Female

Athlete Triad

PMAS AAUR 1
Submitted To

Dr Kashif Sarfraz Abbasi

HND-609
Sports Nutrition

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 Road Map

Topic Slide No

Introduction 4-8
1. Disordered Eating 9-15
2. Amenorrhea 16-17
3. Osteoporosis 18-19

Prevalence 20-23
Signs & Symptoms 24
Physical & Mental Signs & Symptoms 25
Behavioral Signs & Symptoms 26
Symptoms of Anorexia & Bulimia Nervosa 27
Causes & Risk Factor 28
Causes 29
Risk Factor 30-31
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 Topic Slide No

Disorder of Eating 32-34

Bone Mineral Density 35
Menstruations Dysfunction 36-38
Energy Availability 39-42
Bone Health 43-45
Diagnostic Evaluation 46-47
Assessing Low Energy Availability 48-49
Disordered Eating 50-53
Delayed Puberty & Menstrual Dysfunction 54-56
Altered Bone Mineral Density 57-60
Treatment 61
Treatment Goals 62
Multi Disciplinary Approach 63
Treatment Options 64-65
Non- Pharmacological Treatment 66-76
Pharmacological Treatment 77-82

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1.Introduction

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PMAS AAUR 6
What is FAT?

The Female Athlete Triad is defined as the combination of disordered eating, amenorrhea and

osteoporosis. This disorder often goes unrecognized. The consequences of lost bone mineral density
can be devastating for the female athlete. Premature osteoporotic fractures can occur, and lost bone
mineral density may never be regained. Early recognition of the female athlete triad can be
accomplished by the family physician through risk factor assessment and screening questions.

Instituting an appropriate diet and moderating the frequency of exercise may result in the natural
return of menses. Hormone replacement therapy should be considered early to prevent the loss of
bone density.
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PMAS AAUR 8
Cont.

A collaborative effort among coaches, athletic trainers, parents, athletes and physicians is optimal for
the recognition and prevention of the triad. Increased education of parents, coaches and athletes in
the health risks of the female athlete triad can prevent a potentially life-threatening illness.

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1.1 Disordered Eating
Most girls with female
athlete triad try to lose weight as
a way to improve their athletic
performance. The disordered
eating that accompanies female
athlete triad can range from not
eating enough calories to keep up
with energy demands to avoiding
certain types of food the athlete
thinks are "bad" (such as foods
containing fat) to serious eating
disorders like anorexia nervosa or
bulimia nervosa.

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 Criteria for Eating Disorders

1. Anorexia Nervosa
2. Bulimia Nervosa

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 1.1.1 Anorexia Nervosa

1. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight
loss leading to maintenance of body weight less than 85 percent of that expected; or failure to make
expected weight gain during period of growth, leading to body weight less than 85 percent of that
expected).
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which 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.
4. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.
(A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen,
administration.)
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Types of Anorexia Nervosa

• Restricting type: during the current episode of anorexia nervosa, the person has not regularly
engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics or enemas)
• Binge-eating/purging type: During the current episode of anorexia nervosa, the person has regularly
engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives,
diuretics or enemas)

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 1.1.2 Bulimia Nervosa

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the

following:

• Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is

definitely larger than most people would eat during a similar period of time and under similar

circumstances

• A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating

or control what or how much one is eating).

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Cont.

• Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced
vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting; or excessive exercise.

• The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a
week for three months.

• Self-evaluation is unduly influenced by body shape and weight.

• The disturbance does not occur exclusively during episodes of anorexia nervosa.

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 Types of Bulimia Nervosa

• Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in
self-induced vomiting or the misuse of laxatives, diuretics or enemas.

• Non Purging type: during the current episode of bulimia nervosa, the person has used other
inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly
engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas.

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 1.2 Amenorrhea

Exercising intensely and not eating enough calories can lead to decreases in the hormones that help
regulate the menstrual cycle. As a result, a girl's periods may become irregular or stop altogether. Of
course, it's normal for teens to occasionally miss periods, especially in the first year. A missed period
does not automatically mean female athlete triad. It could mean something else is going on, like
pregnancy or a medical condition. If you are having sex and miss your period, talk to your doctor.

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 Cont.

Some girls who participate intensively in sports may never even get their first period because they've
been training so hard. Others may have had periods, but once they increase their training and change
their eating habits, their periods may stop.

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1.3 Osteoporosis

Estrogen is lower in girls with female

athlete triad. Low estrogen levels and
poor nutrition, especially low calcium
intake, can lead to osteoporosis, the
third aspect of the triad. Osteoporosis is
a weakening of the bones due to the loss
of bone density and improper bone
formation. This condition can ruin a
female athlete's career because it may
lead to stress fractures and other
injuries.
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 Cont.

Usually, the teen years are a time when girls should be building up their bone mass to their highest
levels — called peak bone mass. Not getting enough calcium now can also have a lasting effect on
how strong a woman's bones are later in life.

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2. Prevalence of
Female
Athlete Triad

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2.Prevalence of
Female Athlete Triad

• The female athlete triad occurs in girls and women, especially if they are highly competitive athletes.
The development of female athlete triad is also possible in those who are sedentary and
recreationally active but the prevalence rate is less than that of more competitive athletes. Younger
individuals are greatly impacted by the non-reversible, long-term consequences of this syndrome. In
fact, a study on animals found that low energy availability can decrease growth and hinder sexual
development.

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Cont.

• A systematic review by Gibbs and colleagues (2013) compiled available evidence and identified 9
studies investigation prevalence of 3/3, 2/3, and 1/3 of the triad conditions in exercising women. Of
the 9 included studies, they found a prevalence of 0-15.9% for 3/3 conditions. When it came to
determining the prevalence of the combination of any 2 components they found the following:
– Menstrual dysfunction (MD) and low bone mineral density (BMD) had a prevalence of 0-7.5%
– MD and disordered eating (DE) had a prevalence of 2.7-50%
– Low BMD and DE had a prevalence of 0.9 -3.2%
– MD and low energy availability (EA) had a prevalence of 17.5%, and
– Low BMD and low EA had a prevalence of 3.75%.
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Cont.

To investigate the prevalence of individual components of the triad in exercising women, Gibbs and
colleagues (2013) found that the prevalence ranged from 0-56% for primary amenorrhea, 1-60% for
secondary amenorrhea, 0.9%-52.5% for oligomenorrhea, 7.1-89.2% for clinical and subclinical
disordered eating, and 0-39.8% for low BMD (defined by z-score between -1.0 and -2.0).

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3. SIGNS AND SYMPTOMS:
THE FEMALE ATHLETE TRIAD

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3.1 Physical/Medical
Signs And Symptoms

– Amenorrhea

– Dehydration

– Hypothermia

– Stress Fractures (overuse injuries)

– Significant Weight Loss

– Muscle Cramps, Weakness, or Fatigue

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3.2 Psychological/Behavioral
Signs And Symptoms

– Anxiety and/or Depression

– Excessive Exercise

– Unfocused, Difficultly Concentrating

– Preoccupation with Weight and Eating

– Avoidance of Eating and Eating Situations

– Use of Laxatives, Diet Pills, etc.

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3.3 SYMPTOMS OF ANOREXIA
NERVOSA AND BULIMIA NERVOSA

– Fatigue – Swollen parotid glands

– Anemia – Sore throat
– Bradycardia
– Erosion of tooth enamel
– Low blood pressure
– Low caloric intake
– Cold hands and feet
– Weight loss
– Self induced vomiting
– Low self-esteem

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4. Causes and
Risk Factors :

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4.1 Causes for
Female Athlete Triad
The main cause of the female athlete triad is an energy imbalance. This imbalance causes you to use more
energy than you consume. This results in symptoms of excess fatigue, irregular periods, and, ultimately,
bone loss. Females who are very active may have this problem. It may be on purpose or on accident. The
female athlete triad also may be due to an eating disorder, such as anorexia.
Girls and women may be at risk for the female athlete triad if they:
– Are a competitive athlete.
– Play sports that require them to maintain a certain weight or to check their weight often.
– Exercise more than what is healthy.
– Are obsessed with being thin.
– Have body image issues.
– Are depressed.
– Are pushed by their coach or parents to win at all costs.
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4.2 Risk Factors for
Female Athlete Triad

Anybody can develop female athlete triad. But the following factors increase the risk of developing this
condition:

– Athletic females who have immense pressure of winning

– Competitive athletic females

– Depressed females

– Females who play sports that requires weight management

– Girls having obsession with being thin

– Girls who practice extensive exercises

– Girls with body image issues

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Cont.

• The prevalence of menstrual irregularities, disordered eating, and low BMD varies widely in the
general population and in the athletic community. In women who participate in sports that
emphasize aesthetics or leanness, such as ballet or running, the prevalence of secondary
amenorrhea can be as high as 69%, compared with 2% to 5% in the general population.

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4.1.1 Disordered eating:

• It including a range of irregular eating behaviors that do not necessarily meet criteria for severe
disorders, such as anorexia nervosa (AN) and bulimia nervosa (BN)—is also fairly common in the
athletic community. Up to 70% of elite athletes competing in weight class sports (male and female)
are dieting and have some type of disordered eating pattern with the goal to reduce weight before
competition. The prevalence of clinical eating disorders among female elite athletes ranges from 16%
to 47%.The differences in prevalence rates among studies are likely related to variability in the sports
studied (e.g., weight class or aesthetic sports versus ball games), different screening methods (eg,
questionnaires versus interviews), intensity and ages of athletes, and other methodological
differences.

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Cont.

However, the various prevalence rates of eating disorders in athletes are still in stark contrast to the
0.5% and 10% prevalence among nonathletic men and women in the general population.:
The prevalence of low BMD in the female athlete has been studied as well. The prevalence of
osteopenia ranges from 22% to 50% in female athletes, with osteoporosis spanning 0% to 13%.This
compares to the 12% and 2.3% prevalence reported in the average population, respectively.
However, these percentages are based on T-Scores, a diagnostic measure previously used in research
and clinical settings that is no longer applicable to premenopausal women. More recently, when
assessing bone density in the adolescent population or in any premenopausal woman, Z-Scores are
utilized to determine low bone density for age and osteoporosis.

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Cont.

The reason for using Z-Scores (which compare DXA results among age-matched peers) instead of T-
Scores (which compare DXA results of postmenopausal women to young adult women in their 20s) is
that adolescent patients are still growing and not expected to have achieved the BMD of women
outside their age group. The International Society for Clinical Densitometry has defined a Z-Score of ≤
−2.0 SD as “below expected range for age” and a Z-Score > −2.0 SD as “within the expected range for
age.”Because athletes participating in weight-bearing activities typically have higher BMD than non-
athletes, the American College of Sports Medicine defines “low BMD” in an athlete as a Z-Score
between −1 and −2 along with clinical risk factors for fracture (eg, decreased energy availability,
amenorrhea, history of stress fractures). It considers “osteoporosis” in an athlete to be a BMD Z-
Score ≤ −2.0 with clinical risk factors for fracture.
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4.2.2
Bone mineral density (BMD):

It is difficult to assess the pervasiveness of the triad when considered separately. One study examining
female athletes found that the prevalence of all 3 components of the triad was 4.3%, not far off from the
3.4% found among healthy controls.124 However, the prevalence of 2 components of the triad ranged
from 5.4% to 26.6%.

The findings in these studies indicate that while the number of athletes suffering from all 3 aspects of the
triad simultaneously is fairly low, there are still many young women who are affected by some component
of the spectrum of the disease. It is also important to realize that not all components of the triad need to
be present concurrently for a female athlete to suffer negative health sequelae of the triad, as the 3
components may have different time sequences of presentation.

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4.2.3 Menstrual Dysfunction:

Menstrual dysfunction in the female athlete includes a wide spectrum of disorders. The most

commonly discussed menstrual abnormality is amenorrhea, which is generally defined as the

absence of menses 3 months or more, but can be subcategorized into primary and secondary types.
Primary amenorrhea refers to a delay in the age of menarche (no menses by age 15 years in the
presence of normal secondary sexual development or within 5 years after breast development if that
occurs before the age of 10 years).5 Secondary amenorrhea is a loss of menses after menarche.
Other types of menstrual irregularity include an ovulation, luteal phase deficiency, and
oligomenorrhea.

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Cont.

Amenorrhea can be caused by a variety of diseases and genetic abnormalities, as well as energy
deficiency and even stress. The type of amenorrhea resulting from changes in energy availability is
functional hypothalamic amenorrhea (FHA). FHA is characterized by the absence of menses due to
suppression of the hypothalamic-pituitary-ovarian axis, without an identifiable anatomic or organic
cause. This type of amenorrhea, commonly associated with exercising and stress, is most relevant to
the female athlete. FHA is caused by an alteration in gonadotropin-releasing hormone pulsatility,
which in turn causes a disruption of luteinizing hormone pulses from the pituitary and gonadal
steroid release from the ovaries. It reflects a state of estrogen deficiency, which may be one of the
causes of decreased BMD.

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Cont.

FHA may also be associated with several physiological changes, including overactivity of the
hypothalamic-pituitary-adrenal axis (causing an increase in cortisol release) and disturbances of the
hypothalamic-pituitary-thyroid axis (resulting in a “sick euthyroid” pattern).Leptin, a cytokine
expressed by adipose tissue and strongly associated with fat mass, is lower in the amenorrheic
athlete, most likely due to changes in body composition, particularly a decrease in fat mass. Since
leptin has a positive effect on gonadotropin-releasing hormone secretion and regulates the release of
gonadotropins, its deficiency contributes to the loss of menses. In amenorrheic athletes, luteinizing
hormone pulsatility is disrupted while pituitary responsiveness to gonadotropin-releasing hormone is
increased, causing amenorrhea of a hypothalamic origin.

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4.2.4 Energy Availability:

• Energy availability is the amount of dietary energy for all physiologic functions after accounting for
energy expenditure from exercise. Low energy availability may be the result of an eating disorder but
can also occur in the absence of a psychiatric diagnosis such as AN or BN. Athletes may have
disordered eating simply by unknowingly failing to attain their energy requirements secondary to
time constraints or lack of nutritional knowledge. Some studies have also found that athletes often
lack the appetite necessary to promote food intake as compensation for energy expenditure from
intense exercise regimens.

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Cont.

Female athletes are at risk of developing eating disorders due to pressure to maintain a low body
weight along with poor guidance about nutrition and weight loss from the athletic community. Many
have placed blame on the coach, who often fails to teach athletes about healthy dieting or cultivates
an environment in which weight loss is encouraged regardless of the methods employed to attain it.
Disordered eating and amenorrhea are most common among sports that emphasize leanness,
aesthetics, a weight class, or endurance, including gymnastics, ballet, figure skating, lightweight
rowing, and running.

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Cont.

There is a wide spectrum of disordered eating among athletes that ranges from simple dieting to
clinically defined eating disorders such as AN, BN, and an eating disorder not otherwise specified
(EDNOS). Anorexia athletica is a term used by some researchers to describe a disordered eating
pattern seen in the female athlete who has an intense fear of gaining weight, even though she is
underweight. Women with anorexia athletica reduce their energy intake and exercise excessively.
They may display features of AN and BN without meeting strict criteria for these diagnoses.

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Cont.

Criteria for eating disorders

Among female athletes, there also exist several different forms of dieting that fall on a continuum.
Healthy dieting is considered a modest lowering of daily calories, while harmful dieting or disordered
eating includes restrictive behaviors, such as fasting, skipping meals, use of diet pills or laxatives, and
binging and purging. Some athletes practice what has been called dietary restraint, an intent to limit
food intake, regardless of how successful it is in execution.

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4.2.5 Bone Health:

• The greatest accretion of bone mass happens during puberty. Maximal increases in bone mass
accrual occur between 11 and 14 years of age in girls. Menarche is a signal of bone mass growth, and
25% of bone mass accrual occurs in the 2 years that surround menarche. Generally, young healthy
women achieve 92% of their total body bone mineral content by 18 years of age and approximately
99% by age 26 years. Bone loss usually occurs later with menopause and aging.

• In young female athletes with the triad, a compromise in bone strength, ranging from low BMD and
stress fractures to osteoporosis, may occur at a much younger age. Several different components
contribute to bone strength, including bone mineral content, BMD, bone microarchitecture, and
bone remodeling.
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Cont.

Bone remodeling, or bone turnover, is a constant process of bone formation and matrix development
by osteo-blasts and bone breakdown by osteo-clasts. When this process is interrupted, bone is
weakened and more prone to injury.

Healthy athletes tend to have a higher BMD than their nonathletic counterparts as physical activity,
particularly weight bearing exercise has a beneficial effect on bone accrual and architecture. High-
impact physical activity increases bone density in women. Exercise can even cause a 4% to 5% gain in
bone accrual in pre-pubertal children. Despite similar weight bearing exercise, amenorrheic athletes
have lower BMD than their eumenorrheic counterparts.

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Cont.

• In fact, amenorrheic athletes have 10% to 20% less lumbar spine BMD than eumenorrheic athletes.
Oligomenorrhea and amenorrhea can be detrimental to bone because they are hypo-estrogenic
states. Since estrogen normally inhibits osteo-clastic activity, a lack of this important hormone may
cause disruption of bone remodeling and accelerated bone reabsorption. As a result, menstrual
status in these young female athletes may override the beneficial effects of physical activity on bone.

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5. DIAGNOSTIC
EVALUATION:

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DIAGNOSTIC EVALUATION:
Female Athlete Triad

Primary care providers play an integral role in the diagnosis of the triad. Identifying at-risk athletes

optimally occurs during academic and sports related screenings or in the setting of office visits for

menstrual dysfunction, pathologic or stress fractures or disordered eating. Ideally, parents and

athletic trainers should be able to recognize components of the female athlete triad and its negative

health consequences.

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5.1
Assessing Low Energy Availability

Activity level should be determined by evaluating duration and intensity of daily exercise and sports
involvement.

Examination should include measurement of orthostatic vital signs assessing for resting tachycardia
and volume depletion, weight, and BMI.

It is important to note findings suggestive of eating disorders including lanugo, parotid gland
enlargement, dental enamel erosions and knuckle calluses caused by self-induced vomiting.

If electrolyte abnormalities are present or the patient presents with bradycardia, an EKG should be
performed to assess for arrhythmia or prolonged QT interval.

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Cont.

• Laboratory evaluation includes:

– complete blood counts

– complete metabolic profile

– thyroid function tests

– urinalysis

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5.2 DISORDERED EATING

Signs and symptoms of disordered eating include:

– weight loss

– a decrease in athletic ability and skill

– preoccupation with calories

– fat intake and weight

– increasing self-criticism

The athlete may have wide fluctuations in her weight, and avoid eating in the presence of
others.
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Cont.

• As a trainer has close contact to his/her athlete, changes in behaviour and physical symptoms should
easily be recognized.

• However, symptoms of disordered eating in competition athletes are often ignored, not seen or
realized.

o One explanation is a lack of knowledge about this problem.

o Most persons with eating disorders do not realize their health problems by themselves. They only
see that something is going wrong when they get injured or loose performance.

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Cont.

• Athletes suffering from bulimia nervosa often have a normal or nearly normal body weight and are
therefore, difficult to be diagnosed.

• Therefore, trainers, parents, and the people around the athlete should be able to see and realize the
symptoms of disordered eating patterns.

• The suspicious behaviour may include frequent visits to the bathroom after meals, laxative packages
in lockers, and excessive physical activity over and above what is required for training.

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Cont.

• The ACSM recommends screening for the triad in any female athlete with a total of six months of
amenorrhea or oligomenorrhea.

• When evaluating a patient for menstrual dysfunction, providers should ask about:

– age at menarche

– frequency and duration of menstrual cycles

– last menstrual period

– medication use including oral contraceptives

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5.3 DELAYED PUBERTY AND
MENSTRUAL DYSFUNCTION

• The diagnosis of exercise-associated menstrual disorders is still one of exclusion and it is important to
first rule out other common causes of amenorrhea.
• Menstrual dysfunction is obvious by the time frank amenorrhea occurs.
• Earlier disturbances of the hypothalamic pituitary axis, however, often initially go unrecognized.
• The first step in laboratory evaluation is a pregnancy test.
• Subsequent work up may include evaluation for polycystic ovarian syndrome (PCOS), thyroid or
pituitary abnormalities.
• Drugs which affect the menstrual cycle such as contraceptives, antipsychotics or thyroid medications
should be identified.
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Cont.

• In moderation, ovulatory symptoms such as breast tenderness, food cravings, fluid retention and
mood changes in the week or so before menstruation, signal that all of the interdependent hormonal
systems are working correctly.

• If the athlete does not have any of these symptoms, she may be suffering from short luteal phase or
anovulatory cycles, despite the presence of "regular" menstrual bleeding.

• A full history should be taken with special emphasis on type of activity and competitive level, energy
output, nutrition, eating behaviour, changes in weight, and fractures history.

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Cont.

• Signs and symptoms include:

– androgen excess

– Galactorrhea

– hot flushes

• Physical measurements include:

– blood concentrations of prolactin

– thyroid function tests

– FSH, LH, testosterone

– DHEA-S, E2

– MRI evaluation for a pituitary process

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5.4 ALTERED BONE
MINERAL DENSITY (BMD)

• Osteoporosis does not become evident on radiographs until approximately 20 - 30 % of bone density
is lost.

• As definition of osteoporosis or osteopenia is based on bone mineral density (BMD), measurement of

BMD is the standard method for the determination of a beginning osteopenia or more severe
osteoporosis.

• Altered BMD may present as abnormal bone development, osteopenia, and osteoporosis.

• Initial evaluation should include obtaining a history of stress fractures, overuse injuries, and
pathologic fractures. A careful assessment of ovulatory status should be performed.

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Cont.

• The evaluation of BMD can be difficult in the female athlete given continued bone development in
adolescence.

• Newer techniques of measuring BMD, specifically dual energy x-ray absorptiometry (DEXA) can
identify individuals with low BMD.

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Cont.

DEXA scanning

– Osteoporosis is evaluated with DEXA scanning using the T-score or the Z-score.

– The T-score compares BMD to a 30 year old adult control whereas the Z-score compares BMD to
age and gender matched controls.

– The latter is a more appropriate diagnostic method for female athletes who have yet to achieve
maximum bone density.

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Cont.

• In athletes with eating disorders or menstrual irregularities, who are at risk for osteoporosis or
osteopenia, measurement of BMD should be performed as early as possible in order to start
intervention and therapy immediately.

• Evaluation of osteoporosis in the young female athlete is further complicated by site dependent
alteration in BMD.

• Decreased bone density should especially be suspected in women presenting with recurrent stress
fractures, or fractures associated with minimal trauma.

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6.
Treatment

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Treatment Goals

– Re-gain weight lost, with improvement in overall nutritional and energetic status.

– Atattainment of BMI ≥18.5 or >85% expected weight

– Restore regular menstruation.

– Re-balance energy expenditure with consumption.

– Restore bone mineral density

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Multi-disciplinary Approach

• A multidisciplinary team approach is essential, and knowledge of athletes is preferable.

• Persons with female athlete triad should get treatment from a multi-disciplinary team that includes a
physician, dietician, gynecologist, and mental health counselor, and seek support from family, friends,
and their coach.

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Treatment Options

– Lifestyle changes

– Medications

– Hormone Replacement Therapy

– Supplementation for restoring BMD

– Family Involvment

– Cognitive Therapy and Nutritional Counseling

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Non-Pharmacological
Treatment

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6.1.1
Lifestyle Changes-Improve EA

• Improving Energy Availability (EA) and Weight

• Improving EA is basis of treatment of triad disorders and is linked with return of normal menses,
improved BMD and weight.

• Done by both decreasing exercise expenditure and increasing dietary intake.

• Improving EA to >45 kcal/kg FFM /day is optimal.

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6.1.2 Lifestyle Changes-Eat More

• Low energy availability with or without eating disorders, pose significant risks to female athletes.

• Due to raised caloric requirements of female athletes, nutritional support and diet counselling are
integral to treatment, regardless of presence or absence of disordered eating.

• Prepare written weight goals.

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6.1.3
Lifestyle Changes-Eat More

• Patients are recommended to work with a dietician who can monitor their nutritional status and help
patient work towards a healthy goal weight.

• Patients should also meet with a psychiatrist or psychologist to address eating disorder aspects of
triad.

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6.1.4
Lifestyle Change-Exercise Less

• Continued athletic participation depends on physical and mental health of athlete. Athletes who
weigh < 80 % of their ideal body weight are able to safely participate.

• Realistic training goals should be identified.

• Patients are often asked by health professionals to reduce exercise duration by 10-12 %.

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6.1.4
Lifestyle Change-Exercise Less

• Do not stop exercisee completely but activity should be reduced and monitor weight closely for 2-3
months.

• Reduce training volume by 1 day/week is to get needed improvement in weight and EA.

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6.1.5 Psychological Support

• Seeking psychological support can help change patient’s relationship with food and help with any
mental health problems, such as anxiety, depression or low self-esteem.
• Ppsychiatric evaluation helps in assessment of depression or eating disorders, and in selection of
medications.

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6.1.6 Family Involvement

• Family involvement is crucial to success of treatment.

• Family should be included in treatment plans from beginning, specially with adolescent pts.

• At first treatment may seem to be detrimental to athletic career of child, but education about female
athlete triad may motivate parents to participate in treatment program.

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6.1.7 Cognitive Therapy

• Cognitive therapy is highly effective as it works with individuals having female athlete triad to change
negative thinking and behaviours around disordered eating, exercise, and body image.

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6.1.8 Nutritional Counseling

• Main element of preventing female athlete triad is raising awareness and educating
female athletes and coaches.

• Athletes need to be informed about nutrition and importance of eating enough, as

well as knowing when to rest and recover.

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Cont.

• Additionally, all women should have a good understanding of what a healthy

menstrual cycle looks like.

• It is vital to have good communication between the athlete, their coach and their
family.

• Encouraging athletes to seek counselling can help too to prevent the full onset of the
triad.

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6.2 Pharmacological Treatment

• Patients are also sometimes treated pharmacologically. Medication is useful to treat osteoporosis,
low bone density, eating disorders, and underlying mental health issues like depression and anxiety.

• Estrogen or progesterone: To both induce menses and improve bone density, cyclic estrogen or
progesterone is used to treat post-menopausal women.

• Oral contraceptives to stimulate regular periods and treat osteoporosis but these won’t often be
effective without diet changes and necessary weight gain.

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Cont.

– Bisphosphonates and calcitonin, used to treat osteoporosis, may be prescribed, although their
effectiveness has not yet been established.

– Antidepressants, if indicated by a psychiatric examination, the affected athlete may be

prescribed.

– SSRIs: Depending on severity of eating disorder, a selective serotonin reuptake inhibitor (SSRI)
may be indicated for treatment of a specific disorder.

– Benzodiazepines for treatment of severe mealtime anxiety.

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6.2.1
Hormone Replacement Therapy

• To treat menstrual dysfunction and osteoporosis.

• HRT includes oral contraceptives and gonadal steroids (estrogen, progesterone, and testosterone).

• Appropriate timing for initiation of HRT is after six months of amenorrhea.

• Patients with bone mineral density loss (osteopenia) are strongly encouraged to start hormonal
therapy.

• Both oral contraceptives and cyclic estrogen-progesterone are used to treat amenorrhea of triad.

• Estrogen may be replaced in a variety of ways

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Cont.

• Oral contraceptives - particularly beneficial if birth control is also desired.

• Hormone replacement regimens as prescribed for postmenopausal women are also feasible options.

• Progesterone is included to prevent endometrial hyperplasia that can result from use of unopposed
estrogen.

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6.2.2
Supplementation for BMD Loss

• Nutritional supplements like calcium and vitamin D are recommended to increase calcium absorption
to improve bone density.
• Recommendation of calcium is 1,200-1,500 mg/day for female athletes of age 11-24 years.
• Additional daily supplementation of 400-800 IU of vitamin D will facilitate calcium absorption.
• Optimizing Ca and vitamin D intake is vital part of treatment.
• More athletes with stress fractures have low calcium intakes than do athletes without stress
fractures.
• Other micronutrients also play role in bone health (B vitamins, vitamin K, and iron) and are needed in
a well-balanced diet.
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PMAS AAUR 84