Triad Trouble

Some female athletes at risk for rare diagnosis

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The female athlete triad: energy deficiency (with or without disordered eating), menstrual disturbances and bone loss or osteoporosis.

When a women’s soccer coach in Southern Oregon noticed players at risk for a complicated and rare medical condition, she asked for help from local registered dietitian Julie Kokinakes.

Female athlete triad, a combination of three factors, caused the soccer team to reevaluate its nutrition and perceptions around athletic training, body composition and menstruation. Kokinakes, who has a private practice in the Rogue Valley, gave the women an overview of the problem and individual assessments during the 2017 soccer season.

“There’s no one-size-fits-all,” says Kokinakes. “It’s a really complex metabolic process.”

Even medical practitioners don’t have all the expertise and tools to treat female athlete triad, which often requires a team of people representing diverse disciplines. The term first coined in 1992 by the American College of Sports Medicine, female athlete triad describes co-occurring indicators of disordered eating, amenorrhea — or the menstrual cycle’s cessation for at least three months — and loss of bone-mineral density. While the first two factors typically constitute short-term struggles, the third puts young women at risk for lifelong osteoporosis and fractures.

“There’s a very specific skeletal disorder,” says Kokinakes.

Evaluating the soccer team, Kokinakes determined that some players had disordered eating. Some had shown signs of amenorrhea, which isn’t a cause for concern on its own. Kokinakes recommended more protein for some, more total calories for others and a whole-foods diet for all.

“All of them had low energy intake,” says Kokinakes, explaining that calorie restriction isn’t always the culprit. Poor-quality food, she says, also could be to blame. And not all athletes, particularly younger men and women, are aware of the need to consume the right quantity of calories for their sport, she adds. Female athlete triad is diagnosed primarily in women with lower body mass, making a naturally slim physique among the risk factors.

“They could be overnourished calorically but undernourished from a micronutrient standpoint,” says Kokinakes. “It doesn’t always go hand in hand with anorexia-bulemia.”

An imbalance of dietary fats often plagues patients with female athlete triad, says Dr. Alison Edelman, an obstetrician, gynecologist and faculty member at Oregon Health & Science University in Portland. Patients also tend to be low in ferratin, a naturally occurring protein that stores iron in the body’s cells and releases it when needed. Low levels can — but not always do — result in anemia, says Edelman.

But a prescription for better nutrition typically isn’t sufficient to treat patients who “usually have to change everything,” says Edelman, who works closely with staff of OHSU’s human performance lab.

“A lot of it is behavioral,” she says. “There’s a lot riding on these folks and their ability to perform athletically. Usually, they’re coming in because their performance is off.”

Once physicians know that patients’ menstruation has ceased, or they’ve never even had a period, female athlete triad emerges as a possible diagnosis, says Edelman.

“We see the menstrual period as a vital sign,” she says, adding that patients who have never menstruated may never reach peak bone mass, due to lower estrogen.

Periods that start and stop based on the intensity of athletic training, or suppressing menstruation for major competitions is a goal of many patients, says Edelman. Because menstrual irregularities, or the complete lack of menstruation, don’t have lasting consequences for women’s health and fertility, says Edelman, physicians focus on treating behaviors that contribute to amenorrhea and culminate in female athlete triad.

“You’re basically tipping into a point where you’re metabolically imbalanced,” says Edelman. “They put themselves at risk for poor performance and stress fractures.

“They can actually be out of their sport for a really long time,” she adds. “In Oregon, we see a lot of runners and cyclists.”

Modifying patients’ training programs and diets often goes hand in hand with shifting their mentalities, says Edelman. Families and coaches may have to adjust expectations about patients’ body weight and which foods should be on an athlete’s menu, she says. Mental-health support can be a component of treatment plans, she adds.

“Many of them are having depression and anxiety because they’re not performing well,” says Edelman. “It’s hard to get people out of this cycle. What we do know that works is have a team of people.”

This interdisciplinary approach to treatment is familiar to elite athletes, say Edelman and Kokinakes. Fortunately, these teams of professionals don’t encounter female athlete triad very often. While it’s hard to pin down a precise number, says Edelman, the rate is probably 10% or less of all female athletes in their early teens until the age of menopause. However, the numbers may be as many as half of all female distance runners in that age group, she adds. Kokinakes says she has treated five patients, perhaps fewer, in 25 years as a dietitian.

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