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Jennifer Sygo, Alexandra M. Coates, Erik Sesbreno, Margo L. Mountjoy, and Jamie F. Burr

) and triiodothyronine, and is associated with menstrual dysfunction and secondary functional hypothalamic amenorrhea in women ( Loucks & Thuma, 2003 ; Nattiv et al., 2007 ). LEA suppresses other hormones and substrates, including insulin, insulin-like growth factor-1 (IGF-1), glucose, growth hormone

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Joan E. Benson, Kathryn A. Engelbert-Fenton, and Patricia A. Eisenman

Female athletes experience a high incidence of menstrual abnormalities. This has critical health consequences because amenorrhea athletes are at greater risk of developing osteopenia and bone injury compared to normally menstruating athletes or nonathletic normally cycling females. Female performers and athletes are also at risk for developing disordered eating behaviors. There appears to be a connection between menstrual dysfunction, athletic training, and disordered eating, but how they relate is not fully understood. In this paper we explore how low calorie intakes, nutritional inadequacies, vegetarianism, low body fat stores, and specific training behaviors may contribute to the abnormal menstrual patterns seen in this population. Recommendations for the detection and prevention of eating and training problems and consequent menstrual abnormalities are included.

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Stephanie M. Miller, Sonja Kukuljan, Anne I. Turner, Paige van der Pligt, and Gaele Ducher

Purpose:

Prevention of the female athlete triad is essential to protect female athletes’ health. The aim of this study was to investigate the knowledge, attitudes, and behaviors of regularly exercising adult women in Australia toward eating patterns, menstrual cycles, and bone health.

Methods:

A total of 191 female exercisers, age 18–40 yr, engaging in ≥2 hr/wk of strenuous activity, completed a survey. After 11 surveys were excluded (due to incomplete answers), the 180 participants were categorized into lean-build sports (n = 82; running/athletics, triathlon, swimming, cycling, dancing, rowing), non-lean-build sports (n = 94; basketball, netball, soccer, hockey, volleyball, tennis, trampoline, squash, Australian football), or gym/fitness activities (n = 4).

Results:

Mean (± SD) training volume was 9.0 ± 5.5 hr/wk, with participants competing from local up to international level. Only 10% of respondents could name the 3 components of the female athlete triad. Regardless of reported history of stress fracture, 45% of the respondents did not think that amenorrhea (absence of menses for ≥3 months) could affect bone health, and 22% of those involved in lean-build sports would do nothing if experiencing amenorrhea (vs. 3.2% in non-lean-build sports, p = .005). Lean-build sports, history of amenorrhea, and history of stress fracture were all significantly associated with not taking action in the presence of amenorrhea (all p < .005).

Conclusions:

Few active Australian women are aware of the detrimental effects of menstrual dysfunction on bone health. Education programs are needed to prevent the female athlete triad and ensure that appropriate actions are taken by athletes when experiencing amenorrhea.

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Susan Carter

Center in Colorado Springs in 1982 at a meeting of the Athletic Amenorrhea Bulletin , when the singer Karen Carpenter was suffering from anorexia. Her situation brought heightened public awareness of the condition. As anorexia was one of the original concerns of the Triad, along with osteoporosis and

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Jeanne F. Nichols, Mitchell J. Rauh, Michelle T. Barrack, Hava-Shoshana Barkai, and Yael Pernick

The authors’ purpose was to determine the prevalence and compare associations of disordered eating (DE) and menstrual irregularity (MI) among high school athletes. The Eating Disorder Examination Questionnaire (EDE-Q) and a menstrual-history questionnaire were administered to 423 athletes (15.7 ± 1.2 y, 61.2 ± 10.2 kg) categorized as lean build (LB; n = 146) or nonlean build (NLB; n = 277). Among all athletes, 20.0% met the criteria for DE and 20.1% for MI. Although the prevalence of MI was higher in LB (26.7%) than NLB (16.6%) athletes (P = 0.01), no differences were found for DE. For both sport types, oligo/amenorrheic athletes consistently reported higher EDE-Q scores than eumenorrheic athletes (P < 0.05). Athletes with DE were over 2 times as likely (OR = 2.3, 95%CI: 1.3, 4.2) to report oligo/amenorrhea than athletes without DE. These data establish an association between DE and MI among high school athletes and indicate that LB athletes have more MI but not DE than NLB athletes.

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Jenna C. Gibbs, Nancy I. Williams, Jennifer L. Scheid, Rebecca J. Toombs, and Mary Jane De Souza

A high drive-for-thinness (DT) score obtained from the Eating Disorder Inventory-2 is associated with surrogate markers of energy deficiency in exercising women. The purposes of this study were to confirm the association between DT and energy deficiency in a larger population of exercising women that was previously published and to compare the distribution of menstrual status in exercising women when categorized as high vs. normal DT. A high DT was defined as a score ≥7, corresponding to the 75th percentile for college-age women. Exercising women age 22.9 ± 4.3 yr with a BMI of 21.2±2.2 kg/m2 were retrospectively grouped as high DT (n = 27) or normal DT (n = 90) to compare psychometric, energetic, and reproductive characteristics. Chi-square analyses were performed to compare the distribution of menstrual disturbances between groups. Measures of resting energy expenditure (REE) (4,949 ± 494 kJ/day vs. 5,406 ± 560 kJ/day, p < .001) and adjusted REE (123 ± 16 kJ/LBM vs. 130 ± 9 kJ/LBM, p = .027) were suppressed in exercising women with high DT vs. normal DT, respectively. Ratio of measured REE to predicted REE (pREE) in the high-DT group was 0.85 ± 0.10, meeting the authors’ operational definition for an energy deficiency (REE:pREE <0.90). A greater prevalence of severe menstrual disturbances such as amenorrhea and oligomenorrhea was observed in the high-DT group (χ2 = 9.3, p = .003) than in the normal-DT group. The current study confirms the association between a high DT score and energy deficiency in exercising women and demonstrates a greater prevalence of severe menstrual disturbances in exercising women with high DT.

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Margo Mountjoy, Jorunn Sundgot-Borgen, Louise Burke, Kathryn E. Ackerman, Cheri Blauwet, Naama Constantini, Constance Lebrun, Bronwen Lundy, Anna Melin, Nanna Meyer, Roberta Sherman, Adam S. Tenforde, Monica Klungland Torstveit, and Richard Budgett

differential responses of various body systems ( Burke & Deakin, 2015 ), many of these systems are substantially perturbed at an EA < 30 kcal/kg FFM/day (125 kJ/kg FFM/day), making it historically a targeted threshold for LEA. However, recent evidence suggests that this cutoff does not predict amenorrhea in

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Jason D. Vescovi and Jaci L. VanHeest

This observational case study examined the association of inter- and intraday energy intake and exercise energy expenditure with bone health, menstrual status and hematological factors in a female triathlete. The study spanned 7 months whereby energy intake and exercise energy expenditure were monitored three times (13 d); 16 blood samples were taken, urinary hormones were assessed for 3 months, and bone mineral density was measured twice. Energy availability tended to be sustained below 30 kcal/kg FFM/d and intraday energy intake patterns were often “back-loaded” with approximately 46% of energy consumed after 6 p.m. Most triiodothyronine values were low (1.1–1.2nmol/L) and supportive of reduced energy availability. The athlete had suppressed estradiol (105.1 ± 71.7pmol/L) and progesterone (1.79 ±1.19nmol/L) concentrations as well as urinary sex-steroid metabolites during the entire monitoring period. Lumbar spine (L1-L4) bone mineral density was low (age-matched Z-score −1.4 to −1.5). Despite these health related maladies the athlete was able to perform typical weekly training loads (swim: 30–40 km, bike: 120–300 km, run 45–70 km) and was competitive as indicated by her continued improvement in ITU World Ranking during and beyond the assessment period. There is a delicate balance between health and performance that can become blurred especially for endurance athletes. Education (athletes, coaches, parents) and continued monitoring of specific indicators will enable evidence-based recommendations to be provided and help reduced the risk of health related issues while maximizing performance gains. Future research needs to longitudinally examine how performance on standardized tests in each discipline (e.g., 800-m swim, 20-km time trial, 5-km run) is impacted when aspects of the female athlete triad are present.

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Katherine A. Beals and Melinda M. Manore

This study examined the prevalence of and relationship between the disorders of the female athlete triad in collegiate athletes participating in aesthetic, endurance, or team/anaerobic sports. Participants were 425 female collegiate athletes from 7 universities across the United States. Disordered eating, menstrual dysfunction, and musculoskeletal injuries were assessed by a health/medical, dieting and menstrual history questionnaire, the Eating Attitudes Test (EAT-26), and the Eating Disorder Inventory Body Dissatisfaction Subscale (EDI-BD). The percentage of athletes reporting a clinical diagnosis of anorexia and bulimia nervosa was 3.3% and 2.3%, respectively; mean (±SD) EAT and EDI-BD scores were 10.6 ± 9.6 and 9.8 ± 7.6, respectively. The percentage of athletes with scores indicating “at-risk” behavior for an eating disorder were 15.2% using the EAT-26 and 32.4% using the EDI-BD. A similar percentage of athletes in aesthetic, endurance, and team/anaerobic sports reported a clinical diagnosis of anorexia or bulimia. However, athletes in aesthetic sports scored higher on the EAT-26 (13.5 ± 10.9) than athletes in endurance (10.0 ± 9.3) or team/anaerobic sports (9.9 ± 9.0, p < .02); and more athletes in aesthetic versus endurance or team/anaerobic sports scored above the EAT-26 cut-off score of 20 (p < .01). Menstrual irregularity was reported by 31% of the athletes not using oral contraceptives, and there were no group differences in the prevalence of self-reported menstrual irregularity. Muscle and bone injuries sustained during the collegiate career were reported by 65.9% and 34.3% of athletes, respectively, and more athletes in aesthetic versus endurance and team/anaerobic sports reported muscle (p = .005) and/or bone injuries (p < .001). Athletes “at risk” for eating disorders more frequently reported menstrual irregularity (p = .004) and sustained more bone injuries (p = .003) during their collegiate career. These data indicate that while the prevalence of clinical eating disorders is low in female collegiate athletes, many are “at risk” for an eating disorder, which places them at increased risk for menstrual irregularity and bone injuries.

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Christine A. Dueck, Kathleen S. Matt, Melinda M. Manore, and James S. Skinner

The purpose of this study was to determine the effect of a 15-week diet and exercise intervention program on energy balance, hormonal profiles, body composition, and menstrual function of an amenorrheic endurance athlete. The intervention program reduced training 1 day/week and included the use of a sport nutrition beverage providing 360 kcal/day. Three eumenorrheic athletes served as a comparison group and were monitored over the same 15-week period. The amenorrheic athlete experienced a transition from negative to positive energy balance, increased body fat from 8.2 to 14.4%, increased fasting luteinizing hormone (LH) from 3.9 to 7.3 mlU/ml, and decreased fasting cortisol from 41.2 to 33.2 pg/dl. The eumenorrheic subjects showed a 0.4% reduction in body fat, a decrease in follicular phase levels of LH from 7.9 to 6.5 mlU/ml, and no change in cortisol. These results suggest that nonpharmacological treatment can contribute to reestablishing normal hormonal profiles and menstrual cyclicity in amenorrheic athletes.