Endocrine disorders in adolescent and young female athletes: impact on growth, menstrual cycles, and bone mass acquisition

Associations of Serum Irisin and Fibroblast Growth Factor-21 Levels With Bone Mineral Characteristics in Eumenorrheic Adolescent Athletes With Different Training Activity Patterns

PURPOSE

To describe serum irisin and fibroblast growth factor-21 (FGF-21) concentrations in healthy female adolescents with different training activity patterns and their associations with bone mineral properties and metabolic markers.

METHODS

A total of 62 adolescent girls aged 14-18 years were recruited: 22 rhythmic gymnasts, 20 swimmers, and 20 untrained controls. Bone mineral characteristics by dual-energy X-ray absorptiometry, daily energy intake by dietary recall, serum irisin, FGF-21, undercarboxylated osteocalcin, and C-terminal telopeptide of type I collagen were measured in all girls.

RESULTS

Whole body and lumbar spine areal bone mineral density and lumbar spine bone mineral content were higher in the rhythmic gymnasts group compared with swimmers and untrained controls groups (P < .05). Serum irisin, FGF-21, undercarboxylated osteocalcin, and C-terminal telopeptide of type I collagen levels were not significantly different between the groups. In the rhythmic gymnasts group, serum FGF-21 concentration was positively correlated with lumbar spine areal bone mineral density independently of confounding factors (r = .51; P = .027).

CONCLUSIONS

Serum irisin and FGF-21 levels were not different between adolescent eumenorrheic girls with different training activity patterns. FGF-21 was positively associated with lumbar spine areal bone mineral density, which predominantly consists of trabecular bone in adolescent rhythmic gymnasts.

Characteristics of bone mineral density in patients with functional hypothalamic amenorrhoea and its association with reproductive hormones and body composition

OBJECTIVE

Bone mineral density (BMD) is typically reduced in patients with female athlete triad (FAT) and anorexia nervosa (AN). However, bone health in most patients with functional hypothalamic amenorrhoea (FHA), who may not suffer from severe energy deficiency, has not received adequate attention in clinical practice. This study aimed to investigate BMD and its association with clinical and endocrine features in individuals with FHA and to provide clinical evidence for improving bone loss and preventing osteoporosis in FHA.

DESIGN

To assess the bone status of patients with FHA and investigate its association with various clinical and endocrinological characteristics.

PATIENTS

We retrospectively analysed 80 patients with FHA who attended the Obstetrics and Gynecology Hospital of Fudan University from January 2022 to March 2023.

MEASUREMENTS

The levels of reproductive hormones, including luteinising hormone (LH), follicle-stimulating hormone, oestradiol (E2 ) and total testosterone (TT), were examined at the time of initial diagnosis, and a body composition analyser was used to measure body fat percentage (BF%), lean body mass (LBM) and segmental muscle/fat. Dual-emission X-ray absorptiometry was used to measure lumbar spine BMD and femoral neck BMD in patients with FHA, and the Z score was calculated.

RESULTS

The study cohort consisted of 80 female patients with FHA. The average age of the patients was 24.64 ± 6.02 years, and their body mass index (BMI) was 19.47 ± 2.86 kg/m2 . The duration of weight loss was 12 (6, 24) months, while the duration of oligo/amenorrhoea was 12 (4.5, 24) months. The mean degree of weight loss was 18.39 ± 9.53%. Low BMD were present in 15% of patients with FHA at the lumbar spine and/or femoral neck; 12.5% and 10% had low bone mass at the lumbar spine and femoral neck, respectively. The low bone mass group experienced a longer period of weight loss than the normal group [24 (16.5, 60) vs. 12 (4.5, 24) months, p = .037]. In addition, the abnormal group had a lower BMR (basal metabolic rate, BMR) [1158 ± 85 vs. 1231 ± 91 kcal/day, p = .011] and lower bone mineral content [2.15 ± 0.26 vs. 2.43 ± 0.31 kg, p = .009] than the normal group. Both LBMD and femoral neck BMD (Fn BMD) were positively correlated with BMI, BF%, LBM, and regional muscle/fat mass (all p < .05). There was also a positive correlation between LBMD and basal LH levels (p = .009) and waist-to-hip ratio (p = .034), whereas Fn BMD was positively correlated with TT levels (p = .029). Multiple linear regression analysis showed that LBM was positively associated with LBMD (β = .007, 95% confidence interval [CI] = 0.004-0.009, p < .001), while trunk muscle mass was positively associated with Fn BMD (β = .046, 95% CI = 0.013-0.080, p = .008).

CONCLUSION

Fifteen percent of the patients with FHA exhibited low bone mass, a condition associated with prolonged weight loss. The basal LH and TT levels showed positive correlations with LBMD and Fn BMD, respectively. Meanwhile, BMR levels, BMI, BF%, and muscle mass were all positively correlated with LBMD and Fn BMD. Clinically, we should be attentive to suboptimal bone health in patients with FHA and take early screening, diagnosis and intervention measures, especially appropriate muscle mass gain, to prevent the onset of osteoporosis and fragility fractures in the long term.

The Influence of Menstrual Cycle Phases on Maximal Strength Performance in Healthy Female Adults: A Systematic Review with Meta-Analysis

Maximal strength is a significant factor in achieving peak performance and injury prevention in athletes. In individualization strategies for the efficient development of athletes, it is necessary to consider the respective components separately. The purpose of this study was to systematically examine the effects of the different cycle phases on isometric, isokinetic, and dynamic maximum strength. A systematic literature review was conducted; databases were searched from January 1960 to September 2023. The included studies focused on the expression of maximal strength in the earlier follicular phase as well as at least one comparative phase. Of the initial 707 articles identified, 22 met the selection criteria and were included. The studies considered a total of 433 subjects. Our results revealed medium effects (weighted mean standardized mean difference (SMD) = 0.60; seven studies) for isometric maximal strength in favor of the late follicular phase, small effects (weighted mean SMD = 0.39; five studies) for isokinetic maximal strength in favor of the ovulation phase, and small effects (weighted mean SMD = 0.14; three studies) for dynamic maximal strength in favor of the late follicular phase. The results indicate that the early follicular phase is unfavorable for all strength classes. Peak performance in isometric strength is seen in the late follicular phase, whereas isokinetic strength peaks during ovulation. Dynamic strength is optimal in the late follicular phase.

Primary, secondary and tertiary prevention of Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the IOC consensus on REDs

Relative Energy Deficiency in Sport (REDs) is common among female and male athletes representing various sports at different performance levels, and the underlying cause is problematic low energy availability (LEA). It is essential to prevent problematic LEA to decrease the risk of serious health and performance consequences. This narrative review addresses REDs primary, secondary and tertiary prevention strategies and recommends best practice prevention guidelines targeting the athlete health and performance team, athlete entourage (eg, coaches, parents, managers) and sport organisations. Primary prevention of REDs seeks to minimise exposure to and reduce behaviours associated with problematic LEA. Some of the important strategies are educational initiatives and de-emphasising body weight and leanness, particularly in young and subelite athletes. Secondary prevention encourages the early identification and management of REDs signs or symptoms to facilitate early treatment to prevent development of more serious REDs outcomes. Recommended strategies for identifying athletes at risk are self-reported screening instruments, individual health interviews and/or objective assessment of REDs markers. Tertiary prevention (clinical treatment) seeks to limit short-term and long-term severe health consequences of REDs. The cornerstone of tertiary prevention is identifying the source of and treating problematic LEA. Best practice guidelines to prevent REDs and related consequences include a multipronged approach targeting the athlete health and performance team, the athlete entourage and sport organisations, who all need to ensure a supportive and safe sporting environment, have sufficient REDs knowledge and remain observant for the early signs and symptoms of REDs.

Passing on the exercise baton: What can endocrine patients learn from elite athletes?

As elite athletes demonstrate through the Olympic motto 'Citius, Altius, Fortius- Communiter', new performance records are driven forward by favourable skeletal muscle bioenergetics, cardiorespiratory, and endocrine system adaptations. At a recreational level, regular physical activity is an effective nonpharmacological therapy in the treatment of many endocrine conditions. However, the impact of physical exercise on endocrine function and how best to incorporate exercise therapy into clinical care are not well understood. Beyond the pursuit of an Olympic medal, elite athletes may therefore serve as role models for showcasing how exercise can help in the management of endocrine disorders and improve metabolic dysfunction. This review summarizes research evidence for clinicians who wish to understand endocrine changes in athletes who already perform high levels of activity as well as to encourage patients to exercise more safely. Herein, we detail the upper limits of athleticism to showcase the adaptability of human endocrine-metabolic-physiological systems. Then, we describe the growing research base that advocates the importance of understanding maladaptation to physical training and nutrition in males and females; especially the young. Finally, we explore the impact of physical activity in improving some endocrine disorders with guidance on how lessons can be taken from athletes training and incorporated into strategies to move more people more often.

Bone health in functional hypothalamic amenorrhea: What the endocrinologist needs to know

In the original definition by Klinefelter, Albright and Griswold, the expression "hypothalamic hypoestrogenism" was used to describe functional hypothalamic amenorrhoea (FHA). Given the well-known effects of estrogens on bone, the physiopathology of skeletal fragility in this condition may appear self-explanatory. Actually, a growing body of evidence has clarified that estrogens are only part of the story. FHA occurs in eating disorders, overtraining, and during psychological or physical stress. Despite some specific characteristics which differentiate these conditions, relative energy deficiency is a common trigger that initiates the metabolic and endocrine derangements contributing to bone loss. Conversely, data on the impact of amenorrhoea on bone density or microarchitecture are controversial, and reduced bone mass is observed even in patients with preserved menstrual cycle. Consistently, oral estrogen-progestin combinations have not proven beneficial on bone density of amenorrheic women. Low bone density is a highly prevalent finding in these patients and entails an increased risk of stress or fragility fractures, and failure to achieve peak bone mass and target height in young girls. Pharmacological treatments have been studied, including androgens, insulin-like growth factor-1, bisphosphonates, denosumab, teriparatide, leptin, but none of them is currently approved for use in FHA. A timely screening for bone complications and a multidisciplinary, customized approach aiming to restore energy balance, ensure adequate protein, calcium and vitamin D intake, and reverse the detrimental metabolic-endocrine changes typical of this condition, should be the preferred approach until further studies are available.

Bone health in adolescence

Adolescence is a fundamental period for the formation of the skeleton, because is the stage in which bones grow more in both size and strength, laying a solid foundation for the future health of the skeleton. Any condition interfering with optimal peak bone mass accrual can increase fracture risk later in life. Up to 80% of peak bone mass is genetically determined while the remaining 20% is modulated by environmental factors that, if deleterious, may result in low bone mineral density (BMD) and an increased risk of fracture. The preferred test to assess bone health is dual-energy x-ray absorptiometry (spine or total body less head) using Z scores instead of T scores, even though in short stature or growth delay, should be used the height Z-score. The correction of risk factors is the first treatment for low BMD in children and adolescents. It's necessary having a correct lifestyle for preserving bone health: a proper nutrition, an adequate physical weight-bearing activity and avoidance of alcohol intake and tobacco smoke. Bisphosphonates could be used in children who sustained osteoporotic fractures, impairing quality of life, when spontaneous recovery is low for the persistence of osteoporosis risk factors. This clinical review discusses factors affecting bone health during childhood and adolescence and deals with diagnosis and treatment of low bone mass or osteoporosis in this age group.

The Impact of Diet and Physical Activity on Bone Health in Children and Adolescents

There is growing recognition of the role of diet and physical activity in modulating bone mineral density, bone mineral content, and remodeling, which in turn can impact bone health later in life. Adequate nutrient composition could influence bone health and help to maximize peak bone mass. Therefore, children's nutrition may have lifelong consequences. Also, physical activity, adequate in volume or intensity, may have positive consequences on bone mineral content and density and may preserve bone loss in adulthood. Most of the literature that exists for children, about diet and physical activity on bone health, has been translated from studies conducted in adults. Thus, there are still many unanswered questions about what type of diet and physical activity may positively influence skeletal development. This review focuses on bone requirements in terms of nutrients and physical activity in childhood and adolescence to promote bone health. It explores the contemporary scientific literature that analyzes the impact of diet together with the typology and timing of physical activity that could be more appropriate depending on whether they are children and adolescents to assure an optimal skeleton formation. A description of the role of parathyroid hormone (PTH) and gut hormones (gastric inhibitory peptide (GIP), glucagon-like peptide (GLP)-1, and GLP-2) as potential candidates in this interaction to promote bone health is also presented.

Nutritional Risks among Adolescent Athletes with Disordered Eating

In their attempt to achieve the optimum weight or body shape for their activity, athletes frequently use harmful weight-control practices that may lead to the development of disordered eating or eating disorders. These practices are linked to several medical and mental consequences that may be more serious in adolescent athletes, as their bodies must meet both intensive growth demands and training requirements at the same time. Among other consequences, adolescent athletes may be at nutritional risk, due to their high nutrient needs and unhealthy eating behaviors. A literature review was conducted to examine the main nutritional risks and malnutrition issues faced by adolescent athletes that present disordered eating attitudes or eating disorders. Most studies refer to adult elite athletes, however research on adolescent athletes also indicates that the most common nutritional risks that may arise due to disordered eating include energy, macronutrient and micronutrient deficiencies, dehydration and electrolyte imbalances and changes in body composition that may lead to menstrual abnormalities, and decreased bone mass density. Educational programs and early detection of disordered eating and eating disorders are crucial to avoid the emergence and ensure timely management of nutrition-related problems in the vulnerable group of adolescent athletes.

Contemporary Variables that Impact Sleep and Development in Female Adolescent Swimmers and Gymnasts

The effects of sleep on elite athletes in late adolescence and early adulthood have been well documented in a myriad of sports. However, there is underrepresentation of pre-pubertal and young female adolescent athlete research between the ages of 11-17, and specifically female gymnast and swimmers. Neglecting to understand how high energy demand at a young age relates to sleep and restoration may lead to developmental ramifications for this group, as they display physiological dysfunctions like delayed puberty, amenorrhea and are at risk for the female athlete triad or components of the triad. This review aims to summarize the contemporary variables of blue light emitting screens, social media, and caffeine on quality and quantity of sleep in young athletes while identifying gaps in the literature on how these factors impact the target group of young female swimmers and gymnasts.  The implications of this work include sleep hygiene recommendations for increasing duration and quality of sleep, as well as future research with respect to electronic device usage, social media participation, caffeine consumption, and sport engagement in female early adolescent athletes.

Relationships of Bone Mineral Variables with Body Composition, Blood Hormones and Training Volume in Adolescent Female Athletes with Different Loading Patterns

The aim of this investigation was to determine the relationships of areal bone mineral density (aBMD) and content (BMC) with body composition, blood hormone and training load variables in adolescent female athletes with different loading patterns. The participants were 73 healthy adolescent females (14–18 years), who were divided into three groups: rhythmic gymnasts (RG; n = 33), swimmers (SW; n = 20) and untrained controls (UC; n = 20). Bone mineral and body compositional variables were measured by dual-energy X-ray absorptiometry, and insulin-like growth factor-1 (IGF-1), estradiol and leptin were analyzed from blood samples. In addition, aerobic performance was assessed by a peak oxygen consumption test. No differences (p > 0.05) in weekly training volume were observed between rhythmic gymnasts (17.6 ± 5.3 h/week) and swimmers (16.1 ± 6.9 h/week). Measured areal bone mineral density and bone mineral content values were higher in rhythmic gymnasts compared with other groups (p < 0.05), while no differences (p > 0.05) in measured bone mineral values were seen between swimmers and untrained control groups. Multiple regression models indicated that IGF-1 alone explained 14% of the total variance (R² × 100) in lumbar spine aBMD, while appendicular muscle mass and training volume together explained 37% of the total variance in femoral neck BMC in the rhythmic gymnast group only. In swimmers, age at menarche, estradiol and appendicular muscle mass together explained 68% of the total variance in lumbar spine BMC, while appendicular muscle mass was the only predictor and explained 19 to 53% of the total variance in measured bone mineral values in untrained controls. In conclusion, adolescent rhythmic gymnasts with specific weight-bearing athletic activity present higher areal bone mineral values in comparison with swimmers and untrained controls. Specific training volume together with appendicular muscle mass influenced cortical bone development at the femoral neck site of the skeleton in rhythmic gymnasts, while hormonal values influenced trabecular bone development at the lumbar spine site in both athletic groups with different loading patterns.

A Longitudinal Study of Bone Mineral Accrual during Growth in Competitive Premenarcheal Rhythmic Gymnasts

The purpose of this investigation was to study whether prolonged competitive rhythmic gymnastics training influenced bone mineral accrual in premenarcheal girls. Eighty-nine girls (45 rhythmic gymnasts [RG] and 44 untrained controls [UC]) between 7 and 9 years of age were recruited and measured annually for four years (not all participants were measured at every occasion). Dual energy x-ray absorptiometry was used to assess the development of whole body (WB), femoral neck (FN) and lumbar spine (LS) bone mineral content (BMC). In addition, body composition, blood adipokine and jumping performance characteristics were obtained. For longitudinal analyses, hierarchical mixed-effects models were constructed to predict differences in the development of WB, FN and LS BMC between RG and UC groups, while accounting for differences in body composition, blood adipokine and jumping performance values. It appeared that from 8 years of age, RG had lower (p < 0.05) fat mass and leptin values, and higher (p < 0.05) jumping performance measures in comparison with UC girls. Hierarchical mixed-effects models demonstrated that RG had 71.9 ± 12.0, 0.23 ± 0.11 and 1.39 ± 0.42 g more (p < 0.05) WB, FN and LS BMC, respectively, in comparison with UC girls. In addition, WB, FN and LS BMC increased more (p < 0.05) between 7 to 12 years of age in RG girls in comparison with UC. In conclusion, these findings suggest that the prolonged exposure to competitive rhythmic gymnastics trainings in premenarcheal girls is associated with greater bone mineral accrual despite lower body fat mass and leptin values.

Functional hypothalamic and drug-induced amenorrhea: an overview

BACKGROUND

Functional hypothalamic amenorrhea (FHA) is a form of chronic anovulation not due to identifiable organic causes and with adverse health consequences. The identification of women with this disorder or the precocious identification of women at risk is based on the knowledge of lifestyle risk factors or behaviors such as stress, weight loss, and excessive physical exercise that are known to negatively impact gonadal axis activity.

METHODS

In this overview, we described the most common forms of FHA, in particular stress-induced amenorrhea and overtraining-induced amenorrhea. In addition, although its mechanisms can differ from those involved in FHA, we reviewed the available literature on drug-induced amenorrhea, highlighting the clear connection between this condition and psychoactive drugs such as antipsychotics, antidepressants and anti-epilectics thus raising concern about the role that the abuse of substances such as opioids or alcohol can possibly have on the growing unexplained infertility of the female population.

Adipose tissue and reproductive health

The understanding of adipose tissue role has evolved from that of a depot energy storage organ to a dynamic endocrine organ. While genetics, sexual phenotype and sex steroids can impact the mass and distribution of adipose tissue, there is a counter-influence of white adipocytes on reproduction. This primarily occurs via the secretion of adipokines, the most studied of which- leptin and adiponectin- are highlighted in this article. Leptin, the "satiety hormone" primarily acts on the hypothalamus via pro-opiomelanocortin (POMC), neuropeptide Y (NPY), and agouti-related peptide (AgRP) neurons to translate acute changes in nutrition and energy expenditure, as well as chronic adipose accumulation into changes in appetite and potentially mediate insulin resistance via shared pathway and notably impacting reproductive health via influence on GnRH secreting neurons. Meanwhile, adiponectin is notable for its action in mediating insulin sensitivity, with receptors found at every level of the reproductive axis. Both have been examined in the context of physiologic and pathologic reproductive conditions. Leptin has been shown to influence puberty, pregnancy, hypothalamic amenorrhea, and lipodystrophy, and with a potential therapeutic role for both metabolic and reproductive health. Adiponectin mediates the relative state of insulin resistance in pregnancy, and has been implicated in conditions such as polycystic ovary syndrome and reproductive malignancies. There are numerous other adipokines, including resistin, visfatin, chemerin and retinol binding protein-4, which may also play roles in reproductive health and disease states. The continued examination of these and other adipokines in both normal reproduction and reproductive pathologies represents an important avenue for continued study. Here, we seek to provide a broad, yet comprehensive overview of many facets of these relationships and highlight areas of consideration for clinicians and future study.

Physical activity for primary dysmenorrhea: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Primary dysmenorrhea is cramping abdominal pain associated with menses. It is prevalent, affects quality of life, and can cause absenteeism. Although evidence-based medical treatment options exist, women may not tolerate these or may prefer to use nonmedical treatments. Physical activity has been recommended by clinicians for primary dysmenorrhea since the 1930s, but there is still no high-quality evidence on which to recommend its use.

OBJECTIVE

We sought to determine the effectiveness of physical activity for the treatment of primary dysmenorrhea.

STUDY DESIGN

Systematic literature searches of MEDLINE, Embase, Cochrane, Web of Science, CINAHL, PsycINFO, SPORTDiscus, PEDro, Allied and Complimentary Medicine Database, World Health Organization International Clinical Trials Registry Platform, Clinicaltrials.gov, and OpenGrey were performed, from database inception to May 24, 2017. Google searches and citation searching of previous reviews were also conducted. Studies were selected using the following PICOS criteria: participants were nonathlete females experiencing primary dysmenorrhea; intervention was physical activity delivered for at least 2 menstrual cycles; comparator was any comparator; outcomes were pain intensity or pain duration; and study type was randomized controlled trials. Study quality was assessed using the Cochrane risk of bias tool. Random effects meta-analyses for pain intensity and pain duration were conducted, with prespecified subgroup analysis by type of physical activity intervention. Strength of the evidence was assessed using GRADE.

RESULTS

Searches identified 15 eligible randomized controlled trials totaling 1681 participants. Data from 11 studies were included in the meta-analyses. Pooled results demonstrated effect estimates for physical activity vs comparators for pain intensity (-1.89 cm on visual analog scale; 95% CI, -2.96 to -1.09) and pain duration (-3.92 hours; 95% CI, -4.86 to -2.97). Heterogeneity for both of these results was high and only partly mitigated by subgroup analysis. Primary studies were of low or moderate methodological quality but results for pain intensity remained stable during sensitivity analysis by study quality. GRADE assessment found moderate-quality evidence for pain intensity and low-quality evidence for pain duration.

CONCLUSION

Clinicians can inform women that physical activity may be an effective treatment for primary dysmenorrhea but there is a need for high-quality trials before this can be confirmed.

Menstrual irregularity and use of oral contraceptives in female adolescent athletes in Swedish National Sports High Schools

Objective Female adolescent athletes seem to use oral contraceptives (OCs) in the same proportion as the general population. In athletes not using OCs, menstrual irregularity (MI) is reported to be common but there are few studies of MI in adolescent athletes. The aim of the study was to survey menarche, menstrual irregularity and use of OCs in adolescent athletes in the National Sports High Schools in Sweden. A further aim was to study the associations between current sport injury and menstrual irregularity as well as use of OCs. Subjects Two hundred and ninety-eight female adolescent athletes at Swedish National Sports High Schools. Methods A web-based questionnaire containing questions related to menstrual status, contraception and current injury. Results One third (32.6%) of the athletes used OCs and of the remaining athletes 31.8% had MI. The group of athletes with MI had a significantly (p = 0.038; Cohen's d, 0.32) lower BMI and consisted of a significantly (p = 0.043) higher proportion of endurance athletes. OC users were less likely to participate in endurance sports compared to non-OC users (p = 0.024). Current injury was equally distributed in the OC and the non-OC group but athletes with MI had fewer sports injuries compared to eumenorrheic women. Conclusion OCs are frequently used among athletes at Swedish National Sports High Schools. OC users were less likely to participate in endurance sports compared to non-OC users. MI was common and athletes with MI had lower BMI compared to eumenorrheic athletes. Sports injuries were not associated with use of OC and eumenorrheic athletes had a higher proportion of current injury.

Committee Opinion No.702: Female Athlete Triad

The female athlete triad is a medical condition observed in physically active females involving three components: 1) low energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone density. An individual does not need to show clinical manifestations of all three components of the female athlete triad simultaneously to be affected by the condition. Consequences of these clinical conditions may not be completely reversible, so prevention, early diagnosis, and intervention are critical. All athletes are at risk of the female athlete triad, regardless of body build or sport. All active females should be assessed for components of the triad and further evaluation should be performed if one or more components are identified. The obstetrician-gynecologist has the opportunity to screen athletes for components of the female athlete triad at comprehensive visits for preventive care. Using the menstrual cycle as a vital sign is a useful tool for identifying athletes at risk of female athlete triad and should be an integral part of the preparticipatory sports physical. The goal of treatment for those diagnosed with female athlete triad is restoration of regular menses as a clinical marker of reestablishment of energy balance and enhancement of bone mineral density. The female athlete triad is a result of energy imbalance; thus, adjusting the energy expenditure and energy availability is the main intervention. Pharmacologic treat-ment may be considered when nonpharmacologic treatment has failed. A team approach involving the patient, obstetrician-gynecologist, sports nutritionist, coaches, parents, and mental health care provider, if indicated, is optimal.

The female athlete triad: special considerations for adolescent female athletes

The number of adolescent girls participating in sports has dramatically increased throughout the last few decades. In the early 1990's, an association between amenorrhea, osteoporosis, and disordered eating was recognized and eventually labeled the 'Female Athlete Triad'. In 1997, the Task Force on Women's Issues of American College of Sports Medicine (ACSM) published a position statement on this triad of conditions that were becoming increasingly more prevalent amongst female athletes. Initially, the 'Female Athlete Triad' was characterized by disordered eating, amenorrhea, and osteoporosis. However, as the number of adolescent female athletes has continued to grow, there has been further research and investigation into this field and the triad has evolved in definition. It is essential for all health care practitioners and other professionals who care for adolescent athletes to be attentive to the clinical signs, detection, evaluation, and management of the female athlete triad, as the sequelae can have a significant impact on the health and well-being of a young person both in the short and long-term.

Participation in sports in relation to adolescent growth and development

Puberty is defined by physical growth, development of secondary sexual characteristics, and maturation of psychosocial skills. The initiation and rate of progression of pubertal events varies among adolescents, but pubertal changes occur in a predictable stepwise manner. Factors including individual differences in physical and psychosocial development, stage of development based on age (early, middle, and late), and the rate of pubertal development, may all contribute to the way in which adolescents experience sports activities. During adolescence, gender differences also become more apparent and may significantly impact sports participation. As practitioners evaluate overall development and adolescent readiness for sports participation, they should consider the different areas of development including: somatic, neurologic, cognitive, psychosocial-function in an integrated and interdependent approach.

Protecting Bone Health in Pediatric Rheumatic Diseases: Pharmacological Considerations

Bone health in children with rheumatic conditions may be compromised due to several factors related to the inflammatory disease state, delayed puberty, altered life style, including decreased physical activities, sun avoidance, suboptimal calcium and vitamin D intake, and medical treatments, mainly glucocorticoids and possibly some disease-modifying anti-rheumatic drugs. Low bone density or even fragility fractures could be asymptomatic; therefore, children with diseases of high inflammatory load, such as systemic onset juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, and those requiring chronic glucocorticoids may benefit from routine screening of bone health. Most commonly used assessment tools are laboratory testing including serum 25-OH-vitamin D measurement and bone mineral density measurement by a variety of methods, dual-energy X-ray absorptiometry as the most widely used. Early disease control, use of steroid-sparing medications such as disease-modifying anti-rheumatic drugs and biologics, supplemental vitamin D and calcium, and promotion of weight-bearing physical activities can help optimize bone health. Additional treatment options for osteoporosis such as bisphosphonates are still controversial in children with chronic rheumatic diseases, especially those with decreased bone density without fragility fractures. This article reviews common risk factors leading to compromised bone health in children with chronic rheumatic diseases and discusses the general approach to prevention and treatment of bone fragility.

Effects of intensive training on menstrual function and certain serum hormones and peptides related to the female reproductive system

The aim of this study was to assess the effects of intensive training on menstrual function and related serum hormones and peptides.Forty female participants who attended a training course for an officer at the Korea Third Military Academy, and had regular menstrual periods were enrolled. Menstrual questionnaires and fasting blood samples were collected before entry and at 4-week intervals for 8 weeks. The levels of corticotropin-releasing hormone (CRH), cortisol, prolactin, endorphin-β, neuropeptide Y (NPY), leptin, orexin-A, ghrelin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), thyrotropin (TSH), and thyroxine (T4) were determined.Body mass index and waist circumference decreased during the training course. Intensive training of military cadets resulted in changes of menstruation and related biomarkers. The levels of CRH, endorphin-β, NPY, orexin-A, ghrelin, E2, and T4 decreased substantially, and cortisol, prolactin, and TSH increased. Seventy percent of participants with regular menstrual periods before developed irregular during the training course. Participants were then categorized into 2 groups: those with regular menstruation (n = 12) and those with irregular menstruation (n = 28). The levels of hormones and peptides were not different between the 2 groups.In conclusion, cortisol, prolactin, and TSH level increased but levels of CRH, endorphin-β, NPY, orexin-A, ghrelin, E2, and T4 decreased throughout the training. Moreover, the levels were not different between participants with normal menstruation and those with irregular menstruation. Further research should extend these findings by investigating the exact mechanism by which high exercise levels, including intensive training, interfere with regular menstruation.

Disordered eating in French high-level athletes: association with type of sport, doping behavior, and psychological features

PURPOSE

Over the last few years, disordered eating in athletes has received increasing attention. According to several studies, athletes could be more vulnerable to disordered eating and some characteristics specific to the athletic community could be in favour of an increased risk of poor body image and disturbed eating habits in athletes. However, the literature is sparse and some methodological issues in studies have been pointed out. In this context, we aimed at determining the prevalence of disordered eating in French high-level athletes using clinical interviews of three different clinicians and identifying what are the factors associated with disordered eating in athletes.

METHODS

In France, all athletes registered on the French high-level list have to undergo a yearly evaluation. Data collected during the somatic assessment, the dietary consultation, and the psychological of the yearly evaluation were used. Multivariate analysis was performed for identification of factors associated with disordered eating.

RESULTS

Out of the 340 athletes included, 32.9% have been detected with a disordered eating. They were difficult to detect by clinicians, as usual criteria did not seem to be reliable for athletes. Competing in sports emphasizing leanness or low body weight was associated with disordered eating; however, gender was not.

CONCLUSION

These results highlight the need for the development of specific screening tools for high-level athletes. Furthermore, the identification of factors associated with disordered eating could improve early detection and prevention program effectiveness.

Running Injuries During Adolescence and Childhood

The popularity of running among young athletes has significantly increased over the past few decades. As the number of children who participate in running increases, so do the potential number of injuries to this group. Proper care of these athletes includes a thorough understanding of the unique physiology of the skeletally immature athlete and common injuries in this age group. Treatment should focus on athlete education, modification of training schedule, and correction of biomechanical deficits contributing to injury. Early identification and correction of these factors will allow a safe return to running sports.

Female athletes and menstrual disorders: a pilot study

BACKGROUND

There is a greater incidence of menstrual disorders in female athletes than in their sedentary counterparts. The menstrual disorder is reported in female athletes suffering from athletic triad syndrome, while few data in those free of this syndrome are available. The study aims to ascertain the presence of menstrual disorders and the eventual relationship with myocardial performance in female athletes practicing different sports.

METHODS

A sample of 64 subjects aged 18.5±2 was selected and divided into 3 groups (37 subjects practicing rhythmic gymnastics, 11 swimmers, and 16 volleyball players). All underwent echocardiography, biompendance analysis, and answered a questionnaire.

RESULTS

All anthropometrics parameters were normal. Few athletes reported menstrual disorders. No association between the presence of menstrual disorders and BMI. All echo results were within the normal range. Cardiac Mass Index (CMI) was normal for all athletes despite in swimmers significantly higher values (90.64±14.9 g/m2) compared to the volleyball players (78.25±14.0 g/m2; p<.04) and rhythmic gymnasts (77.89±13.4 g/m2; p<.009) were found.

CONCLUSIONS

Despite menstrual disorders are represented among female athletes, the eventual relationship with the sport practiced is not so evident. Questionnaire should be used to identify menstrual disorders in non-elite athletically active females.

Eating disorders, menstrual dysfunction, weight change and DMPA use predict bone density change in college-aged women

INTRODUCTION

There are limited longitudinal studies that have evaluated bone mineral density (BMD) changes in college-aged women. Our objective was to simultaneously evaluate factors influencing 4-year BMD change.

METHODS

This was a longitudinal cohort study of healthy, physically active women in the US Military Academy (n=91; average age=18.4years). Assessments over four years included: height, weight, calcium intake, physical fitness, menstrual function (annual number cycles), oral contraceptives (OCs) or depot-medroxyprogesterone acetate (DMPA) use, and eating disorder behavior (Eating Disorder Inventory; (EDI)). BMD was measured annually at the lumbar spine and total hip by dual X-ray absorptiometry and calcaneal BMD by PIXI. Slope of 4year BMD change at each skeletal site (spine total hip and calcaneus) was calculated for each woman.

RESULTS

BMD gains occurred at the spine in 50% and the hip in 36% of women. In unadjusted analyses, spine bone gain was positively related to menstrual cycle frequency (p=0.04). Spine and hip BMD loss occurred in those using DMPA (p<0.01) and those with the highest EDI quartile scores (p<0.05). BMD change was unrelated to OC use. Hip and calcaneus BMD decreased with weight loss (average 4.8+2.2lb/year) as compared to those with stable weight/weight gain (p<0.05). In multivariable analysis, spine BMD increase was significantly related to African American (AA) race, normal EDI score and normal menses. Hip BMD increase was related to AA race, weight increase and normal menses. DMPA use was associated with spine, hip, and calcaneus bone loss.

CONCLUSION

On average, BMD may modestly increase in college-aged women, in the absence of risk factors. However, risk factors including subclinical eating disorders, weight loss, menstrual dysfunction and DMPA use can have significant detrimental effects on BMD in young healthy physically active women.