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2014 Female Athlete Triad Consensus Statement on Guidelines for Treatment and Return to Play

Female Athlete Triad Picture

This is the first of a four-part series that will present the diagnosis, treatment and return to play recommendations recently published in the British Journal of Sports Medicine on the Female Athlete Triad (BJSM, 2014. The 2014, Feb:48(4),289).  The new 2014 Consensus Statement was developed by experts from the Female Athlete Triad Coalition: an international consortium devoted to the care and health of the female athlete.

The 2014 Consensus Statement represents a set of recommendations and clinical guidelines for physicians, athletic trainers, and other health care providers for the screening, diagnosis, and treatment of the Female Athlete Triad. The Triad has been well established as a medical condition often observed in physically active girls and women, and involves three components, (1) low energy availability with or without disordered eating, (2) menstrual dysfunction, and (3) low bone mineral density. Female athletes often present with one or more of the three Triad components, and early intervention is essential to prevent its progression to clinical eating disorders, amenorrhea and osteoporosis. Confirming the Triad in an athlete does not require finding all three components; indeed the presence of one Triad component confirms its existence.

The 2014 Consensus Statement provides clear recommendations for clearance and return to play.  These clinical recommendations are the first official guidelines published on these issues. A risk stratification point system is proposed to assist the clinician and take into account magnitude of risk in decision-making regarding sport participation, clearance and return to play. The treatment guidelines and return-to-play recommendations proposed are based on published literature available as of 2014, with consensus from an international team of 18 experts that convened at two consensus meetings held in 2012 and 2013 [ 1st (2012, San Francisco, CA, USA) and 2nd (2013, Indianapolis, IN, USA) International Symposia on the Female Athlete Triad].

A NEW TRIAD MODEL

In 2007, the Triad was re-defined as a syndrome of low energy availability (EA) with or without disordered eating, functional hypothalamic amenorrhea and osteoporosis. EA is defined conceptually and behaviorally as the amount of dietary energy remaining after exercise for all other physiological functions each day.  At the “healthy” end of the model, each Triad component is optimized, (e.g., EA meets total energy expenditure, reproductive and bone health needs; ovulatory menstrual cycles are maintained; and bone mass is normal).  At the “unhealthy” end, each Triad component presents the clinical endpoints of the syndrome, including low energy availability with or without disordered eating (DE), amenorrhea and osteoporosis.

SCREENING TIPS

Although there is limited evidence related to the efficacy of screening questions, the Consensus Panel recommended that female athletes undergo annual screening with a Triad-specific self-report questionnaire, followed by a more in-depth evaluation if the athlete has, or is at risk for, any Triad component. While such screening is most typically completed at the collegiate level, the Panel recommended screening for younger athletes, including high school student-athletes.

A major point that the Panel emphasized is that existence of any one Triad component should prompt more thorough investigation for the others. The Triad Consensus Panel recommends asking the following screening questions at the time of the sport pre-participation evaluation.

Triad Consensus Panel Screening Questions


  • Have you ever had a menstrual period?
  • How old were you when you had your first menstrual period?
  • When was your most recent menstrual period?
  • How many periods have you had in the last 12 months?
  • Are you presently taking any female hormones (estrogen, progesterone, birth control pills)?
  • Do you worry about your weight?
  • Are you trying to or has anyone recommended that you gain or lose weight?
  • Are you on a special diet or do you avoid certain types of foods or food groups?
  • Have you ever had an eating disorder?
  • Have you ever had a stress fracture?
  • Have you ever been told you have low bone density (osteopenia or osteoporosis)?

 

DIAGNOSIS OF THE TRIAD

General Comments: Following screening, accurate diagnosis of any of the Triad disorders depends on a thorough evaluation of the student-athlete by the team physician and other members of the health care team. Members of the team should include a physician, a sports dietitian (a registered dietitian, who preferably is a board certified specialist in sports dietetics - CSSD), and a mental health professional if the athlete has DE or a clinical eating disorder (ED). Other members of the team may include a strength and conditioning specialist, certified athletic trainer and medical consultants.

How is low EA diagnosed? Low EA cannot be diagnosed by estimating energy balance because athletes in a negative energy balance may experience a suppression of physiological functions that restores energy balance and weight stability. As a first pass, overt signs of low EA can be indicated by low energy stores such as a body mass index (BMI) less than 17.5 kg/m2, or in adolescents less than 85 percent of expected body weight. In adolescents, absolute BMI cut offs should not be used. When body weight is not particularly low, more detailed information regarding food intake and energy expenditure is necessary to diagnose low EA. Other markers of low EA in the absence of DE and recent weight loss, include physiological signs of adaptation to chronic energy deficiency such as reduced resting metabolic rate (RMR), low triiodothyronine (low T3), and a ratio of measured RMR/predicted RMR less than 0.90.

Energy availability is defined as energy intake (kcals) minus exercise energy expenditure (kcals), divided by kg of fat-free mass or lean body mass. The Panel noted that outside the laboratory, determination of EA is difficult and is dependent on less precise methods. Strategies to estimate dietary intake include dietary logs, 24-hour dietary recall and food-frequency questionnaires. Actual estimates of energy expenditure can be accomplished using heart rate monitors and accelerometers, but practical estimates of exercise energy expenditure are also available, and are dependent on self-report.

There are numerous web-based calculators of exercise energy expenditure; however, the 2011 Compendium of Physical Activities can be used, whereby kilocalories of energy expenditure = metabolic equivalent of task (MET) x weight in kilograms x duration of activity in hours (although in athletes, expenditure may be underestimated). The third component of the EA equation is kilograms of fat-free mass, which is obtained from measurement of body weight in kilograms and from an estimate of body fat. Various methods can be used to estimate body fat. Dual-energy X-ray absorptiometry (DXA) is a precise method. Other clinically accessible methods include air-displacement plethysmography (Bod Pod), skin fold measurements and bioelectrical impedance. Having gathered the aforementioned data, one can access the EA Calculator to estimate EA. Physically active women should aim for at least 45 kcal/kg FFM/day of energy intake to ensure adequate EA for all physiologic functions.

How is amenorrhea diagnosed? Student-athletes and physically active women presenting with primary or secondary amenorrhea require evaluation to rule out pregnancy and endocrinopathies since no single blood test can confirm a diagnosis. The diagnosis of functional hypothalamic amenorrhea (FHA) – a cessation of menstruation for more than 90 days – in athletes secondary to low EA is a diagnosis of exclusion. An algorithm for the diagnosis of primary/secondary amenorrhea can be viewed in the full paper.  

How is low BMD diagnosed? The Panel utilized definitions published by the International Society of Clinical Densitometry (ISCD) for low bone mineral density (BMD) and osteoporosis in children and adolescents, and for premenopausal women, as well as American College of Sports Medicine (ACSM) suggested criteria for female athletes involved in regular weight bearing sports. Criteria are described in the full paper for who and what site should be considered for a DXA scan and how often DXA should be performed.

Definition of low BMD and osteoporosis in children and adolescents (ages 5-19)


  • The diagnosis of osteoporosis in children and adolescents requires the presence of both a clinically significant fracture history AND low bone mineral content (BMC) or low bone mineral density (BMD)
    • A clinically significant fracture history is one or more of the following:
      • Long bone fracture of the lower extremities
      • Vertebral compression fracture
      • Two or more long-bone fractures of the upper extremities
  • Low BMC or BMD* is defined as a BMC or areal BMD Z-score that is ≤-2.0, adjusted for age, gender and body size, as appropriate.

*ACSM defines low BMC or BMD as a Z-score that is less than-1.0 in female athletes in weight-bearing sports.

Definition of low BMD and osteoporosis in premenopausal women


  • The diagnosis of osteoporosis in premenopausal women cannot be diagnosed on the basis of BMD alone.
  • A BMD Z-score of ≤ -2.0* is defined as “below the expected range for age.”
  • A BMD Z-score above -2.0 is “within the expected range for age.”
  • Osteoporosis is diagnosed if there is a BMD Z-score of ≤-2.0 plus secondary causes of osteoporosis.

 

The Panel agreed that the frequency of BMD assessment by DXA will depend on the initial BMD and ongoing clinical status of the athlete. We agree with the ISCD 2013 guidelines that repeat DXA screening should be obtained when the expected change in BMD Z-scores equals or exceeds the least significant change.  Those with definitive indications for DXA testing may require BMD testing every 1 to 2 years to determine if there is ongoing bone loss, and to evaluate treatment.

Next month, part two of this four-part series will discuss the health consequences of the Triad. This article will also cover the effects of the Triad on athletic performance.

About the Female Athlete Triad Coalition

The Female Athlete Triad Coalition, a non-profit 501(c)(3) organization, represents key medical, nursing, athletic, and sports medicine groups, as well as concerned individuals who come together to promote optimal health and well-being for female athletes and active girls and women. The Coalition strives to prevent the Female Athlete Triad through advocacy, education, international leadership, public policy and research. Formed in 2002, the Female Athlete Triad Coalition is a group of national and international organizations dedicated to addressing unhealthy eating behaviors, hormonal irregularities and bone health among female athletes and active women. For more information, visit www.femaleathletetriad.org.

The Consensus Paper was sponsored by the Female Athlete Triad Coalition: An International Consortium, and endorsed by Female Athlete Triad Coalition, American College of Sports Medicine and the American Medical Society for Sports Medicine

About Mary Jane De Souza, PhD., FACSM

Mary Jane De Souza, PhD., FACSM is a professor in the Department of Kinesiology and Physiology at Pennsylvania State University and the Director of the Women's Health and Exercise Lab. She is the Past President, Female Athlete Triad Coalition. Dr. De Souza’s research has focused on the physiological basis of how exercise modulates reproductive function and bone health through alterations in energy balance. Dr. De Souza has published over 100 peer-reviewed papers, book chapters, monographs and letters to the editor.