Female athletic triad

Česká verzia

Authors: J. Novák
Authors place of work: Vedoucí: doc. MUDr. Aleš Kroužecký, Ph. D. ; Lékařská fakulta v Plzni ; Ústav sportovní medicíny a aktivního zdraví ; Univerzita Karlova v Praze
Published in the journal: Prakt. Lék. 2021; 101(4): 187-193
Category: Reviews

Summary

The female athlete triad (the triad) is an interrelationship of menstrual dysfunction, low energy availability (with or without an eating disorder), and decreased bone mineral density – osteoporosis. In extreme cases, a low proportion of adipose tissue is evident, often accompanied by a below-average body mass index, amenorhea is present, as well as bone stress syndrome, which progresses to a stress fracture. It affects girls and women in various sports with a high volume of training load, both of an endurance nature and focused on the aesthetic impression of their own sports performance. The basic reason is the long-lasting relative energy deficiency in sports activities (RED-S), when the imbalance between energy intake and energy expenditure is intentional. From the athletes’ point of view they want to optimize body weight. Long-term energy deficiency despite hard training efforts negatively affects sports performance. An athlete who is about to intentionally adjust her body composition to reduce weight should seek professional nutritional advice. Time-limited weight loss programs should be accompanied by a return to an energy-balanced diet with full energy availability. Triad treatment includes an adequate calorie-rich diet needed to restore a positive energy balance.

Keywords:

athletic triad of sportswomen – energy availability – relative energy deficiency – menstrual dysregulation – stress bone syndrome – nutritional counseling

Zdroje

1. Abraham SF, Beumont PJ, Fraser IS, et al. Body weight, exercise and menstrual status among ballet dancers in training. Br J Obstet Gynaecol 1982; 89(7): 507–510.

2. Ackerman KE, Nazem T, Chapko D, et al. Bone microarchitecture is impaired in adolescent amenorrheic athletes compared with eumenorrheic athletes and nonathletic controls. J Clin Endocrinol Metab 2011; 96(10): 3123–3133.

3. Arthurs-Brennan M. Cycling, underfuelling and amenorrhea. 6. 5. 2020. Dostupné z: https://ridewriterepeat.com/2020/05/06/ cycling-underfuelling-and-amenorrhea/ [cit. 2021-08-06].

4. Beals, KA, Hill, AK. The prevalence of disordered eating, menstrual dysfunction, and low bone mineral density among US collegiate athletes. Int J Sport Nutr Exerc Metab 2006; 16(1): 1–23.

5. Bennell KL, Malcolm SA, Thomas SA, et al. The incidence and distribution of stress fractures in competitive track and field athletes. A twelve-month prospective study. Am J Sports Med 1996; 24(2): 211–217.

6. Corujeira S, Silva RS, Vieira T, et al. Gymnastics and the female athlete triad: reality or myth? Sci Gymnastics J 2012; 4(3): 5–13.

7. de Souza MJ, Koltun KJ, Williams NI. The role of energy availability in reproductive function in the female athlete triad and extension of its effects to men: an initial working model of a similar syndrome in male athletes. Sports Medicine 2019; 49: 125–137.

8. Doyle-Lucas AF, Akers JD, Davy BM. Energetic efficiency, menstrual irregularity, and bone mineral density in elite professional female ballet dancers. J Dance Med Sci 2010; 14(4): 146–154.

9. Folscher L-L, Grant CC, Fletcher E, et al. Ultra-marathon athletes at risk for the female athlete triad. Sports Med Open 2015; 1: 29. [Published online 2015 Sep 9]. doi:10.1186/s40798- 015-0027-7.

10. Fredericson M, Jennings F, Beaulieu C, et al. Stress fractures in athletes. Top Magn Reson Imaging 2006; 17(5): 309–325.

11. Gavin ML. Female athletic triad [online]. Dostupné z: https:// kidshealth.org/en/teens/triad.html [cit. 2021-08-06].

12. Gordon CM. Clinical practice: functional hypothalamic amenorrhea. N Engl J Med 2010; 363(4): 365–371.

13. Havlová B. Devět varovných signálů, které hlásí, že tvůj příjem kalorií je příliš nízký! Kulturistika.com. 18. 11. 2020 [online]. Dostupné z: https://www.kulturistika.com/vyziva/ zaklady-stravovani/devet-varovnych-signalu-ktere-hlasi-zetvuj- prijem-kalorii-je-prilis-nizky [cit. 2021-08-06].

14. Heikura IA, Stellingwerff T, Areta JL. Low energy availability in female athletes: From the lab to the field. Eur J Sport Sci 2021; 3: 1–11.

15. Hincapié CA, Cassidy JD. Disordered eating, menstrual disturbances, and low bone mineral density in dancers: a systematic review. Arch Phys Med Rehabil 2010; 91(11): 1777–1789.

16. Hoch AZ, Pajewski NM, Moraski L, et al. Prevalence of the female athlete triad in high school athletes and sedentary students. Clin J Sport Med 2009; 19(5): 421–428.

17. Joy EA, Wilson C, Varechok S. The multidisciplinary team approach to the outpatient treatment of disordered eating. Cur Sports Med Rep 2003; 2(6): 331–336.

18. Kaufman BA, Warren MP, Dominguez JE, et al. Bone density and amenorrhea in ballet dancers are related to a decreased resting metabolic rate and lower leptin levels. J Clin Endocrinol Metab 2002; 87(6): 2777–2783.

19. Keay N. Raising awareness of RED-S in male and female athletes and dancers. Br J Sport Med blog 2018 [online]. Dostupné z: https://blogs.bmj.com/bjsm/2018/10/30/raising-awarenessof- red-s-in-male-and-female-athletes-and-dancers/ [cit. 2021- 08-06].

20. Loucks AB. Energy balance and energy availability. In: Maughan RJ. (ed). The encyclopaedia of sports medicine. An IOC medical commission publication (1st ed). New York, NY; John Wiley & Sons 2014; 72–87.

21. Mountjoy M. The basics of synchronized swimming and its injuries. Clinics Sports Med 1999; 18(2): 321–336.

22. Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the female athlete triad-relative energy deficiency in sport (RED-S). Brit J Sports Med 2014; 48(7): 491–497.

23. National Osteoporosis Foundation. Physician’s guide to prevention and treatment of osteoporosis. Washington, DC: National Osteoporosis Foundation 2003.

24. Nattiv A, Agostini R, Drinkwater B, et al. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13: 405–418.

25. Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 2007; 39(10): 1867–1882.

26. Nazem TG, Ackerman KE. The female athlete triad. Sports Health 2012; 4(4): 302–311.

27. Otis CL, Drinkwater B, Johnson M, et al. American College of Sports Medicine position stand: The female athlete triad. Med. Sci. Sports Exerc 39(10): 1867–1882.

28. P2Life Collaborator. What is the female athlete triad and how does it affect swimming training? P2Life 19. 7. 2016 [online]. Dostupné z: https://www.p2life.com/blogs/blog/what-is-thefemale- athlete-triad-and-how-does-it-affect-swimming-training [cit. 2021-08-06].

29. Papageorgiou M, Martin D, Colgan H, et al. Bone metabolic responses to low energy availability achieved by diet or exercise in active eumenorrheic women. Bone 2018; 114: 181–188.

30. Robertson GA, Wood AM. Lower limb stress fractures in sport: optimising their management and outcome. World J Orthop 2017; 8(3): 242–255.

31. Schtscherbyna A, AbreuSoares E, Oliveira FP, et al. Female athlete triad in elite swimmers of the city of Rio de Janeiro, Brazil. Nutrition 2009; 25(6): 634–639.

32. Siatras T, Mameletzi D. The female athlete triad in gymnastics. Sci Gymnastics J 2014; 6(1): 5–22.

33. Skorseth AP, Segovia N, Hastings K, Kraus E. Prevalence of female athlete triad risk factors and iron supplementation among high school distance runners: results from a triad risk screening tool. Orthop J Sports Med 2020; 8(10): 2325967120959725. [Pub. online 2020 Oct 27].

34. Staal S, Sjödin A, Fahrenholtz I, et al. Low RMRratio as a surrogate marker for energy deficiency, the choice of predictive equation vital for correctly identifying male and female ballet dancers at risk. Int J Sport Nutr Exerc Metab. 2018; 28(4): 412–418.

35. Straus LB. High incidence of disordered eating in female gymnastics. Designed for the disease? momsTEAM [online]. Dostupné z https: //www.momsteam.com/nutrition/disordered-eating/female-athlete-triad/high-incidence-of-disordered- eating-in-female-gymna [cit. 2021-08-06].

36. Sun HS , Jung HK. Bone stress injuries in runners: a review for raising interest in stress fractures in Korea. J Korean Med Sci 2020; 35(8): e38.

37. Šišková K. Hodnocení energetické dostupnosti ve vybraných sportovních disciplínách. Bakalářská práce. Brno: FSS Masarykovy Univerzity 2020.

38. Tenforde AS, Kraus E, Fredericson M. Bone stress injuries in runners. Phys Med Rehabil Clin N Am 2016; 27(1): 139–149.

39. Thein-Nissenbaum J, Hammer E. Treatment strategies for the female athlete triad in the adolescent athlete: current perspectives. Open Access J Sports Med 2017; 8: 85–95.

40. Tornberg ÅB, Melin A, Koivula FM, et al. Reduced neuromuscular performance in amenorrheic elite endurance athletes. Med Sci Sports Exerc 2017; 49(12): 2478–2485.

41. Tosi M, Maslyanskaya S, Dodson NA, et al. The female athlete triad: a comparison of knowledge and risk in adolescent and young adult figure skaters, dancers, and runners. J Ped Adol Gyn 2019; 32(2): 165–169.

42. Vanheest JL, Rodgers, CD, Mahoney CE, et al. Ovarian suppression impairs sport performance in junior elite female swimmers. Med Sci Sports Exerc 2014; 46(1): 156–166.

43. Walsh JM, Wheat ME, Freund K. Detection, evaluation, and treatment of eating disorders the role of the primary care physician. J Gen Intern Med 2000; 15(8): 577–590.