6/6/2011. September January June. Photos courtesy of Pierre d Hemecourt, MD, FACSM

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1 Female Athlete Triad- Looking Beyond Stress Fractures Kathryn E. Ackerman, MD MPH Harvard Medical School- Instructor of Medicine Children s Hospital Boston- Division of Sports Medicine Massachusetts General Hospital- Neuroendocrine Unit USRowing- Team Physician KEAckerman@partners.org Senior High School Year September January June Photos courtesy of Pierre d Hemecourt, MD, FACSM Female Athlete Triad Disordered eating Anorexia Bulimia Disorder NOS Amenorrhea Osteoporosis 1

2 Female Athlete Triad Disordered eating Anorexia Bulimia Disorder NOS Including behaviors not in DSM IV and concept of energy availability Amenorrhea Osteoporosis Functional hypothalamic amenorrhea and various types of menstrual dysfunction Including less severe forms of poor bone health Female Athlete Triad Nattiv A, et al. Med Sci Sports Exerc Oct;39(10): Energy Availability 2

3 Low Energy Availability Eating disorder: clinical mental disorder defined by DSM-IV and characterized by abnormal eating behaviors, an irrational fear of gaining weight, and false beliefs about eating, weight, and shape. Disordered eating: various abnormal eating behaviors including restrictive eating, fasting, frequently skipped meals, diet pills, laxatives, diuretics, enemas, overeating, binging and purging. Eating Disorders- DSM-IV Anorexia Nervosa Bulimia Eating Disorder Not Otherwise Specified (EDNOS) American Psychological Association. Diagnostic and statistical manual of mental disorders. 4th edition. Washington, DC: APA; Unofficial Eating Disorder Terms Anorexia athletica- sub-group of athletes with eating disorder symptoms that do not permit a diagnosis of anorexia nervosa or bulimia nervosa to be made and would therefore fall within EDNOS. Ortharexia nervosa- individuals who take their concerns around eating healthy foods to dangerous and/or obsessive extremes. 3

4 Low Energy Availability 30! Energy Availability (EA): Dietary energy intake (EI)- Exercise energy expenditure (EEE) normalized to fat-free free mass (FFM): EA= (EI- EEE)/FFM Ex. EI= = 2000 kcal/d, EEE= = 600 kcal/d, FFM= = 51 kg ( )/51 = 27.5 kcal/kg of FFM/d Exercise energy expenditure: energy expended during exercise in excess of energy that would have been expended in nonexercise activity during same time interval. Nattiv A, et al. Med Sci Sports Exerc. 2007;39(10): Prevalence of Low Energy Availability/Eating Disorders 15 to 62% of female college athletes have disordered eating. How the questions are asked? Self-report via questionnaire, In-depth interview, 2 stage screening: questionnaire and then interview Who s asking? Coach, trainer, doctor? Privacy, consequence concerns What s being asked? Different questionnaires (ex. EAT-26, EDI, EDI-BD, EDI-2, EDE) Beals KA, Meyer NL. Clin Sports Med 2007;26(1): Sundgot-Borgen J. Int J Sport Nutr 1993;3(1):29-40 Beals KA, Manore MM. Int J Sport Nutr Exerc Metab Sundgot-Borgen J, Torstveit MK. Clin J Sport Med 2002;12(3): ;14(1): Johnson C, et al. Int J Eat Disord 1999;26(2): Who gets eating disorders? Anyone! Increased risk? Women Athletes Female athletes Female athletes in aesthetic and weight-class sports Athletes started in sport-specific specific training early in life Transitions/Traumatic event Pressure to reduce weight, improve sport performance, look better in uniform, achieve body type consistent with societal ideals Nattiv A, et al. Med Sci Sports Exerc. 2007;39(10):

5 Reasons for Developing Eating Disorders Reported by Athletes Reason Eating disordered athletes % Prolonged periods of dieting 29 New coach 23 Injury/illness 18 Casual comments 15 Leaving home/failure at school or work 8 Problem in a relationship 8 Family problems 5 Illness/injury to family members 5 Death of significant others 3 Sexual abuse 3 Sungot-Borgen J. Med Sci Sport s Exerc 1994;4: Menstrual Function Menstrual Cycle GnRH 5

6 Menstrual Dysfunction Chan JL, Mantzoros CS. Lancet 2005;366(9479): Menstrual Dysfunction Eumenorrhea: menstrual cycles at intervals near the median for young adult women (28 days ± 7 days). Oligomenorrhea: menstrual cycles longer than 35 days. Luteal Suppression: menstrual cycle with a luteal phase shorter than 11 days or with a low concentration of progesterone. Anovulation: menstrual cycle without ovulation. Amenorrhea: no menstrual cycles for > 90 days. Menstrual Dysfunction Primary amenorrhea (aka delayed menarche): no menstrual cycle by age 15 in a girl with secondary sex characteristics. Secondary amenorrhea- experienced menarche, but subsequently lost cycles. Practice Committee of the American Society for Reproductive Medicine. 2004;82:

7 Prevalence of Menstrual Dysfunction 3.4 to 66% of female athletes are amenorrheic. Subclinical i l menstrual disorders d are typical for both highly trained and recreational eumenorrheic athletes: luteal deficiency or anovulation was found in 78% of eumenorrheic recreational runners in at least 1 of 3 menstrual cycles. DeSouza MJ, et al. J Clin Endocrinol Metab 1998;83(12): Rosen LW, Hough DO. Phys Sports Med 1988;16: Hobart JA, Smucker DR. Am Fam Physician. 2000;61(11): Rosen LW, et al. Phys Sports Med 1986;14: Nattiv A, et al. Clin Sports Med 1994;13: Shangold M, et al. JAMA 1990;263: Otis CL. Clin Sports Med 1992;11: Sundgot-Borgen J. Med Sci Sports Exerc 1994;26: Energy Availability and Menstrual Function Dose-response relationship between energy availability and LH pulsatility Loucks AB and Thuma JR. J Clin Endocrinol Metab 2003;88(1): Low Bone Mineral Density 7

8 Bone Mineral Density 90% of women s peak bone mass is accrued by age 18. Bailey DA, et al. J Bone Miner Res 1999;14(10): DXA Scan Population Postmenopausal Women Terminology Osteopenia Criteria T-score: -1 to -2.5 WHO * ISCD ACSM Premenopausal Women Osteoporosis BMD within expected range for age T-score: -2.5 Z-score: > -2 BMD below expected range for age Z-score: -2 Premenopausal Female Athletes Low Osteoporosis BMD Z-score: -1 to -2 with 2⁰ clinical risk factors for fracture Z-score: -2 with 2⁰ clinical risk factors for fracture * WHO: World Health Organization; ISCD: International Society for Clinical Densitometry; ACSM: American College of Sports Medicine; 2⁰ clinical risk factors for fracture: chronic malnutrition, eating disorders, hypogonadism, glucocorticoid exposure, previous fractures Kanis JA, et al. Bone. Mar 2008;42(3): Updated 2005 official positions for the ISCD. Nattiv A, et al. Med Sci Sports Exerc. Oct 2007;39(10):

9 Fractures/Stress Fractures Bone Scan Images and Findings Mild areas of tracer uptake in the inferior pubic rami (right greater than left). Focal high uptake in the distal tip of the left fibula posteriorly. Mild areas of tracer uptake along the plantar and superior aspects of the left calcaneus. Mild areas of tracer uptake in the mid and distal aspects of the right tibia and fibula. A few Low BMD risk factors Lifestyle factors Low calcium intake Vitamin D insufficiency Excess vitamin A High caffeine intake Alcohol (3 or more drinks/d) Smoking Genetics Hemochromatosis Parental history of hip fracture Hypophosphatasia Idiopathic hypercalciuria Hypogonadal state Athletic amenorrhea Androgen insensitivity Hyperprolactinemia Turner s & Klinefelter s syndromes Anorexia nervosa and bulimia Panhypopituitarism Premature ovarian failure Other Endocrine disorders Adrenal insufficiency Diabetes mellitus Thyrotoxicosis Cushing s syndrome Hyperparathyroidism 9

10 and some more Gastrointestinal Celiac disease Inflammatory bowel disease Primary biliary cirrhosis Malabsorption Pancreatic disease Hematologic disorders Hemophilia Sickle cell disease Thalassemia Rheumatic and autoimmune diseases Ankylosing spondylitis Lupus Rheumatoid arthritis Miscellaneous Conditions Epilepsy Scoliosis Prior fracture as an adult Depression Medications Anticoagulants (heparin) GnRH agonists Anticonvulsants Lithium Aromatase inhibitors Depo-medroxyprogesterone Barbiturates Glucocorticoids Prevalence of Low BMD 20-50% of female athletes have osteopenia using WHO criteria. Of 187 elite female athletes, 10.7% had BMD Z-scores < -2. Varies depending on sport. Kahn KM, et al. Br J Sports Med 2002;36: Torstveit MK, Sundgot-Borgen J. Br J Sports Med 2005;39(5): Grinspoon S, et al. J Clin Endocrinol Metab 1999; 84: Low Bone Density in Adolescent Amenorrheic Athletes (AA) Compared with Eumenorrheic Athletes (EA) and Sedentary Controls (C) Z-s core Lumbar Z LBMAD Z Hip Z WB BMC/Ht Z * * * * * * * AA EA C Ages years Christo K, et al. Pediatrics 2008;121(6):

11 College and Elite Rowers and Runners ages Runners N=51 Body fat % 19.5 ( ) [Medians (25 th -75 th percentiles)] Rowers N= ( ) Openwt N= ( ) Ltwt N= ( ) Amenorrheic ever (%) Amenorrheic age 22 to present (%) z-score <-1 z-score % (33% spine) 30% (50% spine) Ackerman KE, et al. Endocrine Society Bone Microarchitecture at the Distal Tibia in yo Females Non-Athletic Controls Eumenorrheic Athletes Amenorrheic Athletes Nazem T, Ackerman KE, et al. Endocrine Society Interrelationship of Components of the Triad Negative Energy Balance Disruption of Hypothalamic-Pituitary-Ovarian (HPO) axis Low energy availability alters levels of metabolic hormones: Increase in fasting PYY, ghrelin, cortisol, and GH concentrations in the Triad Decrease in FSH, LH, estradiol, insulin, glucose, insulin-like like growth factor-1 (IGF-1), 3,3,5- triiodothyronine (T 3 ) and leptin. Russell M et al. Bone 2009;45(1): Cheung CC, et al. Endocrinology 1997;138(2): Bradley SJ, et al. J Clin Exper Neuropsych 1997;19(1): Laughlin GA, Yen SCC. J Clin Endocrinol Metab 1997; 82(1): Burguera B, et al. Endocrinology 2001;142(8): Misra M, et al. Am J Physiol Endocrinol Metab 2005;289(2):E

12 Effects on Short-term term Health Fluid/electrolyte imbalances Acid-base abnormalities Cardiac arrythmias Decreased coordination, balance, muscle function Increased suicide attempts in those with eating disorders Anorectics have 6x the mortality rate compared to the general population Nielsen, S et al. J. Psychosom Res 1998;44: Effects on Performance, Injury and Recovery Decreased energy & earlier fatigue Decreased coordination, concentration, & speed More frequent muscle strains/sprains and fractures More frequent illnesses Longer to recover from hard workouts, races/games Effects on Mental Health and Relationships Isolating Stressful Misunderstood Less able to relate to others and form friendships/romantic relationships Perna FM, et al. Ann Behav Med 2003;25(1):

13 Effects on Long-term Health OSTEOPOROSIS! Possible infertility complications Bad lifetime habits which can lead to full- blown, life-threatening disorders Etc! Diagnosis An athlete with 1 component of the Triad should be evaluated for the other 2! Diagnosis: Low Energy Availability/Eating disorder Suspect when: Weight loss Decline in performance Change in mood Frequent injury/illness Fracture, low BMD Menstrual dysfunction Poor score on Eating Questionnaire 13

14 Becker A et al. NEJM 1999;340: Diagnosis: Menstrual Dysfunction Primary vs. Secondary amenorrhea Differential: Prolactinoma Hyperparathyroidism Adrenal tumor PCOS Hyperthyroidism Hormones- ex) Depoprovera, Synthroid Stimulants Laxatives Diuretics Diagnosis: Low BMD Suspect when: Malabsorption syndrome syndrome Celiac Disease Irritable Bowel Eating Disorder Stress Fractures Menstrual dysfunction 14

15 Work-up for Triad History: Diet Training Medical conditions Family history Reproductive history Stresses Medications Work-up for Triad Physical: General: Build, affect, height, weight, BMI, temp, BP, pulse Skin: hair distribution and texture HEENT: eyes, teeth, gums, lips, parotid enlargement Cardiac: rate, rhythm, murmurs Lungs: auscultation and percussion Abdomen: masses, bowel sounds Breast Exam: Tanner stage,?galactorrhea Vaginal exam: Tanner stage,?clitoral enlargement Extremities: bony tenderness, temp, edema, hand callouses (Russell s sign) Work-up for Triad Component of Triad Diagnostic Testing Low Energy Availability CBC Chemistry Panel +/- ECG Menstrual Dysfunction Follicle Stimulating Hormone (FSH) TSH and Free T4 Prolactin If suspect hyperandrogenism: LH (to assess LH:FSH ratio) Total Testosterone Sex hormone binding globulin (SHBG) DHEA-S 17-OH Progesterone To confirm estrogen status: Progesterone challenge Low Bone Mineral Density DXA 15

16 Therapist/Sports Psychologist/ Psychiatrist Treatment Nutritionist MD/NP/RN: Primary Care, Sports Med, Endocrine, Ortho, etc. Interdisciplinary i Team! Coach/ Trainer Support Group Teammates Family/Friends Treatment Diet adjustments Training adjustments Counseling Pharmocotherapy Basic Vitamin/Mineral Needs Calcium: ~1300 mg/day for adolescents, 1000 mg/day for young adult men and women (can t absorb more than 500mg at a time) Vitamin D: IU/day or about 15 minutes of good sun exposure (Goal 25-OH Vit D level is 32ng/mL) Iron: 18 mg/day or 9 mg/1000 cal/day Caloric intake < cal/day: difficult to meet vitamin and mineral requirements without supplements 16

17 Periodization of Training (and Eating) Courtesy of Izzie Brown, MS, RD, CSCS Body Mass Index BMI: wt (kg)/ht (m 2 ) most athletes weigh more, but have less body fat and more muscle than sedentary counterparts Ideal Body Weight Female 5 ft= 100 lbs + 5 lbs per inch No body composition method is perfect Personal body set point Athletic % body fat averages can t be extrapolated to individuals Athlete and coach should focus on strength, speed, athletic performance Some athletes feel tired and weak at body fat levels above minimum expected Counseling Individual therapy/sports psychology/psychiatry Family Therapy (if needed) Eating Disorder program (if needed) What is the drive behind the disorder? Deviant Overconformity to the Sport Ethic? Sport Ethic: 1) An athlete makes sacrifices for the game 2) An athlete strives for distinction 3) An athlete accepts risks and plays through pain 4) An athlete accepts no limits in the pursuit of possibilities 17

18 Medications??? Medical Treatment Medications??? Antidepressant Progestin challenge OCP Estrogen Bisphosphonate PTH DHEA Denosumab Aircast boot? Bone stimulator? Estrogen Replacement in Amenorrheic Athletes Common practice 92% of sports medicine specialists and family physicians supported OCP use to increase BMD* Data limitations Studies of efficacy of OCPs not definitive, no change, in BMD Often small Many do not control for weight changes Need for definitive studies assessing efficacy of estrogen in BMD *Haberland CA, et al. Clin J Sport Med 1995;5(4): Effects of transdermal estradiol or no treatment on BMD measures in girls with hypothalamic amenorrhea years old over a 12-month period of transdermal estrogen or no therapy 8 * 6 BMD % change in lumbar Estrogen patch No treatment Preliminary data 18

19 SEEKING FEMALE ATHLETES YEARS OLD NOT GETTING MENSES *FOR A RESEARCH STUDY* INCLUDES BONE DENSITY TESTING, NUTRITIONAL, FITNESS, AND HORMONAL EVALUATION. 1 YEAR LONG STUDY 3-6 OUTPATIENT VISITS 1 POSSIBLE INPATIENT VISIT MEDICAL HISTORY AND QUESTIONNAIRE OCP, transdermal estrogen, or no treatment UP TO $ 475 STIPEND CALL NEUROENDOCRINE UNIT MASSACHUSETTS GENERAL HOSPITAL THANK YOU! QUESTIONS? KEAckerman@partners.org 19