The purpose of this study was to examine the prevalence of disordered eating (DE), menstrual dysfunction (MD), and low bone mineral density (BMD) among US collegiate athletes (n = 112) representing 7 different sports (diving, swimming, x-country, track, tennis, field hockey, and softball) and determine differences in prevalence existed between athletes participating in lean-build (LB) and non-lean build (NLB) sports. DE and MD were assessed by a health, weight, dieting, and menstrual history questionnaire. Spinal BMD was determined via dual energy x-ray absorptiometry. Twenty-eight athletes met the criteria for DE, twenty-nine for MD, and two athletes had low BMDs (using a Z score below −2.0). Ten athletes met the criteria for two disorders (one with disordered eating and low BMD and nine with disordered eating and menstrual dysfunction), while only one athlete met the criteria for all three disorders. Using a Z score below −1.0, two additional athletes met the criteria for all three disorders and three more athletes met the criteria for a combination of two disorders. With the exception of MD, which was significantly more prevalent among LB vs. NLB sports (P = 0.053), there were no differences between the groups in the prevalence of individual disorders or combinations of disorders. These data indicate that the combined prevalence of DE, MD, and low BMD among collegiate athletes is small; however, a significant number suffer from individual disorders of the Triad.
The Prevalence of Disordered Eating, Menstrual Dysfunction, and Low Bone Mineral Density among US Collegiate Athletes
Katherine A. Beals and Amanda K. Hill
Role of Energy Balance in Athletic Menstrual Dysfunction
Christine A. Dueck, Melinda M. Manore, and Kathleen S. Matt
The cessation of menstrual function in the female athlete may reflect her inability to adapt to the environmental and lifestyle stressors associated with training and competition. As society's emphasis on thinness, dieting, and exercise continues to increase, so will the incidence of menstrual dysfunction in active females. Unfortunately, some individuals view athletic menstrual dysfunction as a benign consequence of strenuous exercise. Conversely, it is most likely a strong indicator of overtraining and a marker for future decrements in performance, and it can have long-term health consequences. Thus, it is imperative that the active female be appropriately educated regarding the adverse consequences of menstrual dysfunction and the interventions available. This paper focuses on the most current information regarding athletic menstrual dysfunction and its multifactorial etiology, especially the role of energy drain. In addition, common misconceptions, adverse health and performance effects, and available treatment options are discussed.
Case Study: Resumption of Eumenorrhea in Parallel With High Training Load After 4 Years of Menstrual Dysfunction: A 5-Year Follow-Up of an Elite Female Cyclist
José L. Areta
The female athlete triad has been identified as a condition where chronic low energy availability (LEA) is typically concomitant with menstrual dysfunction and/or low bone mineral density ( Nattiv et al., 2007 ). Elements of the triad are often observed in athletes from sports focusing on leanness
Hormonal Contraceptive Use, Menstrual Dysfunctions, and Self-Reported Side Effects in Elite Athletes in Denmark
Mikkel Oxfeldt, Line B. Dalgaard, Astrid A. Jørgensen, and Mette Hansen
:10.1123/ijspp.2017-0330 10.1123/ijspp.2017-0330 29283683 19. Torstveit MK , Sundgot-Borgen J . Participation in leanness sports but not training volume is associated with menstrual dysfunction: a national survey of 1276 elite athletes and controls . Br J Sports Med . 2005 ; 39 ( 3 ): 141
Nutritional Aspects of Amenorrhea in the Female Athlete Triad
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.
Energy Deficiency, Menstrual Disturbances, and Low Bone Mass: What Do Exercising Australian Women Know About the Female Athlete Triad?
Stephanie M. Miller, Sonja Kukuljan, Anne I. Turner, Paige van der Pligt, and Gaele Ducher
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.
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).
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).
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.
Behavioral, Psychological, and Physical Characteristics of Female Athletes with Subclinical Eating Disorders
Katherine A. Beals and Melinda M. Manore
The purpose of this study was to delineate and further define the behavioral, psychological, and physical characteristics of female athletes with subclinical eating disorders. Subjects consisted of 24 athletes with subclinical eating disorders (SCED) and 24 control athletes. Group classification was determined by scores on the Eating Disorder Inventory (EDI), the Body Shape Questionnaire (BSQ), and a symptom checklist for eating disorders (EDI-SC). Characteristics representative of the female athletes with subclinical eating disorders were derived from an extensive health and dieting history questionnaire and an in-depth interview (the Eating Disorder Examination). Energy intake and expenditure (kcal/d) were estimated using 7-day weighed food records and activity logs. The characteristics most common in the female athletes with subclinical eating disorders included: (a) preoccupation with food, energy intake, and body weight; (b) distorted body image and body weight dissatisfaction; (c) undue influence of body weight on self-evaluation; (d) intense fear of gaining weight even though at or slightly below (-5%) normal weight; (e) attempts to lose weight using one or more pathogenic weight control methods; (g) food intake governed by strict dietary rules, accompanied by extreme feelings of guilt and self-hatred upon breaking a rule; (h) absence of medical disorder to explain energy restriction, weight loss, or maintenance of low body weight; and (i) menstrual dysfunction. Awareness of these characteristics may aid in more timely identification and treatment of female athletes with disordered eating patterns and, perhaps, prevent the development of more serious, clinical eating disorders.
Treatment of Athletic Amenorrhea with a Diet and Training Intervention Program
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.
The Utility of the Low Energy Availability in Females Questionnaire to Detect Markers Consistent With Low Energy Availability-Related Conditions in a Mixed-Sport Cohort
Margot A. Rogers, Michael K. Drew, Renee Appaneal, Greg Lovell, Bronwen Lundy, David Hughes, Nicole Vlahovich, Gordon Waddington, and Louise M. Burke
polymenorrheic based on self-reported cycle length and start date of the most recent menstrual cycle, obtained from the LEAF-Q or the AIS pre-DXA questionnaire ( Supplementary Material 2 [available online]). Noneumenorrheic athletes were considered to have menstrual dysfunction (MD). Menstrual cycle phase was
Eating and Weight Disorders in the Female Athlete
Jack H. Wilmore
This paper presents an overview of eating disorders, including definitions, clinical criteria for appropriate diagnosis, and a discussion of the potential for increased risk for eating disorders in special populations of female athletes. This is followed by a discussion of the prevalence of eating disorders in normal and athletic populations. From this discussion, it seems clear that female athletes in endurance or appearance sports are at an increased risk for disordered eating. Finally, the paper focuses on related disorders—a triad associating eating disorders, menstrual dysfunction, and bone mineral disorders. It is clear that secondary amenorrhea is associated with malnutrition and disordered eating. Further, bone mineral disorders are related to menstrual dysfunction. Disordered eating may represent the initiating factor of this triad.