The Adolescent Female And The Athlete Triad
Many RMTs, Athletic Therapists and Physios start their career wanting to work with athletes, I know I did.
I had dreams of spending my days in the locker room and on the field, being part of a team and sharing in the glory of winning (having never been talented enough to compete myself!).
For many years, I did just that.
I worked in a sports clinic with my physical therapy “hat” on treating sports injuries and my evenings and weekends covering athletic events wearing my athletic trainer “hat.” During my time at an all-girls high school, I became involved in female athlete triad research and bone stress injuries.
It opened my eyes to how athletics can affect females differently than males.
Since then, how we view the triad and how we treat it has changed.
Can you recognize and screen for the signs of the triad? Do you know who is at risk?
What Is The Triad, And How Do We Recognize It?
Adolescent girls should participate in sports. I want that to be clear.
Girls participating in sports have better communication with their parents, are less likely to get pregnant, have more positive body image and are 20% less likely to get breast cancer later in life.
But they are at risk for injury, 48% of female athletes will have injury severe enough for them to miss playing time.
Bone stress injuries are common in adolescent females, occurring in up to 21% of competitive females. Injuries can range from a stress reaction to a stress fracture and occurs from a disturbance in osteoblastic bone formation and osteoclastic resorption. The most common places are the foot, lower leg and pars in the spine. Risk factors include endurance sports, sudden changes in training (duration, intensity, equipment) and inadequate recovery time.
90% of peak bone mass is gained by 18 years of age and research shows athletes have approximately 10% more bone density than non-athletes. So any non-traumatic bone injury is cause for concern.
It is imperative that the underlying cause is investigated and treatment includes resolving more than just the fracture.
Any time there is a bone stress injury, the other components of the Female Athlete Triad should be considered.
The Female Athlete Triad was first described in 1992 as disordered eating, amenorrhea (specifically missing more than 3 periods in a row) and osteoporosis. The triad has now been expanded to include a spectrum of each pathology. Screening should include having less than 6 periods a year (not necessarily consecutive missed cycles), dietary counselling and a DEXA bone density scan that compares the Z-scores, which matches the athlete to others her age. A -2.0 standard deviation or greater is concerning.
The crux of the triad seems to be low energy availability due to disordered eating.
The athlete doesn’t necessarily try to restrict their calories, although some do in body-conscious sports, or if they are concerned about their weight. Many are just unaware of the amount of food it takes to fuel their daily activity. Sometimes they are just eating poorly: fast food, processed food, you know….they are teenagers! This low energy availability leads to hypoestrogenism and disrupts menstrual cycles.
Estrogen normally inhibits bone turnover and maintains a balance between resorption and formation. When there is a nutritional deficit and a lack of estrogen, this balance is disrupted.
Back when we started the research, we thought the best thing to do was replace the estrogen. Makes sense right? Studies now show that using oral birth control does not change the bone density, even with prolonged use. The first treatment should be nutritional counselling and improving caloric intake. There are great resources online at www.femaleathletetriad.org that includes a nutritional calculator to get you started.
Also, find a nutritional counsellor in your area used to working with athletes.
What Can We Do?
So what do you do as a healthcare professional?
Know the signs….an athlete presenting with even one component has a 3x greater risk to develop one of the other components. The Female Athlete Triad Coalition has a great screening tool that is non-confrontational and can easily be done as part of pre-participation screens.
Have information available. Adolescent females need 1300mg of calcium a day and the best source is spread out throughout the day with food. Raw green leafy vegetables, broccoli, almonds, canned sardines with bones, low-fat milk products are the best sources. Certain medications can also impact bone health and may predispose your athlete to bone injuries.
Antiseizure medications (also used for migraine control), prednisone, SSRIs, thyroid medications are common medications for adolescents to be taking for a variety of disorders.
Female Athlete Triad is primarily hormonal and dietary driven. It’s important to have a multidisciplinary approach to diagnosis and treatment. It’s also important to be a nonjudgmental place for your athlete. Athletes are a lot of fun to work with and you are part of a much larger team, especially when dealing with the triad.
- Goolsby M, Boniquit N. Bone Health in Athletes: The Role of Exercise, Nutrition, and Hormones. Sports Health[serial online]. November 7, 2016
- Gibbs JC, Williams NI, De Souza MJ. Prevalence of individual and combined components of the female athlete triad. Med Sci Sports Exerc. 2013;45:985-996
- De Souza MJ, West SL, Jamal SA, Hawker GA, Gundberg CM, Williams NI. The presence of both an energy deficiency and estrogen deficiency exacerbate alterations of bone metabolism in exercising women. Bone. 2008;43:140-14
- Liu SL, Lebrun CM. Effect of oral contraceptives and hormone replacement therapy on bone mineral density in premenopausal and perimenopausal women: a systematic review. Br J Sports Med. 2006;40:11-24
- Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012;4:302-311
- O’Connor D, Blake J, Bell R, Bowen A et al. Canadian Consensus on Female Nutrition: Adolescence, Reproduction, Menopause and Beyond. J Obstet Gynaecol Can 2016;38(6):508-554