Introduction to menstrual disturbances in athletes

Disordered eating, menstrual irregularity, and musculoskeletal injury in high school athletes: a comparison of oral contraceptive pill users and nonusers

BACKGROUND

The female athlete triad is the interrelatedness of energy availability, menstrual function, and bone density. Currently, limited information about triad components and their relationship to musculoskeletal injury in the high school population exists. In addition, no study has specifically examined triad components and injury rate in high school oral contraceptive pill (OCP) users.

HYPOTHESIS

To compare the prevalence of disordered eating (DE), menstrual irregularity (MI), and musculoskeletal injury (INJ) among high school female athletes in OCP users and non-OCP users.

STUDY DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

Level 2.

METHODS

The subject sample completed the Eating Disorder Examination-Questionnaire (EDE-Q) and Healthy Wisconsin High School Female Athletes Survey (HWHSFAS). Athletes were classified by OCP use and sport type.

RESULTS

Of the participants, 14.8% reported OCP use. There was no difference in MI and INJ among groups. The prevalence of DE was significantly higher among OCP users as compared with non-OCP users; OCP users were twice as likely to meet the criteria for DE (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.20-5.09). OCP users were over 5 times more likely to have a global score that met criteria for DE as compared with non-OCP users (OR, 5.36; 95% CI, 1.92-14.89).

CONCLUSION

Although MI and INJ rates are similar among groups, there is a higher prevalence of DE among high school female athletes using OCPs as compared with non-OCP users.

CLINICAL RELEVANCE

Because OCP users may be menstruating, clinicians may fail to recognize the other triad components. However, DE exists in the menstruating OCP user. As such, clinicians should be vigilant when screening for triad components in high school OCP users, particularly DE.

Menstrual irregularity and musculoskeletal injury in female high school athletes

CONTEXT

The female athlete triad describes the interrelatedness of energy availability, menstrual function, and bone density. Although associations between triad components and musculoskeletal injury (INJ) have been reported in collegiate athletes, limited information exists about menstrual irregularity (MI) and INJ in the high school population.

OBJECTIVE

To determine the prevalence of and relationship between MI and INJ in high school athletes.

DESIGN

Cross-sectional study.

SETTING

High schools.

PATIENTS OR OTHER PARTICIPANTS

The sample consisted of 249 female athletes from 3 high schools who competed in 33 interscholastic, school-sponsored sport teams, dance teams, and cheerleading or pom-pon squad during the 2006-2007 school year. Each athlete remained on the roster throughout the season.

MAIN OUTCOME MEASURE(S)

Participants completed a survey regarding injury type, number of days of sport participation missed, and menstrual history in the past year.

RESULTS

The prevalences of M I and INJ were 19.7% and 63.1 %, respectively. Athletes who reported MI sustained a higher percentage of severe injuries (missing ≥ 22 days of practice or competition) than did athletes who reported normal menses. Although the trend was not significant, athletes with MI were almost 3 times more likely to sustain an injury resulting in 7 or more days of time lost from sport (odds ratio = 2.7, 95% confidence interval = 0.8, 8.8) than those who sustained an injury resulting in 7 or fewer days of time lost.

CONCLUSIONS

The incidences of MI and INJ in this high school population during the study period were high. Athletes who reported MI sustained a higher percentage of severe injuries than did athletes who reported normal menses. Education programs to increase knowledge and improve management of MI and its potential effects on injury in female high school athletes are warranted.

Sense and nonsense in metabolic control of reproduction

An exciting synergistic interaction occurs among researchers working at the interface of reproductive biology and energy homeostasis. Reproductive biologists benefit from the theories, experimental designs, and methodologies used by experts on energy homeostasis while they bring context and meaning to the study of energy homeostasis. There is a growing recognition that identification of candidate genes for obesity is little more than meaningless reductionism unless those genes and their expression are placed in a developmental, environmental, and evolutionary context. Reproductive biology provides this context because metabolic energy is the most important factor that controls reproductive success and gonadal hormones affect energy intake, storage, and expenditure. Reproductive hormone secretion changes during development, and reproductive success is key to evolutionary adaptation, the process that most likely molded the mechanisms that control energy balance. It is likely that by viewing energy intake, storage, and expenditure in the context of reproductive success, we will gain insight into human obesity, eating disorders, diabetes, and other pathologies related to fuel homeostasis. This review emphasizes the metabolic hypothesis: a sensory system monitors the availability of oxidizable metabolic fuels and orchestrates behavioral motivation to optimize reproductive success in environments where energy availability fluctuates or is unpredictable.

Female athlete triad and stress fractures

Stress fractures are a common occurrence in athletes, and the incidence of stress fractures in female Division 1 collegiate athletes is double that of men. Hormonal influences on bone and bone morphology may influence the risk for fracture. A high level of suspicion and special imaging procedures allow for accurate diagnosis of these fractures. In stress fractures that are associated with the female athlete triad, addressing the three aspects of the triad--eating disorders, amenorrhea, and osteoporosis--are critical for successful treatment. Preparticipation screening for the presence of signs of the female athlete triad by monitoring weight, energy level, menstrual cycles, and bone mineral density may help to prevent the occurrence of stress fractures in this population.

Normalization of bone density in a previously amenorrheic runner with osteoporosis

PURPOSE

To examine changes in bone mineral density (BMD) and bone mineral content (BMC) in relation to pharmacological and nutritional interventions in a distance runner diagnosed with the female athlete triad of disordered eating, amenorrhea, and osteoporosis.

METHODS

BMD of the lumbar spine (L2-L4) and total proximal femur were measured from ages 22.9 to 30.8 yr using dual x-ray absorptiometry (DXA).

RESULTS

At age 22.9, the patient presented with primary amenorrhea, low body weight (BMI: 15.8 kg.m(-2)), and low BMD in the spine (74% of normal, T score: -2.50) and hip (80% of normal, T score: -1.54). For the next 2 yr, the patient took oral contraceptives to induce menses, but continued to maintain a low weight. Her BMD remained unchanged. At age 25.1 yr, she decided to gain weight and improve her nutrition, resulting in small increases in spinal BMD (+1.1%), hip BMD (+1.6%), and total body BMC (+7.6%) in 4 months. From ages 25.4 to 30.8 yr, the patient continued to gain weight, eventually reaching a healthy BMI of 21.3 kg.m(-2); correspondingly, since baseline, her BMD had increased 25.5% in the spine and 19.5% in the hip, bringing her BMD to within normal values (spine: 94% of normal, hip: 96% of normal).

CONCLUSION

This case illustrates that even if skeletal development is interrupted in adolescence, there is still the potential for "catch-up" in BMD well into the third decade of life. Reversal of large bone density deficits in this patient can be attributed to improved nutrition and weight gain but not to hormone replacement.