Female Triad

Question 1

three interrelated components:

Answer 1

Low Energy Availability (with or without an Eating Disorder)

Menstrual Dysfunction

Decreased Bone Mineral Density (Osteoporosis or Osteopenia)

Question 2

Low Energy Availability (with or without an Eating Disorder):

Answer 2

woman’s energy intake is insufficient to meet the demands of exercise and other daily activities

can result from an eating disorder (e.g., anorexia nervosa or bulimia) or from inadvertent undereating

Low energy availability affects the body’s normal physiological processes

Question 3

Menstrual Dysfunction:

Answer 3

Energy deficiency can disrupt the normal release of hormones, leading to irregular menstrual cycles or amenorrhea (absence of menstruation)

This can have significant consequences on reproductive health and hormone regulation

Question 4

Decreased Bone Mineral Density (Osteoporosis or Osteopenia):

Answer 4

Prolonged low energy availability and hormonal imbalances can lead to reduced bone density, increasing the risk of stress fractures and long-term bone health issues like osteopenia (low bone mass) and osteoporosis

Question 5

Since 2007: Does not need to be all 3, now ____ is considered female triad

Answer 5

just 1

Question 6

Optimal Energy Availability:

Answer 6

Energy intake is AT LEAST sufficient to cover energy expenditure and replenish stored energy

Maintained body weight

Maintained physiological processes

Question 7

Low Energy Availability:

Answer 7

individual’s energy intake is insufficient to support both their exercise demands and the energy required for normal physiological processes

low calorie intake, excessive energy expenditure (from exercise or daily activities), or a combination of both

goal of managing low energy availability is to optimize energy availability, which typically involves increasing caloric intake, reducing energy expenditure, or both

Question 8

Energy Availability Calculation:

Answer 8

difference between dietary energy intake and energy expenditure during exercise, divided by lean body mass

Question 9

Optimal energy availability is around ___ of lean body mass per day

Answer 9

45 kcal/kg

When energy availability drops below 30 kcal/kg of lean body mass per day, it is associated with most of the negative effects on physiological processes, such as reproductive function and bone health

Question 10

Body’s Response to Low Energy Availability:

Answer 10

prioritizes basic survival functions over non-essential processes

Menstrual Dysfunction

Decreased Bone Density

Reduced Metabolic Rate

Impaired Immune Function

Question 11

Menstrual Dysfunction:

Answer 11

The brain suppresses the release of reproductive hormones, leading to irregular periods or amenorrhea (absence of menstruation)

Question 12

Decreased Bone Density:

Answer 12

Reduced hormone levels, particularly estrogen, impair bone formation and increase the risk of osteoporosis and stress fractures

Question 13

Reduced Metabolic Rate:

Answer 13

The body reduces its energy expenditure, leading to fatigue and impaired recovery

Question 13

Impaired Immune Function:

Answer 13

The immune system may become compromised, leading to an increased risk of illness and injury

Question 13

Bulimia Nervosa:

Answer 13

Involves cycles of binge eating followed by compensatory behaviors such as vomiting, excessive exercise, or use of laxatives.

Often accompanied by feelings of shame, guilt, and loss of control over eating.

Question 13

Disordered Eating:

Answer 13

Anorexia, Bulimia, Binging, Exercise Binging, etc
Refer to specialists

range of unhealthy eating behaviors and attitudes toward food, body image, and exercise

Question 13

Binge Eating Disorder:

Answer 13

Characterized by recurrent episodes of eating large amounts of food in a short period, often when not physically hungry.

Unlike bulimia, binge eating episodes are not followed by purging behaviors.

Question 13

Anorexia Nervosa:

Answer 13

Characterized by extreme food restriction, intense fear of gaining weight, and a distorted body image.

Leads to significant weight loss, malnutrition, and potential life-threatening health issues.

Question 13

Exercise Binging:

Answer 13

Refers to the excessive and compulsive need to exercise, often in response to eating, in an attempt to burn off calories.

Can result in overtraining, fatigue, injury, and psychological stress.

Question 14

Individuals exhibiting signs of disordered eating should be referred to qualified specialists, including:

Answer 14

Registered dietitians experienced in sports nutrition.

Mental health professionals who specialize in eating disorders and body image concerns.

Medical professionals (e.g., primary care physicians, endocrinologists) to monitor and manage the physical health consequences.

Question 15

Eumenorrhea

Answer 15

Regular menstruation every 28 days

If abnormal:
Diagnosis by exclusion (thyroid, pregnancy, polycystic ovary)

Question 16

Amenorrhea:

Answer 16

Absence of menstruation for 3 or more months.

Question 17

Oligomenorrhea:

Answer 17

Infrequent or irregular menstrual periods (longer than 35 days apart).

Question 18

Luteal Phase Defects:

Answer 18

Shortened luteal phase, leading to difficulty with fertility or irregular cycles.

Question 19

Thyroid Dysfunction:

Answer 19

Hypothyroidism or hyperthyroidism can disrupt the menstrual cycle. Blood tests for TSH (thyroid-stimulating hormone) and other thyroid hormones can identify abnormalities.

Question 20

Pregnancy:

Answer 20

Amenorrhea can be caused by pregnancy, so a pregnancy test should be conducted if this is a possibility.

Question 21

Polycystic Ovary Syndrome (PCOS):

Answer 21

PCOS is a hormonal disorder that can cause irregular periods, weight gain, and other symptoms. It is typically diagnosed through clinical signs, ultrasound, and blood tests to evaluate hormone levels.

Question 22

Subclinical Menstrual Disorders:

Answer 22

Luteal phase defect- fertility issues, low progesterone Anovulation

Question 23

Luteal Phase Defect:

Answer 23

time between ovulation and the start of menstruation, typically lasting about 12-14 days phase is shorter than normal or characterized by insufficient production of progesterone, a hormone critical for preparing the uterine lining for pregnancy LPD is often seen in athletes with low energy availability or stress, both of which can affect hormonal balance

Question 24

Anovulation:

Answer 24

menstrual cycle in which ovulation does not occur, meaning an egg is not released from the ovary Menstruation may still occur, but without ovulation, fertility is impaired can result from disruptions in the hypothalamic-pituitary-ovarian axis, often caused by low energy availability, stress, excessive exercise, or certain medical conditions

Question 25

Amenorrhea:

Answer 25

Primary- absence after age 15 Secondary- 3 consecutive missed cycles Oligomenorrhea- every 35 days or fewer than 9 per year

Question 26

Functional hypothalamic Amenorrhea-

Answer 26

Gonadotropin releasing hormone due to prolonged exertion and weight loss, impacts luteinizing and follicle stimulating hormone, which impacts release of estrogen

Question 27

Optimal Bone Mass

Answer 27

90% peak BMD achieved by 18 and greatest from 11-14 yrs old Needs: Calcium, Vitamin D, loading DEXA: Normal Z score: 0 and above T score: match peak bone mass Z score: Match to age/sex

Question 28

Calcium:

Answer 28

Essential for bone mineralization and overall bone strength. Adolescents require 1,300 mg/day to support bone growth.

Question 29

Vitamin D:

Answer 29

Facilitates calcium absorption and helps maintain proper bone structure. Vitamin D is obtained through sunlight exposure and dietary sources (e.g., fortified foods), with a recommended intake of 600-800 IU/day

Question 30

T-Score:

Answer 30

T-score of 0 or higher indicates normal bone density. Negative T-scores indicate lower bone density T-score between -1 and -2.5 classified as osteopenia T-score below -2.5 indicating osteoporosis.

Question 31

Z-Score:

Answer 31

Compares an individual’s BMD to the average for their age, sex, and ethnicity. A Z-score of 0 is normal, meaning the person’s bone density is typical for their age and sex. Low Z-scores (below -2.0) may suggest a condition affecting bone health other than aging, such as nutritional deficiencies, hormonal imbalances, or chronic illness.

Question 32

Low Bone Mineral Density

Answer 32

Estrogen inhibits bone remodeling and resorption Decreased estrogen = decreased BMD Decreased BMD = increased fracture risk Increasing BMI is associated with menses Z-score: -1 to -2 is abnormal and requires exploration in WB athlete

Question 33

Osteoporosis:

Answer 33

typically associated with loss of estrogen in menopause Happens earlier if in a chronic state of reduced estrogen Normal: -1.0 and above Osteopenia (low bone mass): Between -1.0 and -2.5 Osteoporosis: -2.5 or lower Severe osteoporosis: -2.5 or lower with a history of one or more fractures.

Question 34

High school athletes:

Answer 34

Overall prevalence of all three Triad conditions: 1.0–1.3%. Prevalence of any two conditions: 4.0–18.0%. Prevalence of any one condition: 16.0–54.0%.

Question 35

Premenopausal exercising and athletic women:

Answer 35

Overall prevalence of all three Triad conditions: 0.0–4.3%. Prevalence of any two conditions: 9.0–27.0%. Prevalence of any one condition: 22.0–60.0%.

Question 36

Among high school athletes, the prevalence of ___ was quite high ____

Answer 36

any one condition (16.0–54.0%)

Question 37

___ showed a much higher prevalence of all three conditions ___

Answer 37

Elite female endurance athletes (15.9%)

Question 38

Triathlon team members had a 0% prevalence of ___ but a high percentage of ____

Answer 38

all three conditions at least one condition (60.0%)

Question 39

The prevalence of Female Athlete Triad conditions varies based on the athletic level and sport type, with ____ showing more severe conditions.

Answer 39

elite endurance athletes

Question 40

Lean sport athletes vs non lean sport: Prevalence of all three Triad conditions:

Answer 40

Lean sport athletes: 1.5–6.7%. Non-lean sport athletes: 0.0–2.0%.

Question 41

Lean sport athletes vs non lean sport: Prevalence of any two Triad conditions:

Answer 41

Lean sport athletes: 6.8–57.8%. Non-lean sport athletes: 5.4–13.5%.

Question 42

Lean sport athletes vs non lean sport: Menstrual disturbances (MD):

Answer 42

Lean sport athletes: Secondary amenorrhea (1.4–27.7%), Primary amenorrhea (0.7–9.5%), Oligomenorrhea (22.3–24.7%). Non-lean sport athletes: Secondary amenorrhea (0.0–12.8%), Primary amenorrhea (0.0–0.4%), Oligomenorrhea (14.3–16.5%).

Question 43

Lean sport athletes vs non lean sport: Disordered Eating (DE):

Answer 43

Lean sport athletes: Clinical DE (1.5–28.1%), Subclinical DE (6.0–89.2%). Non-lean sport athletes: Clinical DE (0.0–15.1%), Subclinical DE (2.9–89.2%).

Question 44

Lean sport athletes vs non lean sport: Low Bone Mineral Density (BMD):

Answer 44

Lean sport athletes: Low BMD (Z-score ≤ -2.0: 3.1%, Z-score < -1.0: 15.4%). Non-lean sport athletes: Low BMD (Z-score ≤ -2.0: 0.0%, Z-score < -1.0: 0.0%).

Question 45

Lean sport athletes show a higher prevalence of all three conditions and a significantly higher rate of :

Answer 45

menstrual disturbances and eating disorders, which are central to the Female Athlete Triad.

Question 46

Non-lean sport athletes have a lower prevalence of these conditions, particularly:

Answer 46

low bone density and primary amenorrhea

Question 47

Female Triad Risk factors:

Answer 47

1st menstrual period after age 15 < 9 periods per year < 18.5 kg/m2 (BMI) for adults Disordered eating Family Hx of bone disease or DE Vegetarianism (indirectly) Lactose intolerance Low Vit D Hx of bone stress injury Anxiety, OCD, other metal health disorders

Question 48

Medical Management

Answer 48

Multidisciplinary Approach- Physician, Dietitian, Mental Health, Rehab Professional (PT, ATC, Ex Phys), Coach

Question 49

Pharmacological Interventions

Answer 49

Limited use due to poor evidence Potential Drugs: Oral Contraceptives, Hormone replacement therapy, Recombinant Parathyroid Hormone, Antidepressants

Question 50

Non-Pharmacological Interventions

Answer 50

Low energy availability is addressed first- naturally increase luteinizing and follicle stimulating hormone Sports dietitian for nutritional counseling Mental Health if DE suspected Can reduce activity to relatively raise energy availability Vitamin D and Calcium

Question 51

Prevention

Answer 51

Screening and prompt referral (pre-participation and monitoring of those at risk) Education, especially in those with risk factors Pay close attention during transition from high school to college level sports Gymnastics, Ballet, Diving, Figure Skating, Aerobics, Running, Weight Class Sports Resistance training High impact exercise (caution)

Question 52

Management of Injury secondary to female triad

Answer 52

Make sure underlying cause is addressed first (via referral) Follow fracture/bone stress injury management principles May need to adjust depending on where the patient is in fixing underlying causes