Female Athlete Triad

Muhammad Faheem Afzal

◉ Presentation outline

▪
Physical considerations:
▪ Cardiovascular and strength
▪ Flexibility
▪ Body composition
▪ Hormonal factors
◉ The female athlete triad
◉ Nutrition
◉ The Ageing Athlete
Physical Differences

Different
doesn’t mean
better or
worse.
It just means
different.
 Female Athletes: All Shapes & Sizes

What do
these women
have in
common?

They all
participate in
SPORT!
 Cardiovascular Differences
• Generally, women have smaller heart,
lungs, blood volume and haemoglobin
concentration (10% lower) than men – this
limits aerobic metabolism.
• Women have lower VO2max values than
male in general (3l/min vs. 2l/min)
• Female athletes burn more fat when
exercising.
Strength Differences
• Women tend to have less muscle mass due to
lower levels of testosterone (1/10th of men) –
this limits strength and power.
• Upper body – 40/50% weaker than men.
• Lower body – 30% weaker.
• Females have the same proportional
capacity as males to improve their
cardiovascular fitness.
• Females have the same proportional capacity
as males to improve their strength levels
through training.
 Strength
American Males:18 -22kg more muscle
 3 – 6kg less fat
 males taller, wider frame
◉ Relatively- strength differences between males are
females are not too dissimilar when accounting for Lean
body mass relative to strength.
◉ Male muscle greater capacity for anaerobic
metabolism and producing power
◉ Female muscle - more resistance to fatigue and
recovers faster (Fulco 1999, Hakkinen 1993, Linnamo
1998)
Importance of strength training
for females
◉ Enhances bone remodeling (prevent osteoporosis)
◉ Increases joint stability and prevent injury
◉ Increases functional strength for sports
◉ Increases lean body mass
◉ Increases metabolic rate
◉ Increases self esteem and confidence
Body Composition
In general, female athletes
(even lean ones) have a higher
proportion of body fat than
male athletes.

Females – 20-25% body fat

Males – 15 – 20% body fat

Extra fat stores - good for

swimming (buoyancy) and
long endurance events
Flexibility
◉ Females are more flexible than males
◉ Greater range of motion in hip and elbow joint
(Alter 1996)
◉ Due to different bone structure, females smaller
tendons, ligaments and muscles allowing greater
potential for flexibility.
◉ Good for sports like gymnastics, dance, rock
climbing.
◉ Prevents over reach injuries but can be problems with
joint laxity especially people who are hyper mobile.
Injury Risk
Higherincidence (3-5times greater) of ACL injuries in
females playing soccer & basketball.
◉ Due to smaller ACL’s, different Q angle of the knee (angle
greater in women), they over rely on quad strength,
tendency to land more flat footed and with straighter
knees.
◉ Also maybe due to failure in developing basic co- ordination
skills at an early age.
◉ Careful 2-3d before menstrual cycle (sacroiliac joint
predisposed to injury in high impact elastic strength
exercises.
 Hormonal Factors
• Male sex hormone testosterone: responsible for
muscularity and male shape
• Female sex hormones: progesterone and
oestrogen: responsible for female attributes and
regulation of menstrual cycle (and fertility)
Exercise and the Menstrual Cycle
Olympic medals have been won at all
stages of the cycle
• Awareness of pre-menstrual symptoms
– Personal diary, look for patterns
• Flexibility of training programmes
• Regulation of the menstrual cycle and
minimising symptoms
Exploding the myths
◉ Women can train as hard as men
◉ Women can have the same % training
improvement as men
◉ The menstrual cycle does not limit a woman’s
ability to train hard or to compete as hard as a
man
◉ Pain thresholds are not a male domain
THE FEMALE ATHLETE TRIAD
 The Female Athlete Triad
Disordered
Eating

Amenorrhoea Osteoporosis
THE FEMALE ATHLETE TRIAD
What is the female athlete triad
◉ Disordered Eating
◉ Amenorrhea
◉ Osteoporosis
The female athlete triad
◉ Originally described in 1992
◉ First recognized as three separate but
unrelated entities
◉ Now recognized by the American College of Sports
Medicine (ACSM) as a spectrum of symptoms and
conditions between health and disease
The female athlete triad
The three spectrums include:

◉ Energy availability (which may occur with or

without disordered eating)
◉ Menstrual function
◉ Bone Mineral Density
The female athlete triad
Dysfunction in any of any of the components
can lead to dysfunction of the other
components.

While energy availability may change daily, the

effects on menstrual cycle may not occur for
months, and an effect on bone mineral
density may not occur for years.
Energy Balance & Body wt
When an athlete eats enough calories to meet
basic and athletic needs, wt should be
stable.However, it isn’t that simple. When
there is a caloric deficit, the brain & body
try to help reestablish energy balance by
decreasing resting metabolic rate. The body
begins to conserve calories, and this starts a
cascade of events we’ll call low energy
availability.
Low energy availability
 Can occur with or without a formal eating disorder.

May be due to abnormal eating behaviors such as

dietary restraint, binge eating, etc.
OR failure increase dietary intake to match
training needs.
Low energy availability lead to
◉ Disruption of the GnRH pulse generator
in the hypothalamus, possibly because
of changes in:
- leptin -cortisol
- insulin,glucose,ketones
- growth hormone T3, etc.
 Inhibitary effect of hypothalamus

Decreased stimulation of the pituitary with GnRH pulses

Decreased LH and FSH pulses, resulting in less
stimulation of the ovaries to produce
progesterone and estrogen
Abnormal mensis
So why are abnormal menses
important?
-Because Bone Mineral Density decreases with
the number of missed menstrual cycles
accumulated over the months and years.
This leads to increased incidence of stress
fractures in active women with menstrual
irregularities.
Bone mineral density
◉ 60-80% Genetically Determined, peak
BMD achieved between ages 11-15
◉ While weight-bearing exercise should
increase BMD, decreased estrogen
decreases BMD, as do:
◉ smoking, alcohol, malnutrition
◉ Women with normal menses who are
active have 5-15% higher BMD than
sedentary controls.
 Osteoporosis

May result from failure to achieve peak BMD during

adolescence or from accelerated bone loss
Prevalence of the triad
◉ Unsure… Why?

inadvertant low energy availability-

prevalence is unknown

disordered eating without a formal eating –

28-62% prevalence in thin-build athletes

formal eating disorder – 25-31% prevalence in

thin-build athletes compared with 5-9%
general population
 Prevalence of menstrual disorder

Amenorrhea is present in 65-69% of endurance runners

compared to 2-5% in the general population
Prevalence of Low BMD
T-score between -1 and -2.5:
22-50% prevalence among female athletes
T-score less than -2.5:
0-13% prevalence among female athletes
These are higher than the 12% and
2.3%prevalence estimates, respectively, in
a normal population distribution.
Key Concepts
◉ It is not necessary to have all three
components of the Triad simultaneously to
have negative effects on bone health
◉ The triad can be seen in all sports, not just
those traditionally seen as low body wt
sports such as long distance running
 Additional consequences of the triad
-Increased -Excessive fatigue
cardiovascular risk
-Increased risk for -Increased recovery
osteoporosis time
-Reproductive
dysfunction -Decreased response
to training
-Metabolic
Consequences
-Impaired
Performance
Screening
If one component of the Triad is present,
screen for the other two, as there is
significant likelihood they are present.
How?
1. Low Energy Availability: look for high
dietary restraint, high drive for thinness,
excessive or compulsive exercise, restriction
of specific food groups, repeated dieting,
eating disorder.
Screening
2. Menstrual dysfunction: how many
periods has the athlete had within the
past 12 months? Has she
missed >3 periods in a row?
3. BMD: consider performing DXA scan of
the spine and hip if hx of stress fx and/or
h/o
> 6 months of amenorrhea,
oligomenorrhea, disordered eating or
eating disorder.
Prevention/treatment
◉ Education of the athlete as to how much energy is
required to do the kind of training/performance she is
asking of her body.
◉ Increasing nutritional intake or decreasing training
volume may be needed to restore/maintain energy
balance.
◉ Provision of adequate Calcium 1200-1500mg/day and
Vit. D 400-800IU/day.
Prevention/treatment
◉ Adding hormones will not restore BMD
unless adequate nutrition is present
◉ Biophosphonates should not be used in
young athletes with amennorhea or low
BMD
Prevention
◉ Changing the mindset is important, and
successful female ultra runners seem to
understand that food is not “the enemy”
rather what fuels activity and performance andbut
promotes development of training effect and
allows for healing and growth.
◉ The Female Athlete Triad is NOT an inevitable
consequence of training and being an athlete.
At risk

1. Sports in which performance is subjectively

scored
2. Endurance sports emphasising a low body weight
3. Sports requiring contour-revealing clothing
for competition
4. Sports using weight categories for
participants
5. Sports emphasising a pre-pubertal look
Disorder Eating
◉ Refers to a wide spectrum of disordered eating
(restricting food intake, bingeing, purging, anorexia,
bulimia)
◉ The precipitating event for the Triad
◉ Can be very difficult to recognise
◉ May lead to poor nutritional status, reduced
immunity from infections and poor sports
performance
Behavioural signs suggestive of disordered
eating(thompson &sherman 1993)
◉ Preoccupation with food and weight
◉ Repeatedly expressed concerns about being fat
◉ Increased criticism of one’s body
◉ Unnecessary use of laxatives/diuretics
◉ Trips to the bathroom following meals
◉ Compulsive, excessive exercise
◉ Complaining of always being cold
Physical sign of anorexia
Amenhorrea
Dehydration, especially in the
absence of training and
competition
Fatigue beyond that normally
expected in training or
competition
Gastrointestinal problems
bloating, post prandial distress.
Hyperactivity
Physical sign of anorexia
Hypothermia (cold intolerance)
Lanugo (fine hair on face and arms)
Muscle weakness
Overuse injuries
Stress fractures
Weight significantly lower than necessary
for adequate sports performance
Significant weight loss beyond that necessary
for adequate sports performance
Physical sign of anorexia
Claims of “feeling fat” despite
being thin
Anxiety
Avoidance of eating and
eating situations
Compulsiveness and rigidity,
especially regarding eating
and exercise
Depression
Physiological sign of anorexia
Exercising while injured
Insomnia
Obsessiveness and pre-occupation with
weight and eating
Resistance to weight gain or maintenance
Restlessness
Physiological sign of anorexia
Restrictive dieting
Social withdrawal
Unusual weighing
behaviour
Excessive or obligatory exercise beyond that
required for a particular sport or coach
 Untreated eating disorders CAN be life-
threatening
◉ Refer athlete to their GP, or a sports medicine
professional, dietician, or (sports)
psychologist
◉ Eating Disorders clinics at major hospitals
 The female athlete triad

Disordered Eating

Amenorrhoea Osteoporosis
Amenorrohea

◉ Primary: absence of menstruation by the age of 16

◉ Secondary: absence of 3 or more consecutive cycles after
menarche or less than 6-9 periods annually
◉ Associated with:
▪ “Energy drain” – failing to match energy expenditure
with adequate food intake
▪ High training volumes
▪ Possible eating disorders
◉ May lead to osteoporosis and increased cardiac risk if
untreated
 Osteoprosis
Normal
◉ Bones become thin and fragile Bone
◉ Bone is laid down during childhood,
achieves maximum density by late 20s,
and then declines
◉ Linked to female triad/amenorrhea in Osteoporoti
young women and hormonal changes at c Bone
menopause
◉ Exercise is important to prevent it but
excessive exercise can produce the
opposite effect
Avoiding osteoprosis
◉ Avoid the Female Athlete Triad
◉ Refer females who have not reached menarche
by 16yrs to Dr
◉ Ensure adequate Calcium in diet
◉ Avoid excessive smoking, caffeine & alcohol
◉ Get regular weight-bearing exercise
Nutrition for the female athlete
◉ Females generally require less daily calories than
males (smaller body size and less active tissue).
◉ Some athletes may have poor energy intake
and/or food selections with low levels of
macronutrients, especially calcium, iron, B
vitamins and zinc.
 Calcium

Recommended Intake

mg/day 300 mg calcium is found in:

▪ 200 ml milk
Girls (12-15yrs) 1,000
▪ 1 tub (200 g) yoghurt
Girls (16-18yrs) 800
▪ 40 g hard cheese
Women 800
▪ 80 g sardines/salmon
Post 1000 ▪ 1.5 cups beans
menopause >1,200 ▪ 250 g tofu

Pregnancy
Iron

Recommended Intake
mg/day
2 mg iron is found in:
Children 6-8 ▪ 50 g lean beef
Adolescents 10-13 ▪ 250 g chicken
▪ 20 g liver
Women 12-16
▪ ½ cup spinach
Pregnancy >22 ▪ ½ cup dried beans
Athletes >16 ▪ 30 g fortified cereal
The aging athlete
◉ Certain fitness components are affected by
age (Speed, Elastic Power/Strength).
◉ World record times – 5% faster for men aged
40y compared to 45y old age group,
equivalent of 7% in women.
◉ 50y olds declined most (another 3-6%)
◉ Up to the age 80y – best performances
declined at a rate of 1% each year.
The effect of aging on performance
◉ Performances go down with age mainly because of a
decrease in muscle mass especially after the age of
45.
◉ Muscle protein re-pairing and the repair processes
become slower and less effective noted by a decrease
in physical strength.
◉ Injured athletes (45y) recover 15 – 18% slower than a
30y old. Skin thickness reduces by 30% by age 50 –
more cuts, lacerations.
◉ Bone density naturally decreases by 10% by the age
of 50y.
It’s not all doom and gloom!!!!
◉ Strength is one of the fitness components that
doesn’t decline as fast if you work at it. You
can reach peak strength levels in your 30’s and
maintain strength levels well into the 40’s
◉ Cognitive functioning and skill work never
really declines (its something you keep
relatively well all your life).
◉ Marathon runners – usually mature in 30’s, 40’s
then times decline 2% per year up to the age
of 80.
Pregnancy and exercise
◉ Consult your doctor before you undertake any
exercise regime.
◉ Best exercise to do while pregnant is non weight
bearing – cycling, swimming, water aerobics and
walking (mild to moderate intensity). Sit ups not a
good idea.
◉ Avoid exercises that increases your risk of falling,
contact sports or injuries that you might sustain to
the stomach – high impact sprinting and jumping
activities are not suitable.
Pregnancy and exercise
◉ After 3months avoid doing exercises on your back –
weight of baby may interfere with blood circulation.
◉ Avoid long periods of standing.
◉ If weather is hot exercise in the morning or evening
to prevent over-heating.
◉ Drink plenty and eat a well balanced diet.
◉ If at any stage you feel unwell, dizzy, abdominal
pain – stop exercising immediately.
 Returning of sports after Pregnancy
◉ Slowly get back into training, give yourself
enough time to recover first.
◉ Avoid undergoing maximal fitness tests
initially.
◉ Walking is a good start.
◉ Endurance exercise is best for losing weight
and follow this up with toning exercises –
(tummy and pelvic floor exercises).
Gender verification
◉ Top Indian woman athlete Santhi Soundararajan, who won
a silver medal at a recent regional championship, has failed
a gender test, according to official reports.
◉ Sports writer KP Mohan said that a team of doctors,
including a gynecologist, endocrinologist and
psychologist, normally examines athletes and puts them
through physical and clinical examinations during a
gender test.
◉ Santhi Soundararajan's test was done after
Soundararajan came in second in the women's
soon
race on 9 December, but it is not clear how she failed 800m
the test at the Asian Games in Doha.

63
 ◉ How do you know if someone is male or female

Talk to the person next to you and identify at least 5

characteristics to distinguish males from females.

64
Gender Differentiation
Anatomy: Primary and secondary sexual

characteristics - genitalia, body hair, pelvis, etc.

Physiology: Function and interaction of the sex

organs including concentrations of sex hormones such

as estrogen, progesterone, and testosterone.
 Imagine you are a member of the committee assigned
to determine whether santhi is female. Here are
possible results of the initial test

Female genitalia: Yes

Breasts and pubic hair: Yes

Regular menstrual cycle: Never

From this information, you conclude

that Santhi is:

A: Male B: Female
 ◉ Is there another way that sex is
characterized in human
Chromosomes:

▪ Females possess two X chromosomes in each of their

cells, whereas males have one X and one Y
chromosome.

◉ How do you visualize chromosomes?

▪ Chromosomes are only visible when preparing
for nuclear division.
▪ Chromosomes must be stained.

67
◉ During nuclear division,
DNA is tightly packed.
◉ This chromosome is
composed of 2
chromatids.
◉ In this diagram, the DNA
has replicated (more on
this later).

68
If santhi is a normal female her karytype would
be?

A: XX
B: XY
C: YY
D: XXY

69
◉ Sex is determined by the
sperm
sex chromosome carried X Y
by the sperm.
X
◉ What sex chromosome is XX XY
carried by the egg? egg
X XX XY

girls boys

71
In addition to anatomy, physiology, and
chromosomes, there is a 4th answer:
Genes: Specific genes determine whether an
embryo will develop as a male or female.

73
◉ All women can participate and gain benefits from
sport, just like men
◉ Female athletes, like male athletes, come in all
shapes and sizes, and it is possible to find a
sport to suit all types
◉ Education about proper nutrition and safe
practices for women in sport is paramount

Thank you!