CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

The Female Athlete Triad Amanda K. Weiss Kelly, MD, FAAP, Suzanne Hecht, MD, FACSM, COUNCIL ON SPORTS MEDICINE AND FITNESS

The number of girls participating in sports has increased signifi cantly since abstract the introduction of Title XI in 1972. As a result, more girls have been able to experience the social, educational, and health-related benefi ts of sports participation. However, there are risks associated with sports participation, including the female athlete triad. The triad was originally recognized as the interrelationship of amenorrhea, osteoporosis, and disordered eating, but our understanding has evolved to recognize that each of the components of the triad exists on a spectrum from optimal health to disease. The triad occurs when energy intake does not adequately compensate for exercise- This document is copyrighted and is property of the American related energy expenditure, leading to adverse effects on reproductive, Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy bone, and cardiovascular health. Athletes can present with a single of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of component or any combination of the components. The triad can have Pediatrics has neither solicited nor accepted any commercial a more signifi cant effect on the health of adolescent athletes than on involvement in the development of the content of this publication. adults because adolescence is a critical time for bone mass accumulation. Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external This report outlines the current state of knowledge on the epidemiology, reviewers. However, clinical reports from the American Academy of diagnosis, and treatment of the triad conditions. Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

INTRODUCTION All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. The benefits of exercise in adolescents are well established, including improved self-esteem, fewer risk-taking behaviors, increased bone DOI: 10.1542/peds.2016-0922 mineral density (BMD), and decreased obesity. 1– 3 However, when PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). exercise occurs without adequate energy intake to compensate for Copyright © 2016 by the American Academy of Pediatrics exercise-related energy expenditure, there may be adverse effects on reproductive, bone, and cardiovascular health. The female athlete triad FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to (referred to hereafter as the “triad”) was first widely acknowledged disclose. as the 3 interrelated conditions of amenorrhea, osteoporosis, and FUNDING: No external funding. disordered eating in an American College of Sports Medicine position statement published in 1997. 4 Since that time, a more inclusive definition POTENTIAL CONFLICT OF INTEREST: The authors have has evolved because it has become clear that each component of the indicated they have no potential confl icts of interest to disclose. triad exists on a spectrum; the 3 components were renamed menstrual function, BMD, and energy availability (EA) to more accurately represent the spectrum, which can range from optimal health to disease in each To cite: Weiss Kelly AK, Hecht S, AAP COUNCIL ON SPORTS component. 5 In addition, athletes may present with 1, 2, or all 3 of the MEDICINE AND FITNESS. The Female Athlete Triad. Pediatrics. 2016;137(6):e20160922 components.

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 :e 20160922 FROM THE AMERICAN ACADEMY OF PEDIATRICS Adolescent athletes are in a critical age at sport specialization, family TABLE 1 Examples of Sports Emphasizing period of bone mass accumulation, dysfunction, abuse, and dieting. 5,17 Leanness and Endurance so the triad disorders can be Wrestling particularly harmful in this group. 6 Energy Availability Light-weight rowing Gymnastics Appropriate intervention during the EA is defined as daily dietary energy adolescent years may improve peak Dance intake minus daily exercise energy Figure skating bone mass accrual, an important expenditure corrected for fat-free Cheerleading predictor of postmenopausal mass (FFM). 5 Optimal EA has been Long and middle distance running osteoporosis, potentially preventing identified to be 45 kcal/kg FFM per Pole vaulting low BMD, postmenopausal day in female adults but may be osteoporosis, and fractures in even higher in adolescents who are is also a strong predictor for low adulthood. Two investigators have still growing and developing. The BMD. 13 Athletes with a high drive also identified lower BMD as a risk spectrum of EA ranges from optimal for thinness or increased dietary 7,8 factor for stress fracture in athletes. EA to inadequate EA, with or without restraint (an intention to restrict It is difficult to estimate the true the presence of disordered eating/ food intake to control weight) are prevalence of the triad because of eating disorder. Recently, it has significantly more likely to have low the complexity of evaluation of each become clear that many athletes BMD or to sustain a musculoskeletal of the components. Reports have affected by the triad do not exhibit injury than are athletes with normal indicated that the prevalence of pathologic eating behaviors, and eating behaviors. 26, 27 individuals with all 3 components their low EA is unintentional. Low EA Many triggers for the onset of simultaneously is only 1% to 1.2% in adversely affects bone remodeling, 9,10 disordered eating in athletes have high school girls and 0% to 16% and EA <30 kcal/kg FFM per day been identified. 17, 28 Sundgot- in all female athletes. In high school– disrupts menstrual function and Borgen 17 found that prolonged aged female athletes, the prevalence bone mineralization. 18– 20 Disruptions periods of dieting, weight of 2 concurrent components of in luteinizing hormone can be seen fluctuations, coaching changes, the triad is 4% to 18% and of any after only 5 days of reduction in EA to injury, and casual comments made 1 component is as high as 16% to 30 kcal/kg FFM per day. 18 The only 9–15 about weight by coaches, parents, 54%. study of EA in adolescent females and friends were the most common found that, although athletes were reasons given by athletes for the Education of pediatricians, who are more likely to have suboptimal EA, development of disordered eating. most likely to encounter adolescents both athletes and controls restricted Rosen and Hough 28 found that with triad-related disorders, is intake, with 6% of female athletes 75% of gymnasts who were told by especially important. Unfortunately, and 4% of sedentary controls having coaches that they were overweight a 2009 study found that only an EA <30 kcal/kg FFM per day. resorted to pathogenic weight- 20% of pediatricians were able to Furthermore, 39% of athletes and control techniques. Beals21 found correctly identify all 3 components 36% of controls had an EA <45 kcal/ that 13% to 17% of adolescent of the triad, compared with 50% kg FFM per day.9 of family medicine physicians and volleyball players felt pressured by 41% of orthopedic surgeons.16 Disordered eating in adolescent their coaches or parents to achieve Most physicians reported receiving athletes has been evaluated by or maintain a particular body weight. no education in medical school using a variety of survey tools, Pediatricians can help coaches and or through continuing medical such as the Eating Disorder Exam families understand that comments education on triad-related issues. 16 Questionnaire, the Eating Disorder and recommendations they make to Inventory, and the Three-Factor young athletes regarding weight may Eating Questionnaire. Studies that increase the risk of disordered eating. used these tools provide estimates of RISK FACTORS If an athlete, her parents, or her disordered eating ranging from 0% coach believes that changes in weight to 54%. 9, 10, 21– 23 The use of pathologic Although the triad disorders are indicated, they should seek weight-control techniques, such may occur in any sport, athletes medical assessment and nutritional as vomiting, diuretics, or laxatives, participating in sports with supervision before initiating a ranges from 0% to 54% in recent endurance, aesthetic, or weight-class weight-loss plan. studies.9, 10, 24 components or sports that emphasize Menstrual Function and reward leanness are at increased Even in the absence of amenorrhea, risk (see Table 1). 5, 17 Other identified disordered eating is associated with The spectrum of menstrual risk factors for the triad include early lower BMD in athletes. 5, 25 Low BMI disturbances associated with the

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS triad can range from anovulation and TABLE 2 Causes of Secondary Amenorrhea in is likely attained between the ages luteal dysfunction to oligomenorrhea Adolescents of 20 and 30 years. 42, 43 By the end and amenorrhea (primary or Pregnancy of adolescence, almost 90% of adult secondary). Primary amenorrhea is Polycystic ovarian syndrome bone mass has been obtained.43 Pituitary tumor defined as the absence of menarche Genetics, participation in weight- by the age of 15 years. 29 The Prolactinoma Hyperthyroidism bearing activities, and diet all absence of other signs of pubertal Liver/kidney disease influence bone mass in children. 44 development by 14 years of age Medications: oral contraceptive pills, Appropriate dietary intake and chemotherapy, antipsychotics, or a failure to achieve menarche weight-bearing exercise can antidepressants, corticosteroids within 3 years of thelarche is positively influence maximum bone 29,30 Eating disorders also abnormal. Secondary mass gains during childhood and amenorrhea is defined as the absence adolescence. With improved EA of menses for 3 consecutive months oligomenorrhea ranges from 5.4% and resumption of menses, some 10, 15,21, 22, 24, 31 or longer in a female after menarche. to 18%. The prevalence “catch up” bone mass accrual may be Oligomenorrhea is defined as of anovulation and luteal phase possible in athletes with the triad; menstrual cycles longer than 35 days. deficiency has not been evaluated in however, some will have persistently Luteal phase deficiency is defined as adolescent athletes but ranges from lower BMD than their genetic 11 a menstrual cycle with a luteal phase 5.9% to 30% in adult athletes. potential, highlighting the need for shorter than 11 days in length or with Amenorrheic adolescent athletes early, aggressive intervention in a low concentration of progesterone. have a significantly lower BMD than adolescent athletes identified with Menstrual disturbances, such eumenorrheic adolescent athletes triad components. 45 as anovulation and luteal phase or sedentary controls. 13, 31, 33 Some deficiency, are asymptomatic, making BMD in children and adolescents is studies have found that athletes them difficult to diagnose by history typically evaluated by using dual- with menstrual irregularities are alone. After excluding other causes of energy radiograph absorptiometry as much as 3 times more likely to amenorrhea ( Table 2), amenorrhea (DXA), which is best performed sustain bone stress injury and other in the setting of inadequate EA is and interpreted by centers with musculoskeletal injury than are diagnosed as functional hypothalamic certified clinical densitometrists with eumenorrheic athletes, 26, 34– 36 but amenorrhea.5 The word “functional” knowledge of the official pediatric this finding has not been consistent. 37 indicates suppression, attributable to positions of the International Society Oligomenorrhea and amenorrhea 6,46, 47 lack of energy, of an otherwise intact for Clinical Densitometry. have also been associated with reproductive endocrine axis. Because athletes participating in cardiovascular risk factors, including weight-bearing sports are expected to increased cholesterol and abnormal Menstrual irregularities are have higher BMDs than nonathletes, endothelial function. 38, 39 In common during adolescence and the American College of Sports addition, menstrual disturbance has are significantly more common in Medicine recommends different recently been related to decreased adolescent athletes. Of the published criteria than the International Society performance in swimmers with studies of menstrual disturbances for Clinical Densitometry, as shown evidence of ovarian suppression in adolescent athletes, only 1 study in Table 3. In athletes, a Z-score compared with those without ovarian included a sedentary control group. below –1.0 is considered lower than suppression.40 That study reported an incidence expected and indicates that, even of menstrual irregularity of 21% in in the absence of previous fracture, Bone Health sedentary adolescents compared secondary causes of low BMD may 5 with 54% in adolescent athletes. 9 The decreased rate of bone be present. A full discussion of the Other studies reported menstrual acquisition that can be associated secondary causes of low BMD is disturbances in adolescent athletes with the triad in adolescent athletes beyond the scope of this report, but ranging from 12% to 54% for any is particularly concerning, because evaluations for secondary causes 48 menstrual irregularity (primary bone mass gains during childhood typically include the items in Table 4. or secondary amenorrhea or and adolescence are critical for Measures of bone microarchitecture, oligomenorrhea). 9– 11, 21, 22, 24, 31, 32 the attainment of maximal peak although primarily used for research When evaluating specific types of bone mass and the prevention of purposes at this juncture, can add menstrual irregularity, primary osteoporosis in adulthood. 6, 41 The additional information regarding amenorrhea in athletes ranges from maximum rate of bone formation bone quality beyond that of 1.2% to 6%, secondary amenorrhea usually occurs between the ages of BMD. Favorable changes in bone ranges from 5.3% to 30%, and 10 and 14 years, and peak bone mass microarchitecture are associated

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 e3 TABLE 3 Defi nition of BMD Criteria in Adolescents ISCD Offi cial Position for Children and Adolescents46 ACSM Guidelines for Athletes5 Osteoporosis Vertebral compression fracture or Z-score ≤ –2 and Z-Score ≤2 and clinical risk factorsb clinically signifi cant fracture historya Low BMD — Z-Score –1.0 to –1.9 and clinical risk factors Lower BMD than expected — Z-Score ≤ –1.0 ACSM, American College of Sports Medicine; ISCD, International Society for Clinical Densitometry. a Two or more long bone fractures by age 10 or ≥3 long bone fractures at any age up to 19 years. b Nutritional defi ciencies, hypoestrogenism, or stress fracture. with sports participation in female TABLE 4 Evaluation for Low BMD (BMD < –1.0) adolescents. Weight-bearing athletic • Serum 25-hydroxyvitamin D activity is associated with greater • Serum calcium total trabecular area and greater • Complete blood count with differential cortical perimeter in the tibia. 49 • Thyroid-stimulating hormone Conversely, oligomenorrhea and • Parathyroid hormone • Bone-specifi c alkaline phosphatase amenorrhea are associated with • 24-h urine for calcium unfavorable bone microarchitecture, • Screening for cortisol excess: morning cortisol or 24-h urine for cortisol including lower total density, lower • Celiac disease: serum tissue transglutaminase antibodies, total IgA, tissue transglutaminase IgG (in the trabecular number, and greater IgA-defi cient adolescent) trabecular separation at the tibia. 49 • Markers of bone formation and resorption: serum osteocalcin and urine N-telopeptide • Reproductive hormone evaluation: estradiol, FSH, LH in girls, testosterone in boys Estimations of bone strength indicate that eumenorrheic, but FSH, follicle-stimulating hormone; IgA, immunoglobulin A; IgG, immunoglobulin G; LH, luteinizing hormone. not amenorrheic, athletes have greater stiffness and load-to-failure runners have lower BMDs than restraint, greater length of time thresholds, which are associated with sprinters, gymnasts, and ball sport participating in endurance sports, 31,51– 56 53 decreased fracture risk, compared athletes. Barrack et al lower body weight, and lower 1,13, 31, 32, 52 with nonathlete controls. 11, 50 reported a higher prevalence of BMI. The deficits in low BMD in adolescent endurance BMD seen with the triad are Although it is well known that runners (40%) than in ball or power associated with low estrogen levels exercise is a stimulus for bone sport athletes (10%). This study and energy deficiency. Levels of formation, data support that different also showed that runners 17 to 18 bone formation and resorption types of exercise can have differing years of age had similar bone mineral markers are significantly lower in effects on bone formation. For content (BMC) compared with 13- to amenorrheic adolescent athletes than example, adolescent and collegiate 14-year-old runners, whereas BMC in nonendurance athlete controls, swimmers have been shown to in nonrunner athletes showed a indicating a state of overall decreased have a similar BMD compared significantly higher BMC in the older bone turnover. 33 The restriction of with nonathlete controls and to group compared with the younger EA has been shown to cause estradiol have a lower BMD compared with group. These findings suggest suppression and increased bone athletes in other sports. 48 In fact, a a possible suppression of bone resorption as well as suppression of longitudinal BMD study in swimmers, accumulation in adolescent runners, bone formation. 19 gymnasts, and nonathlete controls although other factors may be A recent multisite prospective over an 8-month competitive contributing to this finding, including study 34 identified the contribution season showed that swimmers and possible variable bone accrual of single and multiple triad-related controls had no improvement in patterns attributable to genetics, rate risk factors for bone stress injury in BMD, whereas gymnasts showed of maturation, specific type of current 259 female adolescents and young significant BMD gains despite more and previous physical activity, and adults participating in competitive body dissatisfaction and menstrual EA and menstrual differences often or recreational exercise. The authors disturbance. 51 found between endurance runners found an increased risk of bone and nonendurance athletes. 53 Numerous studies have shown stress injuries as the number of triad- running to have a positive effect Many factors are associated with related risk factors increased. 34 on BMD compared with inactive an increased risk of low BMD in controls, 48 but there is emerging female adolescent athletes, including Cardiovascular Health concern, predominantly from cross- late menarche, oligomenorrhea, Endothelial dysfunction, measured sectional studies, that endurance amenorrhea, elevated dietary by brachial artery flow-mediated

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS dilation (FMD), is an important TABLE 5 The Female Athlete Triad Coalition’s Recommended Screening Questions for the Female predictor of coronary endothelial Athlete Triad68 dysfunction, atherosclerotic disease Question Included on the Fourth- progression, and cardiovascular Edition PPE Form69 event rates. 38, 57, 58 Endothelial 1. Do you worry about your weight or body composition? √ dysfunction has been correlated 2. Do you limit or carefully control the foods that you eat? √ with low whole-body and lumbar 3. Do you try to lose weight to meet weight or image/appearance √ BMD, menstrual dysfunction, and requirements in your sport? 4. Does your weight affect the way you feel about yourself? — low estrogen levels in dancers and 5. Do you worry that you have lost control over how much you eat? — endurance athletes. 38, 39 In endurance 6. Do you make yourself vomit or use diuretics or laxatives after you eat? — athletes, oligomenorrheic and 7. Do you currently or have you ever suffered from an eating disorder? √ amenorrheic athletes had impaired 8. Do you ever eat in secret? FMD compared with eumenorrheic 9. What age was your fi rst menstrual period? √ 10. Do you have monthly menstrual cycles? √ athletes, with amenorrheic athletes 11. How many menstrual cycles have you had in the last year? √ showing the greatest impairment. 39 12. Have you ever had a stress fracture? √ In this group, amenorrhea was also associated with increased menstrual cycles, but they may Female Athlete Triad Coalition and total cholesterol and low-density show suppression of reproductive has been endorsed by the American lipoprotein levels. 39 Among function nonetheless. There is a Academy of Pediatrics (AAP) for use professional dancers, endothelial small body of data suggesting that when performing the PPE (Table 5). dysfunction alone was present in male athletes with inadequate EA If an athlete answers “yes” to any of 64%, whereas the prevalence of may also suffer from hormonal the triad questions on the PPE form, dancers with endothelial dysfunction changes and low BMD. Lower the remaining questions from the and all 3 components of the triad testosterone levels have been found Female Athlete Triad Coalition 68 can was 14%. 38 All of the dancers in male runners compared with be used for further evaluation. who reported current menstrual inactive controls. 61 Similar to female dysfunction (36%) had reduced A sports level of participation athletes, male endurance runners FMD. 38 Amenorrheic runners and and return-to-play medical risk have been found to have lower dancers treated with 4 weeks of stratification scoring rubric has BMD than male athletes in power or folic acid supplementation showed been developed by the Female ball sports. 62 Adolescent males with improvements in FMD.15, 59 Although Athlete Triad Coalition Consensus anorexia nervosa display low BMD at these studies were not exclusive Panel to help the clinician assess multiple skeletal sites. 60, 63 to adolescents, adolescents were an athlete with triad-related risk Although the body of scientific included in the study populations. factors into low-, moderate-, or evidence is still developing, it is These results raise concern that high-risk categories. Decisions important to consider that adolescent an athlete diagnosed with the regarding sports participation, level males participating in sports that triad could be at risk of developing of participation permitted, and emphasize and reward leanness cardiovascular disease. return-to-play are made on the basis may be at risk of a constellation of of the risk category that the athlete findings similar to those seen in falls into and can be reassessed females with components of the as the athlete progresses through MALE ATHLETES 64–66 triad. treatment. 68 Although female athletes have been the exclusive focus of research on SCREENING the triad, low EA resulting in the DIAGNOSIS suppression of the neuroendocrine It is convenient to screen for the Obtaining a complete nutritional, reproductive axis is likely not triad at the time of a well-child visit menstrual, fracture, and exercise gender selective. Low testosterone and/or the preparticipation physical history is the first step in diagnosis. and estradiol levels have been evaluation (PPE). The Female Athlete Vital signs may reveal bradycardia, documented in adolescent males Triad Coalition has developed 12 which can also be a normal finding diagnosed with anorexia nervosa. 60 questions for screening (Table 5).67– 69 in well-trained athletes; orthostatic This finding begs the question: is Another screening tool is found in hypotension; low body weight (<85% there a male athlete triad? Male the fourth-edition PPE consensus expected body weight, which is 50% athletes do not have an easily monograph. 69 This form contains 8 for height); or low BMI (less than the noted symptom such as missed of the 12 questions suggested by the fifth percentile).68 In athletes with

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 e5 eating disorders, cold/discolored TABLE 6 Factors Prompting BMD Evaluation in Athletes With Stress Fracture hands and feet, hypercarotenemia, Low BMI (<18.5 kg/m2) lanugo hair, and parotid gland Recurrent stress fractures enlargement may be found. 5 Oligo- or amenorrhea ≤6 months However, the physical examination A history of an ED, DE, or low EA Chronic medical conditions associated with bone loss is often normal and unrevealing in Medications associated with adverse effects on bone health athletes with the triad, especially Cancellous versus cortical bone fractures, particularly proximal femur, tibial plateau, and calcaneus in those who do not intentionally Cyclists, swimmers restrict EA. 5 No recent change in activity level or training intensity ED indicates eating disorder; DE, disordered eating. Laboratory assessment aims Reproduced with permission from Scofi eld KL, Hecht S. Bone health in endurance athletes: runners, cyclists, and to evaluate for other causes of swimmers. Curr Sports Med Rep. 2012;11(6):328–334. Copyright © 2012 by the American College of Sports Medicine. oligomenorrhea/amenorrhea, including pregnancy, polycystic exercise expenditure and increasing Studies of the effects of oral ovarian syndrome, prolactinoma, dietary intake, with the goal of contraceptive pills on BMD have and thyroid disorders, as reviewed restoration of normal menses produced mixed results, 5, 6, 72– 74 and in Table 2. In athletes with an eating and weight. Improving EA to >30 they may give the athlete a false disorder, a chemistry profile and kcal/kg FFM per day can restore sense of security that EA has been electrocardiography can be used to menses, although an EA >45 kcal/ restored, so their use is typically evaluate for possible arrhythmia or kg FFM per day is optimal. 5, 71 FFM avoided unless they are being metabolic disturbance. BMD testing can be measured by using DXA, prescribed for other indications. It by DXA is indicated in athletes with air-displacement plethysmography is important to recognize that the any of the following: eating disorder (ie, BodPod analysis [National hormonal environment provided (diagnosed by using criteria of the Institute for Fitness and Sport, by oral contraceptive pills is not Diagnostic and Statistical Manual of Indianapolis, IN]), bioelectrical the same as a naturally occurring 70 Mental Disorders, Fifth Edition ), impedance analysis, or skinfold menstrual cycle. Misra et al75 weight <85% of expected, recent caliper measurements. Evaluation reported a significant improvement ≥ weight loss of 10%, menstrual by an experienced sports dietitian in spine and hip BMD with the use ≥ dysfunction or low EA 6 months, or exercise physiologist can be of a transdermal estrogen patch and/or a history of stress or helpful in determining EA and FFM. in anorexic female adolescents, 5, 68 insufficiency fracture. Table 6 lists Because the assessment of EA can be indicating that the transdermal route other factors that, when coupled with challenging, other goals of treatment may be a more favorable method. a single stress fracture, increase the can include the reversal of recent However, this method has not yet 48 risk of low BMD. weight loss (if present), return to a been studied in athletes with the triad. body weight associated with normal Optimizing calcium and vitamin ≥ TREATMENT menses, attainment of BMI 18.5 D intake is an important part of or >85% expected weight, and a treatment. 5, 6 Significantly more Improving EA is the cornerstone of minimum daily energy intake of 2000 athletes with stress fractures have treatment of the triad disorders and 48,60 kcal. A gradual increase of 200 low calcium intakes than do athletes has been associated with the return to 600 kcal/day and a reduction in without stress fractures. 35 Assessing of normal menses and improvements training volume of 1 day per week 25-hydroxyvitamin D concentration in BMD. 5, 48, 60 A multidisciplinary are usually sufficient to attain the is useful in athletes presenting team approach is suggested and may needed improvements in weight and with components of the triad. 1,46 include a physician, a dietitian, a 48,71 EA. It is important to recognize The AAP currently recommends a certified athletic trainer, a behavioral that the resumption of menses may daily intake of 1300 mg calcium for health clinician, and, at times, an take up to 1 year or longer after children and adolescents ages 9 to exercise physiologist. It is preferable restoration of appropriate EA. 48 A 18 years and 600 IU vitamin D for that the medical team be familiar written treatment plan (contract) children and adolescents ages 1 to with treating athletes. For athletes signed by the providers and athlete/ 18 years, although many experts with an unintentionally low EA parent(s) can be a useful tool to recommend higher intakes of without features of disordered eating outline and define the treatment vitamin D, particularly in climates or an eating disorder, a behavioral plan and expectations on the part of where sun exposure is limited. 1 health clinician may not be needed. the athlete, parent(s), and medical The International Osteoporosis Improvements in EA can be providers (for a sample contract, see Foundation calcium calculator can accomplished by both decreasing the Supplementary Data in ref 48). be used as a tool to estimate calcium

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e6 FROM THE AMERICAN ACADEMY OF PEDIATRICS intake from dietary sources (www. unhealthy behaviors. Refusal skills normal in athletes and may be iof. org). In addition to calcium were practiced, and healthy norms detrimental to their health and and vitamin D, other vitamins and were reinforced. The control schools performance. minerals are known to play a role received pamphlets regarding 4. Functional hypothalamic in bone health (B vitamins, vitamin disordered eating, drug use, and amenorrhea is a diagnosis of K, and iron), thus underscoring the sports nutrition. Questionnaires exclusion made after other importance of a well-balanced diet. administered before and after the causes for primary and program revealed decreased use of Bisphosphonates are antiresorptive secondary amenorrhea have diet pills, decreased intent to vomit agents frequently used in the been evaluated. The restoration to lose weight, and improved healthy treatment of postmenopausal of optimal EA is the cornerstone eating behaviors in the teenagers osteoporosis. Unlike postmenopausal of treatment of functional in intervention schools. This trial osteoporosis, the mechanism of low hypothalamic amenorrhea. shows that primary intervention BMD in athletes affected by the triad techniques that use education with 5. The resumption of menses may is predominantly attributable to peer leaders can reduce the risk of take up to 1 year or longer after decreased bone formation rather than disordered eating and other risk- restoration of appropriate EA. increased bone resorption. Therefore, taking behaviors. bisphosphonates would likely be less 6. Oral contraceptive pills are effective in athletes with the triad. 20 not the first-line intervention for an athlete with functional Other concerns regarding treatment CONCLUSIONS AND GUIDANCE FOR THE with bisphosphonates include their CLINICIAN hypothalamic amenorrhea. long half-life and potential teratogenic 7. Weight-bearing exercise in effects, thus making it prudent to 1. The well-child visit or PPE provides an opportune time for the context of appropriate avoid them in females of childbearing nutritional intake is important age. 6 It is important to note that the the pediatrician to screen for and provide education and guidance for the enhancement of bone US Food and Drug Administration mass accrual. has not approved any pharmacologic regarding the components of the interventions for the treatment of female athlete triad and the risks 8. The criteria for performing DXA to osteoporosis in premenopausal of inadequate EA for athletes. The measure BMD in athletes include females. AAP has published a PPE form menstrual dysfunction or low EA that includes a comprehensive (<45 kcal/kg FFM per day) for preparticipation history and ≥6 months and/or a history of PREVENTION physical evaluation (sports stress or insufficiency fractures. physical).69 If the athlete responds Z-Scores are used to assess BMD Athletes and parents often need “yes” to any of the triad screening in adolescents, and a Z-score of education regarding the importance questions included on the PPE < –1.0 is the threshold to prompt of EA and regular menstrual history form, further screening can further evaluation (see Table 4). cycles. Many are unaware that be performed with the use of the 9. Regular physical activity plays an amenorrhea is associated with low remaining questions suggested by important role in optimizing bone BMD and stress fractures and how the Female Athlete Triad Coalition health. Patients and parents can be appropriate EA plays an important (see Table 5). role in the prevention of bone health reassured that as long as exercise- 2. Athletes presenting with 1 consequences. 76 The ATHENA related energy expenditures component of the triad are at (Athletes Targeting Healthy Exercise are appropriately replaced with risk of having or developing the and Nutrition Alternatives) study caloric intake, menstrual, bone, other triad conditions. evaluated the usefulness of a peer and cardiovascular health should intervention on the prevention 3. Menstrual dysfunction in not be adversely affected. The of disordered eating, pathogenic adolescents may be a sign of target EA is >45 kcal/kg FFM per weight-control behaviors, drug use, inadequate energy intake. day. FFM can be determined by and risk-taking behaviors. 77 This Patients presenting with using DXA, biometrical impedance randomized controlled intervention menstrual dysfunction measurements, or skinfold included eight 45-minute, small- provide an opportunity for the measurements. group classroom sessions guided pediatrician to counsel parents 10. When treating athletes with by peer leaders. The curriculum and adolescent athletes that the triad, a multidisciplinary included education regarding menstrual dysfunction and team capable of addressing substance use, nutrition, and restricted energy intake are not the medical, nutritional,

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 e7 psychological, and sports Lisa K. Kluchurosky, MEd, ATC – National Athletic athlete triad. Med Sci Sports Exerc. participation–related issues of Trainers Association 2007;39(10):1867–1882 the triad is helpful. Weight-gain CONSULTANTS 6. Golden NH, Abrams SA; Committee on or -loss concerns in an athlete are Nutrition. Optimizing bone health in better addressed by medical and Neeru A. Jayanthi, MD children and adolescents. Pediatrics. nutritional professionals rather Rebecca Carl, MD, FAAP 2014;134(4). Available at: www. pediatrics. Sally Harris, MD, FAAP than athletic coaching staff. org/cgi/ content/ full/ 134/ 4/ e1229 11. Adequate intakes of calcium STAFF 7. Bennell, Malcolm SA, Thomas SA, et al. Risk factors for stress fractures (1300 mg/day) and vitamin D Anjie Emanuel, MPH in track and fi eld athletes: a twelve- (600 IU/day) play an important month prospective study. Am J Sports role in bone mass accrual for Med. 1996;24(2):810–818 all adolescents. Athletes with ABBREVIATIONS 8. Nattiv A, Puffer JC, Casper J, Dorey greater dietary intake of calcium AAP: American Academy of F. Stress fracture risk factors, will require less supplemental Pediatrics incidence and distribution: a 3-year calcium. When determining BMC: bone mineral content prospective study in collegiate runners the amount of calcium BMD: bone mineral density [abstract]. Med Sci Sports Exerc. supplementation needed, some DXA: dual-energy radiograph 2000;5(Suppl):S347 adolescents may require higher absorptiometry 9. Hoch AZ, Pajewski NM, Moraski L, et vitamin D intakes than others to EA: energy availability al. Prevalence of the female athlete achieve normal vitamin D levels. FFM: fat-free mass triad in high school athletes and FMD: flow-mediated dilation 12. Bisphosphonate use in sedentary students. Clin J Sport Med. PPE: preparticipation physical 2009;19(5):421–428 adolescent females with a low evaluation BMD related to the triad is not 10. Nichols JF, Rauh MJ, Lawson MJ, Ji M, supported by current literature. Barkai HS. Prevalence of the female athlete triad syndrome among high 13. Educational opportunities school athletes. Arch Pediatr Adolesc regarding the recognition, REFERENCES Med. 2006;160(2):137–142 prevention, and treatment of 11. Barrack MT, Ackerman KE, Gibbs issues related to the triad should 1. Ackerman KE, Misra M. Bone health JC. Update on the female athlete be available for practicing and the female athlete triad in triad. Curr Rev Musculoskelet Med. adolescent athletes. Phys Sportsmed. pediatricians, pediatric residents, 2013;6(2):195–204 2011;39(1):131–141 and medical students. 12. Fredericson M, Kent K. Normalization 2. Bailey DA, McKay HA, Mirwald RL, of bone density in a previously LEAD AUTHORS Crocker PR, Faulkner RA. A six-year amenorrheic runner with Amanda K. Weiss Kelly, MD, FAAP longitudinal study of the relationship osteoporosis. Med Sci Sports Exerc. Suzanne Hecht, MD, FACSM of physical activity to bone mineral 2005;37(9):1481–1486 accrual in growing children: the 13. Gibbs JC, Williams NI, De Souza COUNCIL ON SPORTS MEDICINE AND University of Saskatchewan Bone MJ. Prevalence of individual and FITNESS EXECUTIVE COMMITTEE, Mineral Accrual Study. J Bone Miner combined components of the female 2014–2015 Res. 1999;14(10):1672–1679 athlete triad. Med Sci Sports Exerc. Joel S. Brenner, MD, MPH, FAAP, Chairperson 3. Sabo DF, Miller KE, Farrell MP, 2013;45(5):985–996 Cynthia R. LaBella, MD, FAAP, Chairperson-Elect Melnick MJ, Barnes GM. High Margaret A. Brooks, MD, FAAP 14. Hind K. Recovery of bone mineral school athletic participation, sexual Alex Diamond, DO, FAAP density and fertility in a former William Hennrikus, MD, FAAP behavior and adolescent pregnancy: amenorrheic athlete. J Sports Sci Med. Michele LaBotz, MD, FAAP a regional study. J Adolesc Health. 2008;7(3):415–418 1999;25(3):207–216 Kelsey Logan, MD, FAAP 15. Hoch AZ, Papanek PE, Havlik HS, Keith J. Loud, MDCM, MSc, FAAP 4. Otis CL, Drinkwater B, Johnson M, Raasch WG, Widlansky ME, Schimke JE. Kody A. Moffatt, MD, FAAP Loucks A, Wilmore J. American College Prevalence of the female athlete triad/ Blaise Nemeth, MD, FAAP of Sports Medicine position stand: the Brooke Pengel, MD, FAAP tetrad in professional ballet dancers Amanda K. Weiss Kelly, MD, FAAP Female Athlete Triad. Med Sci Sports [abstract]. Med Sci Sports Exerc. Exerc. 1997;29(5):i–ix 2009;41(5):524 LIAISONS 5. Nattiv A, Loucks AB, Manore MM, 16. Porucanik CA, Sullivan MM, Nunu J, Joy Andrew J.M. Gregory, MD, FAAP – American Sanborn CF, Sundgot-Borgen J, Warren E. Physician recognition, evaluation College of Sports Medicine MP; American College of Sports and treatment of the female athlete Mark Halstead, MD, FAAP – American Medical Medicine. American College of Sports triad [abstract]. Med Sci Sports Exerc. Society for Sports Medicine Medicine position stand: the female 2009;41(5):83

Downloaded from www.aappublications.org/news by guest on September 27, 2021 e8 FROM THE AMERICAN ACADEMY OF PEDIATRICS 17. Sundgot-Borgen J. Risk and trigger 28. Rosen LW, Hough DO. Pathogenic a cross-sectional study. BMJ Open. factors for the development of eating weight-control behavior of female 2012;2(6):e001920 disorders in female elite athletes. Med college gymnasts. Phys Sportsmed. 38. Hoch AZ, Papanek P, Szabo A, Widlansky Sci Sports Exerc. 1994;26(4):414–419 1988;16(9):141–144 ME, Schimke JE, Gutterman DD. 18. Loucks AB, Thuma JR. Luteinizing 29. American College of Obstetricians Association between the female athlete hormone pulsatility is disrupted at and Gynecologists Committee triad and endothelial dysfunction a threshold of energy availability in on Adolescent Health Care. ACOG in dancers. Clin J Sport Med. regularly menstruating women. J Clin Committee Opinion No. 349, November 2011;21(2):119–125 Endocrinol Metab. 2003;88(1):297–311 2006: menstruation in girls and 39. Rickenlund A, Eriksson MJ, Schenck- 19. Ihle R, Loucks AB. Dose-response adolescents: using the menstrual Gustafsson K, Hirschberg AL. relationships between energy cycle as a vital sign. Obstet Gynecol. Amenorrhea in female athletes availability and bone turnover in young 2006;108(5):1323–1328 is associated with endothelial exercising women. J Bone Miner Res. 30. Diaz A, Laufer MR, Breech LL; American dysfunction and unfavorable lipid 2004;19(8):1231–1240 Academy of Pediatrics Committee profi le. J Clin Endocrinol Metab. 20. Misra M, Klibanski A. Bone metabolism on Adolescence; American College 2005;90(3):1354–1359 in adolescents with anorexia nervosa. of Obstetricians and Gynecologists 40. Vanheest JL, Rodgers CD, Mahoney J Endocrinol Invest. 2011;34(4):324–332 Committee on Adolescent Health Care. CE, De Souza MJ. Ovarian suppression Menstruation in girls and adolescents: 21. Beals KA. Eating behaviors, nutritional impairs sport performance in junior using the menstrual cycle as a vital status, and menstrual function in elite elite female swimmers. Med Sci Sports sign. Pediatrics. 2006;118(5):2245–2250 female adolescent volleyball players. J Exerc. 2014;46(1):156–166 Am Diet Assoc. 2002;102(9):1293–1296 31. Barrack MT, Rauh MJ, Nichols JF. 41. NIH Consensus Development Panel on Prevalence of and traits associated 22. Nichols JF, Rauh MJ, Barrack MT, Osteoporosis Prevention, Diagnosis, with low BMD among female Barkai HS, Pernick Y. Disordered and Therapy. Osteoporosis prevention, adolescent runners. Med Sci Sports eating and menstrual irregularity in diagnosis, and therapy. JAMA. Exerc. 2008;40(12):2015–2021 high school athletes in lean-build and 2001;285(6):785–795 nonlean-build sports. Int J Sport Nutr 32. Gibbs JC, Nattiv A, Barrack MT, et al. 42. Bonjour JP, Theintz G, Buchs B, Exerc Metab. 2007;17(4):364–377 Low bone density risk is higher in Slosman D, Rizzoli R. Critical years exercising women with multiple triad 23. Rosendahl J, Bormann B, and stages of puberty for spinal and risk factors. Med Sci Sports Exerc. Aschenbrenner K, Aschenbrenner F, femoral bone mass accumulation 2014;46(1):167–176 Strauss B. Dieting and disordered during adolescence. J Clin Endocrinol eating in German high school athletes 33. Christo K, Prabhakaran R, Lamparello Metab. 1991;73(3):555–563 and non-athletes. Scand J Med Sci B, et al. Bone metabolism in 43. Sabatier JP, Guaydier-Souquières Sports. 2009;19(5):731–739 adolescent athletes with amenorrhea, G, Laroche D, et al. Bone mineral athletes with eumenorrhea, and acquisition during adolescence and 24. Havemann L, DeLange Z, Pieterse control subjects. Pediatrics. early adulthood: a study in 574 healthy K, Wright HH. Disordered eating 2008;121(6):1127–1136 females 10-24 years of age. Osteoporos and menstrual patterns in female Int. 1996;6(2):141–148 university netball players. South 34. Barrack MT, Gibbs JC, De Souza MJ, African J Sports Med. 2011;23(3):68–72 et al. Higher incidence of bone stress 44. Slemenda CW, Miller JZ, Hui SL, Reister injuries with increasing female TK, Johnston CC Jr. Role of physical 25. Cobb KL, Bachrach LK, Greendale G, athlete triad-related risk factors: activity in the development of skeletal et al. Disordered eating, menstrual a prospective multisite study of mass in children. J Bone Miner Res. irregularity, and bone mineral density exercising girls and women. Am J 1991;6(11):1227–1233 in female runners. Med Sci Sports Sports Med. 2014;42(4):949–958 Exerc. 2003;35(5):711–719 45. Barrack MT, Van Loan MD, Rauh 35. Myburgh KH, Hutchins J, Fataar MJ, Nichols JF. Body mass, training, 26. Rauh MJ, Nichols JF, Barrack MT. AB, Hough SF, Noakes TD. Low bone menses, and bone in adolescent Relationships among injury and density is an etiologic factor for stress runners: a 3-yr follow-up. Med Sci disordered eating, menstrual fractures in athletes. Ann Intern Med. Sports Exerc. 2011;43(6):959–966 dysfunction, and low bone mineral 1990;113(10):754–759 density in high school athletes: 46. Gordon CM, Leonard MB, Zemel BS; a prospective study. J Athl Train. 36. Thein-Nissenbaum JM, Rauh MJ, Carr International Society for Clinical 2010;45(3):243–252 KE, Loud KJ, McGuine TA. Menstrual Densitometry. 2013 Pediatric Position Development Conference: executive 27. Thein-Nissenbaum JM, Rauh MJ, Carr irregularity and musculoskeletal injury summary and refl ections. J Clin KE, Loud KJ, McGuine TA. Associations in female high school athletes. J Athl Densitom. 2014;17(2):219–224 between disordered eating, menstrual Train. 2012;47(1):74–82 dysfunction, and musculoskeletal 37. Duckham RL, Peirce N, Meyer C, 47. Schousboe JT, Shepherd JA, Bilezikian injury among high school athletes. Summers GD, Cameron N, Brooke- JP, Baim S. Executive summary of the J Orthop Sports Phys Ther. Wavell K. Risk factors for stress 2013 International Society for Clinical 2011;41(2):60–69 fracture in female endurance athletes: Densitometry Position Development

Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 138 , number 2 , August 2016 e9 Conference on bone densitometry. J coronary vasodilator dysfunction Triad Coalition consensus statement Clin Densitom. 2013;16(4):455–466 on adverse long-term outcome of on treatment and return to play of the 48. Scofi eld KL, Hecht S. Bone health in coronary heart disease. Circulation. female athlete triad. Br J Sports Med. endurance athletes: runners, cyclists, 2000;101(16):1899–1906 2014;48(4):289–309 and swimmers. Curr Sports Med Rep. 59. Hoch AZ, Lynch SL, Jurva JW, 69. American Academy of Family 2012;11(6):328–334 Schimke JE, Gutterman DD. Folic acid Physicians; American Academy of 49. Ackerman KE, Nazem T, Chapko supplementation improves vascular Pediatrics; American College of Sports D, et al. Bone microarchitecture function in amenorrheic runners. Clin Medicine. In: Roberts W, Bernhardt is impaired in adolescent J Sport Med. 2010;20(3):205–210 D, eds. Preparticipation Physical Evaluation amenorrheic athletes compared with 60. Misra M, Prabhakaran R, Miller KK, . 4th ed. Elk Grove Village, IL: eumenorrheic athletes and nonathletic et al. Weight gain and restoration of American Academy of Pediatrics; 2010 controls. J Clin Endocrinol Metab. menses as predictors of bone mineral 70. American Psychiatric Association. 2011;96(10):3123–3133 density change in adolescent girls with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 50. Boutroy S, Bouxsein ML, Munoz F, anorexia nervosa-1. J Clin Endocrinol Washington, DC: American Psychiatric Delmas PD. In vivo assessment of Metab. 2008;93(4):1231–1237 Publishing; 2013 trabecular bone microarchitecture 61. De Souza MJ, Arce JC, Pescatello LS, by high-resolution peripheral Scherzer HS, Luciano AA. Gonadal 71. Kopp-Woodroffe SA, Manore MM, quantitative computed tomography. hormones and semen quality in male Dueck CA, Skinner JS, Matt KS. J Clin Endocrinol Metab. runners: a volume threshold effect of Energy and nutrient status of 2005;90(12):6508–6515 endurance training. Int J Sports Med. amenorrheic athletes participating 1994;15(7):383–391 in a diet and exercise training 51. Taaffe DR, Robinson TL, Snow CM, intervention program. Int J Sport Nutr. Marcus R. High-impact exercise 62. Fredericson M, Chew K, Ngo J, Cleek 1999;9(1):70–88 promotes bone gain in well-trained T, Kiratli J, Cobb K. Regional bone 72. Cobb KL, Bachrach LK, Sowers M, et female athletes. J Bone Miner Res. mineral density in male athletes: al. The effect of oral contraceptives 1997;12(2):255–260 a comparison of soccer players, on bone mass and stress fractures in runners and controls. Br J Sports Med. 52. Barrack MT, Rauh MJ, Barkai HS, female runners. Med Sci Sports Exerc. 2007;41(10):664–668 Nichols JF. Dietary restraint and low 2007;39(9):1464–1473 bone mass in female adolescent 63. Castro J, Toro J, Lazaro L, Pons F, 73. Golden NH, Lanzkowsky L, Schebendach endurance runners. Am J Clin Nutr. Halperin I. Bone mineral density J, Palestro CJ, Jacobson MS, Shenker 2008;87(1):36–43 in male adolescents with anorexia IR. The effect of estrogen-progestin 53. Barrack MT, Rauh MJ, Nichols JF. Cross- nervosa. J Am Acad Child Adolesc treatment on bone mineral density in sectional evidence of suppressed Psychiatry. 2002;41(5):613–618 anorexia nervosa. J Pediatr Adolesc bone mineral accrual among female 64. Miller BE, Hackney AC, De Souza MJ. Gynecol. 2002;15(3):135–143 J Bone Miner Res adolescent runners. . The endurance training on hormone 74. Warren MP, Brooks-Gunn J, Fox RP, 2010;25(8):1850–1857 and semen profi les in marathon et al. Persistent osteopenia in ballet 54. Mudd LM, Fornetti W, Pivarnik JM. Bone runners. Fertil Steril. 1997;67(3):585– dancers with amenorrhea and delayed mineral density in collegiate female 586; author reply: 586–587 menarche despite hormone therapy: athletes: comparisons among sports. J 65. Hackney AC. Endurance exercise a longitudinal study. Fertil Steril. Athl Train. 2007;42(3):403–408 training and reproductive endocrine 2003;80(2):398–404 55. Nichols JF, Rauh MJ, Barrack MT, dysfunction in men: alterations in the 75. Misra M, Katzman D, Miller KK, et al. Barkai HS. Bone mineral density hypothalamic-pituitary-testicular axis. Physiologic estrogen replacement in female high school athletes: Curr Pharm Des. 2001;7(4):261–273 increases bone density in adolescent interactions of menstrual function 66. Hackney AC. Effects of endurance girls with anorexia nervosa. J Bone and type of mechanical loading. Bone. exercise on the reproductive system Miner Res. 2011;26(10):2430–2438 2007;41(3):371–377 of men: the “exercise-hypogonadal 76. Feldmann JM, Belsha JP, Eissa MA, 56. Tenforde AS, Fredericson M. Infl uence male condition”. J Endocrinol Invest. Middleman AB. Female adolescent of sports participation on bone health 2008;31(10):932–938 athletes’ awareness of the connection in the young athlete: a review of the 67. Mountjoy M, Hutchinson M, Cruz between menstrual status and bone literature. PM R. 2011;3(9):861–867 L, Lebrun C. Female athlete triad health. J Pediatr Adolesc Gynecol. 57. Anderson TJ, Uehata A, Gerhard MD, screening questionnaire. Female 2011;24(5):311–314 et al. Close relation of endothelial Athlete Triad Coalition. Available at: 77. Elliot DL, Goldberg L, Moe EL, et al. function in the human coronary and www.femaleathletetria d. org/ ~triad/ Long-term outcomes of the ATHENA peripheral circulations. J Am Coll wp- content/ uploads/ 2008/ 11/ ppe_ for_ (Athletes Targeting Healthy Exercise Cardiol. 1995;26(5):1235–1241 website. pdf. Accessed July 15, 2015 & Nutrition Alternatives) program for 58. Schächinger V, Britten MB, 68. De Souza MJ, Nattiv A, Joy E, et al; female high school athletes. J Alcohol Zeiher AM. Prognostic impact of Expert Panel. 2014 Female Athlete Drug Educ. 2008;52(2):73–92

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