More sensitive and specific test for assessing degree of bone loss in osteoporosis. These tests should be considered in the initial workup of these athletes.
Lab:
HCG: R/o pregnancy.
TSH: R/o hypo/hyperthyroidism.
Prolactin: Evaluate for microadenoma or idiopathic prolactinemia.
Estradiol: Confirmatory in unopposed estrogen states.
Crs: Bone loss may be seen in 3-6 mo with irreversible losses in 24-36 mo.
Rx:
Reduced training intensity and volume: 10% reduction has been associated with resumption of normal menses.
Increased % body fat: All EAA cases should receive nutritional counseling by nutritionist familiar with athlete care.
Estrogen replacement:
In EAA, bcp’s are most convenient and readily available form. Ensure there are no contraindications to their use.Related posts:
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