Abstract
The female athlete comprises a unique athletic population that carries with it its own subset of considerations. Two common circumstances exclusive to female athletes include the female athlete triad and pregnancy. This chapter assists the reader in reviewing important factors to consider for each condition, pearls to guide assessment, and how to identify and make sound recommendations.
Female Athlete Triad
Key Concepts
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The female athlete triad is a syndrome of three tightly interwoven conditions: low energy availability (with or without disordered eating or an eating disorder), menstrual dysfunction, and low bone density.
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For each condition, the athlete may fall somewhere on the continuum between the normal healthy end and the pathologic end of the spectrum.
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It is unclear how widespread the triad is. Prevalence is variable by sport—those with highest energy expenditure, sports with an aesthetics component, or those in which a lean physique is preferable have the highest prevalence.
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Early detection and intervention are key to preventing progression to serious sequelae.
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The International Olympic Committee introduced a similar syndrome titled Relative Energy Deficiency in Sport (RED-S). This syndrome applies to female and male athletes alike, athletes with disabilities, and those across ethnicities. Instead of it being a triad, this is a more widely encompassing concept, with low energy affecting a broad array of physiological systems.
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Although some standard approaches exist to apply science to return-to-play decision making, these methods have inherent weaknesses and continue to be refined as more evidence emerges. Taking an individualized approach to each athlete case scenario is imperative to appropriately consider the unique circumstances that influence safe return to sport.
Screening
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Current guidelines recommend screening as part of the preparticipation physical evaluation, although the panel of question varies by organization.
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Any risk factor identified during screening should immediately prompt further evaluation.
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Late-stage findings such as amenorrhea, stress fracture, or signs of an eating disorder may be what triggers further medical evaluation, as much of the early pathology occurs silently.
History
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Dietary/energy inquiries: eating habits, caloric intake, dietary restrictions, disordered eating patterns, recent weight changes (intentional?), changes in training schedule, athlete knowledge regarding “energy balance.”
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Menstrual history to help determine age of menarche, pattern of regularity, lapses, severity, birth control use, and purpose of initiation (i.e., regulation of menses vs. contraception).
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Any history of significant bone pain or injury, even if not officially diagnosed.
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Other: unexplained fatigue, cold intolerance, lightheadedness, drop in athletic performance, mental status, stressors in life, medications/supplements, sleep patterns.
Physical Examination
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Primarily a clinical diagnosis made from the athlete’s history; the physical examination is often normal.
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There may be findings suggestive of an eating disorder, including bradycardia, hypotension (particularly orthostatic hypotension), dental enamel erosion, parotid gland hypertrophy, Russell sign (callus on finger from self-induced vomiting), cold/discolored hands and feet, and lanugo hair or skin dryness. Assess appropriateness of the Tanner stage.
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Often, the presenting athletic concern is a stress fracture; thus the exam will be consistent with findings of bony stress injury.
Imaging
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If concerned about a stress fracture, appropriate images should be obtained.
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The presence of certain factors in the history must be evaluated when considering the need to further assess bone mineral density (BMD). These include number of stress fractures suffered, the location and risk stratification of these fractures, age of menarche, menstrual history and regularity, and/or the presence of an officially diagnosed eating disorder. The test of choice for evaluating BMD is with a dual-energy x-ray absorptiometry (DEXA) scan.
Additional Tests
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Consider obtaining a panel of electrolytes, serum proteins, liver enzymes, complete blood count with differential, ferritin, erythrocyte sedimentation rate, thyroid function tests, vitamin levels, and a urinalysis to investigate an athlete with disordered eating or clinical eating disorder.
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Workup to exclude other causes of amenorrhea may include pregnancy test, follicle-stimulating hormone and luteinizing hormone, prolactin, and thyroid function studies.
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Consider free serum testosterone and dehydroepiandrosterone sulfate (DHEA-S) if evidence of androgen excess is seen on physical examination.
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To further evaluate estrogen levels in the body, a serum estradiol or progesterone challenge test may be helpful. Athletes with functional hypothalamic amenorrhea are likely to be hypoestrogenic and may fail to have expected normal withdrawl bleeding with the challenge test.
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Additional testing for primary amenorrhea should be based on personal and family history, as well as exam findings.
Differential Diagnosis
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Other causes of amenorrhea include, but are not limited to, pregnancy, thyroid disease, pituitary or adrenal tumor/disease, polycystic ovarian syndrome, premature ovarian failure, and Turner syndrome (primary amenorrhea).
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Hyperparathyroidism and excess glucocorticosteroid use may result in decreased bone mineral density and recurrent stress fractures.
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Consider other causes of low energy availability including eating patterns, dietary choices, or malabsorption syndromes such as celiac disease, autoimmune disease, or malignancy.
Treatment
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To reverse this condition, energy availability must increase; thus modifications in diet and exercise need to occur. A written contract may be necessary in at-risk athletes to ensure minimal criteria are being met to continue training and competition.
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Adequate nutrition, optimal energy availability, and healthy body weight should be the primary focus of treatment to restore regular menses and improve bone mineral density ( Fig. 10.1 ).
