Female Athlete Triad

Female athletes, especially those competing, are under pressure to maintain their body weight; therefore, restricted diet and heavy training load are seen in these athletes, resulting in an increased risk of the so-called “Female athlete triad” Syndrome.The American Academy of Family Physician (AAFP) also recognizes this triad as a devastating syndrome for female athletes.The triad, as its name implies, is defined into three interrelated conditions and often presented with at least one of the following components:<ul><li style="list-style-type: none;"><ul><li>Eating Disorder or low energy availability</li><li>Menstrual Dysfunction</li><li>Osteoporosis</li></ul></li></ul>The National Athletic Trainers’ Association published a positioning statement that provides early screening and management recommendations. Recognizing physical signs and symptoms is essential to early detection and prevention.<h2>Management</h2>Nonpharmacologic therapyThe best strategy to restore the function of bone metabolism is to reduce load impact on the bone through reduced exercise load and weight gain, resumption of the menstrual cycle flow, and activation of the hypothalamic-pituitary-ovarian (HPO) axis, which is the tight control regulation for the female reproductive system.Pharmacological therapySuppose female athletes do not resume their menses within 6-12 months; in that case, the increased risk of bone deterioration is high despite following a reasonable intervention with nutrition, exercise modification, and psychological support; then recommendation with progesterone and estradiol is suggested according to the Endocrine Society 2017 guidelines.Hormonal therapy is required when there is a lack of nonpharmacological support for more than a year and a positive dual-energy x-ray absorptiometry (DXA) scan.Second line therapy Bisphosphonates have been the mainstay therapy for patients with osteoporosis in the elderly as it’s an age-degenerative disease. Contrary to Athletes with low BMD, their osteoporosis/osteopenia is mainly due to FHA induced due to low energy availability, and bisphosphonates are avoided unless ineffective estrogenic replacement or estrogen is contraindicated.The Endocrine Society and the Female Athlete Triad Coalition do not recommend using bisphosphonates in FHA status.Bisphosphonates, such as alendronate or risedronate, are known to reside in the bone for years, and concerns of teratogenicity in female athletes, especially in their reproductive age, are high. No data is available on the use of bisphosphonates in athletes so far. Also, data on new agents, such as Denosumab, a monoclonal antibody, is not also available in this female age category. Other alternative therapies as testosterone and leptins, are not recommended by the Endocrine Society and the Female Athlete Triad Coalition in women with FHA.<h2>Conclusion</h2>Management of athletes needs to be approached in a multidisciplinary manner, especially competitive female athletes from physicians, psychotherapists, and nutritionists, besides their certified training coaches. The communication between female athletes and coaches should be based on trust and transparency. Coaches play a huge role as caregivers and pay attention to athletes’ psychosocial environment and all surrounding stressors with which the athlete can be surrounded. Further research and effective implementation are still lacking, and the last consensus was in 2014 (12 years ago), which needs to be updated. Education to all relevant stakeholders should be emphasized the importance and risk of this triad on their performance and health. This article was contributed by our expert <a href="https://www.linkedin.com/in/nadine-qtaish-pharmd-mba-issa-amwa-0a512142/">Nadine Qtaish</a>    <h3>Frequently Asked Questions Answered by Nadine Qtaish </h3><h2>1. What impact may the female athlete triad have on growth development and health?</h2>The younger the athlete the higher the risk she places herself in her growth development or specifically to her menstrual cycle, hence the bone impact & risk of developing osteoporosis.Young athletes (teens and adolescence) are usually the priming age for competitive training & elite racing. Endurance athletes or sports that are weight sensitive are most prone to this triad. All starts with anxiety around their weight when habits of anorexia and restricting calories occurs which can eventually impact their nutritional needs, fat loss & stress, consequently irregularities in their menstrual cycle that can cause delays and risk of amenorrhea. Estrogen is the main protective hormone to the female bone health in her age bearing period, and loss of estrogen can negatively impact her bone mass and increase risk to early osteoporosis through sudden stress fractures. <h2>2. How is female athlete triad prevented?</h2>A multidisciplinary team should be established or let's say have further emphasis on this issue as it has been estimated above 50% of females are suffering from nutritional deficiencies. I suggest the following:<ul><li style="list-style-type: none;"><ul><li>Educate the athletes on the consequences to the health and bone on a periodic basis</li><li>Close follow up from the coach & nutritionist (metrics)</li><li>Track their menstrual cycle & validation (a visit to the gynecologist every once in a while)</li><li>Test Labs (DXA scan once yearly for example)</li><li>Mental stability (anxiety and stress) to be assessed is crucial </li></ul></li></ul>This could be the ideal approach yet expensive depending on the country’s sources and support.

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