by on September 23, 2016

in Monthly,News

Adolescent girls who engage in regular physical activity enjoy many benefits such as improved self-esteem, educational benefits, fewer risk-taking behaviours, a healthier lipid profile, better sensitivity to insulin, less obesity and better bone health. But what happens when adolescent girls become too active, overly competitive, and negligent in fueling their bodies appropriately?

Three systems in the body end up in various stages of disease—menstruation becomes irregular or non-existent, bone formation deteriorates and cardiovascular health is compromised. Experts refer to this as the female athlete triad.

Girls who participate in sports which emphasize leanness and endurance are especially at risk. These sports include: wrestling, light-weight rowing, gymnastics, swimming, dancing, figure skating, cheerleading, long and middle-distance running, volleyball and pole vaulting.

In a culture where competition to be the best has intensified, coaches and parents are mostly well-meaning and supportive, but a growing body of research shows that casual comments made about weight by a coach, parent or peers may put some female athletes at risk of developing this triad. A study done in female gymnasts revealed that 75% were told by their coaches that they were overweight, and that if they were to pay more attention to weight-control, they would have a better chance of excelling in the sport.
The diagnostic criteria has widened since 1997 when the College of Sport Medicine came out with an original position paper. Not all three areas of concern —menstruation, bone health and cardiovascular health—need be present to make this diagnosis.

A 2009 study revealed that only 20 % of pediatricians were able to correctly identify the triad, compared with 50% of family medicine doctors and 40% of orthopedic surgeons.

To improve the situation, an organization named the Female Athlete Triad Coalition developed a questionnaire with 12 questions. These questions center around worries about weight or body composition, a preoccupation with foods eaten, self-esteem, the use of diuretics or laxatives, eating in secret, menstrual patterns and the frequency of stress fractures. The AAP endorses the Female Athlete Coalition’s questionnaire.
The ideal time to ask these questions is during well-child visits and preparticipation physical evaluations.

Menstrual irregularities are common during adolescence. Studies report an incidence of 21% in sedentary adolescents compared with 54% in adolescent athletes. A girl who has never experienced menstruation by age 15 years is defined as primary amenorrhea; when there is an absence of menstruation for three consecutive months we call this secondary amenorrhea.

Because adolescence is a time where the stage gets set for future health, athletes who fit somewhere in the spectrum of the female triad must be diagnosed earlier rather than later to avoid long term damage. It is important to remember that even with the proper treatment it may take as long as one year for normal menstruation to return. Athletes with menstrual irregularities are as much as three times more likely to sustain bone stress injury.

When it comes to healthy bone formation there is also a window of opportunity. The maximum rate of bone formation usually occurs between the ages of 10 and 14 years and the peak bone mass is attained between 20 and 30 years. (By the end of adolescence 90% of the adult bone mass is obtained)

The physical exam is not always abnormal in these adolescents, especially in girls who unintentionally fail to meet their increased energy needs on a daily basis. A lower BMI, blood pressure which drops when the patient stands up, and a history of stress fractures and menstrual irregularities may raise a higher index of suspicion.

In the August 2016 edition of Pediatrics the AAP’s Council on Sports Medicine and Fitness in liaison with the Athletic Trainers Association and the College of Sport Medicine, published a landmark position paper addressing the need to educate pediatricians and medical students about the timely diagnosis of the female triad.

However even if a pediatrician is meticulous in asking the correct questions based on a high index of suspicion, runs the proper special investigations—including a bone scan which will identify an abnormal bone mineral content—the ultimate solution is to access a team of experts such as doctors familiar with the management of this triad, psychologists skilled in changing behaviour, sports dietitians well versed in healthy ways to ensure the proper and consistent energy intake and exercise physiologists familiar with the limits of each athlete.

The cornerstone of treatment involves an improvement in the proper energy intake, but the issue can become very complicated—thus making access to a multidisciplinary team even more critical.

When it comes to prevention the ATHENA Study (Athletes Targeting Healthy Exercise and Nutrition Alternatives) evaluated the usefulness of peer intervention and education. The trail showed that intervention techniques that used education with peer leaders may be able to reduce the risk of developing the female athlete triad.


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