In the past 35 years, a significant increase has occurred in sports participation by women. An estimated 3 million girls and young women compete in American high school sports. Women who participate in sports and fitness programs are generally healthier and have higher self-esteem. However, an increase has also been seen in gender-specific injuries and medical problems. The female athlete triad is a syndrome of separate but interrelated conditions of disordered eating, amenorrhea, and osteoporosis. Athletic amenorrhea is known to have a hormonal profile similar to menopause characterized by decreased circulating estrogens. Menopause is known to be associated with osteoporosis and accelerated cardiovascular disease. Although enhanced risk for cardiovascular disease is theoretically possible, it has not been explored in the young athletic population. Premature cardiovascular disease first manifests as endothelial dysfunction, which can be examined noninvasively with ultrasound. This article discusses disordered eating, amenorrhea, osteoporosis, and the potential for heightened cardiovascular risk in young athletic women.
In the past 35 years, a significant increase has occurred in sports participation by women. An estimated 3 million girls and young women compete in American high school sports. Women who participate in sports and fitness programs are generally healthier and have higher self-esteem. However, an increase has also been seen in gender-specific injuries and medical problems. The female athlete triad (Triad) is a syndrome of separate but interrelated conditions of disordered eating, amenorrhea, and osteoporosis. Athletic amenorrhea is known to have a hormonal profile similar to menopause characterized by decreased circulating estrogens. Menopause is known to be associated with osteoporosis and accelerated cardiovascular disease. Although enhanced risk for cardiovascular disease is theoretically possible, it has not been explored in the young athletic population. Premature cardiovascular disease first manifests as endothelial dysfunction, which can be examined noninvasively with ultrasound. This article discusses disordered eating, amenorrhea, osteoporosis, and the potential for heightened cardiovascular risk in young athletic women.
In the early 1900s women were excluded from the Olympic Games. Athletic competition was believed to be too stressful for women and that their reproductive organs were at risk for injury. Fortunately, the past 35 years have seen an explosion in sports participation by women, largely because of Title IX, the Educational Amendment Act of 1972, which mandated equal access to sports participation in public schools and universities for men and women. In 1972, 1 in 27 high school girls played a varsity high school sport. In 2007, 1 in 2 girls played a varsity sport, an increase of more than 1000%.
From this explosion in sports participation, we have learned that exercise and competitive sports are beneficial to women in many ways. Premenopausal women younger than 45 years who exercise aerobically at least 4 hours per week have a 37% reduction in breast cancer risk . Lopiano reports that high school girls involved in sports are less likely to experience unwanted pregnancies and become involved with drugs. Furthermore, women who play sports have higher self-esteem and lower levels of depression . Experts have also found that sports traditionally teach values that carry over into the competitive workplace . Several studies have shown that exercise increases bone mineral density (BMD) . Teegarden and colleagues found that active girls who participate in high school sports have significantly greater BMD, which may help prevent osteoporosis in the future. Lastly, vigorous physical activity and aerobic exercises are known to lessen symptoms of the menstrual cycle, such as cramping, low back pain, headache, and depression .
However, an increasing prevalence of exercise-associated medical problems, including the Triad, has also been found. The Triad was initially defined in 1992 by a special American College of Sports Medicine (ACSM) task force on women’s issues, and a position stand was published in 1997 defining the condition in detail . Since then, a significant amount of research on the Triad has been performed, and in 2003 the ACSM established a special writing team of researchers and clinicians to publish a revised position stand, which will be published soon.
In a study by Nichols and colleagues , the prevalence of the Triad was examined in 170 high school athletes from eight different sports in southern California. Disordered eating was assessed with the Eating Disorder Examination Questionnaire (EDE-Q) . Menstrual status was also examined with a questionnaire, and BMD was tested with dual energy x-ray absorptiometry (DXA) using Lunar model DPX-NT (Lunar/GE Corp, Madison, Wisconsin).
Of the 170 athletes in the sample, 18.2% met criteria for disordered eating, with vomiting (7%) as the most common pathogenic behavior for controlling weight, and 24% had oligomenorrhea/amenorrhea, with oligomenorrhea (17.1%) the most common menstrual irregularity. Twenty two percent had low BMD for their age based on World Health Organization (WHO) criteria (Z-score < −1.0), whereas 4.1% met the International Society for Clinical Densitometry criteria (Z-score < −2.0) for low bone mass. Ten athletes (5.9%) met criteria for any two Triad components, and two athletes (1.2%) had all three components. Oligomenorrheic/amenorrheic athletes, after adjusting for body mass index (BMI), reported significantly higher dietary restraint and EDE-Q global scores when compared with eumenorrheic athletes. They were also significantly older in menarcheal age and had significantly lower trochanter BMD after adjusting for chronologic age, ethnicity, BMI, and percentage of body fat. These data help alert health care professionals, coaches, and parents that several components of the Triad are present in high school age athletes, which is a critical time for bone mineral accrual .
In another study looking at prevalence of the Triad, the authors studied 80 varsity high school athletes from a competitive all-girls’ school in the Midwest. Results showed that 55% of the girls had low energy availability, with an average deficit of 575 kcal; 33% had amenorrhea; 16% had a Z-score less than −1.0; 1% had a Z-score less than −2.0; and 19% had a history of stress fractures.
Disordered eating
Women, including female athletes, are under intense pressure to be thin and have a low percentage of body fat, not only for aesthetic purposes but also because of the misperception that a thin physique will increase athletic performance. Hence, eating disorders are much more common in female athletes compared with nonathletes. Disordered eating refers to a spectrum of abnormal eating patterns ranging from a mild preoccupation with calories and body image to frank anorexia nervosa and bulimia nervosa, which is a strict Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) diagnosis . By definition, hypothalamic amenorrhea is one of the criteria for anorexia nervosa. Bulimia nervosa can further be divided into purging and nonpurging type. The latest edition of DSM–IV has included a third classification of eating disorders, “eating disorder not otherwise specified (NOS).” This diagnosis covers a wider variety of abnormal eating patterns with different, less-stringent criteria than anorexia nervosa and bulimia nervosa. Box 1 lists the diagnostic criteria for these conditions.
Anorexia nervosa
Refusal to maintain body weight at or above 85% of normal weight for age and height
Intense fear of gaining weight or becoming fat, although underweight
Disturbance in the way one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
Amenorrhea in postmenarchal women
Bulimia nervosa
Recurrent episodes of binge eating. An episode of binge eating is characterized by:
Eating, within a discrete period (eg, any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period under similar circumstances
A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)
Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise
Binge eating and inappropriate compensatory behaviors occur, on average, at least twice a week for 3 months
Self-evaluation is unduly influenced by body shape and weight
The disturbance does not occur exclusively during episodes of anorexia nervosa
Eating disorder not otherwise specified
For women, all criteria for anorexia nervosa are met except that the individual has regular menses
All criteria for anorexia nervosa are met except that, despite significant weight loss, the person’s current weight is in the normal range
All criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week for a duration of less than 3 months
The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (eg, self-induced vomiting after the consumption of two cookies)
Repeatedly chewing and spitting out, but not swallowing, large amounts of food
Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behavior characteristics of bulimia nervosa
From American Psychiatric Association. Eating disorders. In: First M, editor. Diagnostic and statistical manual of mental disorders. 4th edition. Washington, DC: American Psychiatric Publishing, Inc.; 1994. p. 549–50; with permission.
However, DSM–IV criteria for eating disorders are based on nonathletic women. Therefore, some authors believe that disordered eating in athletes should have its own criteria that are more athlete-specific, such as those listed for anorexia in Table 1 . Pathologic eating patterns used by athletes commonly include consumption of diets low in fat and calories, and use of diet pills, laxatives, diuretics, fasting, self-induced vomiting, and excessive exercise to control weight. In a survey of female athletes, Rosen and colleagues found that 25% reported routine use of diet pills, 16% reported laxative abuse, and 14% reported self-induced vomiting. Ultimately, these practices may lead to excessive weight loss, dehydration, loss of fat free mass, and subsequent decreased athletic performance .
| Common features | Sundgot-Borgen a |
|---|---|
| Weight loss b | + |
| Delayed puberty c | (+) |
| Menstrual dysfunction d | (+) |
| Gastrointestinal complaints | + |
| Absence of medical illness or affective disorder explaining the weight reduction | + |
| Distorted body image b | (+) |
| Excessive fear of becoming obese | + |
| Restriction of food (<1200 kcal/d) | + |
| Use of purging methods e | (+) |
| Binging b | (+) |
| Compulsive exercise b | (+) |
a +, absolute criteria; (+), relative criteria.
b >5% of expected body weight.
c No menstrual bleeding at age 18 (primary amenorrhea).
d Primary amenorrhea, secondary amenorrhea, or oligomenorrhea.
The specific etiology and pathophysiology of eating disorders remains largely unknown. Most experts agree that they are multifactorial and complex regarding genetics, environment, biology, cultural influences, and behavior factors . In addition, clinical eating disorders are often accompanied by comorbid psychological conditions, such as obsessive–compulsive disorder, depression, and anxiety disorder . However, several factors are associated with the development of abnormal eating patterns, including extreme pressures from coaches, parents, society, and the athletes themselves to be thin or achieve an “ideal body weight” or “optimal” body fat. Women who participate in sports such as ballet, gymnastics, and figure skating, which emphasize a lean physique or low body weight, are at greater risk . Women participating in endurance sports, such as long distance running, cross country skiing, and Iron Man triathletes, are also at higher risk. Many of these athletes have the misperception that weight loss will increase their performance. Finally, sports with a weight category, such as lightweight crewing, rowing, and martial arts, have a higher risk.
In the nonathletic female population, 1% have anorexia nervosa and between 1% and 4% have bulimia nervosa as defined by DSM-IV . The true prevalence of disordered eating in athletes is unknown. Obtaining prevalence data in female athletes is difficult because athletes are typically in denial or secretive about their eating disorders. Underreporting is also a large problem because of the fear of being discovered and potential consequence to their athletic careers . The prevalence of eating disorders among female collegiate athletes, including low energy availability, disordered eating, pathogenic weight control, subclinical eating disorders, and frank anorexia and bulimia, range from 1% to 62% .
Eating disorders are chronic conditions with significant health consequences, including dehydration, malnutrition, cardiac arrhythmia, menstrual dysfunction, osteoporosis, psychologic disorders, and death. Treatment requires a multidisciplinary team approach with physicians, psychologists, dietitians, family members, coaches, and athletic trainers participating in the healing process. Most importantly, the athletes must be part of the treatment team; for the treatment to be successful, they must want to change behaviors and break disordered eating habits. Behavior contracts may have to be used with some more challenging athletes.
The sports physician must have a high index of suspicion for all female athletes, regardless of the sport, and play an active role in prevention and early detection. Tools that can be used for screening include the “Eat-26” questionnaire . This survey includes 26 questions related to eating attitude and the potential for an eating disorder. Each question is scored 1 to 6 points. A score of 20 or greater suggests an eating disorder . Validated body image forms are also available and helpful . The Harris Benedict basal metabolic energy expenditure equation is useful for determining basal energy requirements:
BEE = 655 . 1 + ( 9 . 563 × W ) + ( 1 . 850 × H ) − ( 4 . 676 × A )
Related posts:
ACL Tears in Female Athletes
Factors That Affect the Young Female Athlete
Exercise for Health and Wellness at Midlife and Beyond: Balancing Benefits and Risks
Current and Future Trends in Lymphedema Management: Implications for Women’s Health
Recognizing and Treating Pelvic Pain and Pelvic Floor Dysfunction
The Role of Physical Activity in Bone Health: A New Hypothesis to Reduce Risk of Vertebral Fracture
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
