​Kembara Xtra - Medicine - Female Athlete Triad

​Kembara Xtra - Medicine - Female Athlete Triad 
Introduction 
Low energy availability (with or without eating disorders), menstrual dysfunction, and low bone mineral density (LBMD) constitute a syndrome.
In 1992, the female athlete triad was defined as low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density (LBMD). In 2007, the American College of Sports Medicine (ACSM) revised the definition to include the following components:
In 2014, the Female Athlete Triad Coalition (TC) released a consensus statement that mainly agreed with the ACSM update and included numerous recommendations (which will be briefly detailed in the following section of this review).
2014 IOC position statement veered off-course to address "Relative Energy Deficiency in Sport" (RED-S).
The broader physiologic impacts of energy shortage, from growth to cardiovascular health, are emphasized.
- Stressed the prevalence of a male-specific condition
Since then, arguments have been made for and against the traditional TC model and RED-S. Since then, TC authors have published articles proposing the concept of the male athlete triad, in which they argue that the RED-S movement is merely "rebranding" 30+ years of triad research.
Men appear to have a higher threshold to meet inadequate energy availability, and this may be linked to male reproductive and skeletal problems. More research into the male triad is required.

The Prevalence of Epidemiology
Prevalence ranges from 0% to 16% when using all three criteria (eczema/acne, menstrual dysfunction, LBMD). For the second set of requirements, we need between 25% and 50%. Criteria for a third: between 16 and 60%.
Higher rates of eating disorders compared to the general population.

Menstrual problems: Secondary amenorrhea is more common among female athletes than the general population (up to 60% vs. 2-5%).
LBMD: The prevalence of osteopenia (T-score between 1 and 2) using the WHO criteria for LBMD varies from 0% to 40% among female athletes, compared to 12% in the general population.
More athletes in lean sports, like swimming and cross country, experience a full triad than in non-lean sports, such volleyball and softball, where the rate is between 0% and 2%.

Causes and Mechanisms of Illness 

Energy availability is measured as food consumed minus calories burned while exercising.
– It's possible to intentionally or unintentionally cause low energy availability. Increasing exercise or dealing with an eating disorder are two good examples.
When resources are scarce, organisms prioritize other, more essential processes above reproduction. These include thermoregulation and cellular maintenance. In particular, menstruation dysfunction is caused by a lack of energy, which reduces the frequency of pulses of the hormone luteinizing hormone (LH). Reduced bone formation and increased bone resorption can result in LBMD if ovulation and estrogen levels are suppressed in this way. Elements of triads can be found along a bidirectional spectrum in severity, from "healthy" to "unhealthy."
Even though there is only an inferred one-way relationship between different elements, it is crucial to note that they do exist as a trio.
Both menstruation dysfunction and LBMD have been linked to low energy availability, whether caused by an eating disorder or not.
LBMD might develop as a result of menstrual disruption (by way of hypoestrogenemia).
● Endothelial dysfunction and different lipid profiles also seem to be a result of limited energy availability.
Low energy availability is thought to have far-reaching physiological impacts; RED-S takes these into account. These effects can be seen in metabolic rate, growth and development, immunity, protein synthesis, hematologic, gastrointestinal, cardiovascular, and psychological systems.
The authors of the TC believe that RED-S could be plausible but is currently unsupported by evidence.

History of menstrual irregularities or amenorrhea; history of stress fractures or other recurring or nonhealing injuries; history of critical comments about eating or weight from parent or coach; history of depression; history of dieting; personality factors such as perfectionism and/or obsessiveness; overtraining; and inappropriate coaching behaviors.
Aesthetic sports requiring a lean body (ballet, figure skating, gymnastics, distance running, diving, and swimming) and combat sports (martial arts, wrestling) with weight categories. Weight checks, penalties for gaining weight, and a "win at any cost" mentality all raise the stakes.
Comorbid psychological conditions (anxiety, depression, and/or obsessivecompulsive disorder); a lack of family or social support; hard training hours; social isolation or entering a new setting (boarding school or college); an athlete with comorbid psychological conditions.

Researchers in Japan discovered that young athletes with the Triad were more likely to suffer a stress fracture than older athletes.

Safety Measures 

Educating student-athletes (from junior high to college), as well as their coaches, trainers, parents, and doctors. Young athletes are easily influenced, and it only takes one unfavorable comment or piece of unhealthy advice to lead to a lifetime of poor choices.
The American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Sports Medicine, and the American School of Sports Medicine all support routine screening as part of annual physicals and pre-participation exams.
There is an 11-question screening developed by the Female Athlete Triad Coalition that can be used in PP.

"red flag" disorders include: fractures, weight changes, weariness, amenorrhea, bradycardia, orthostatic hypotension, syncope, arrhythmias, electrolyte abnormalities, and depression, thus it's important to screen athletes who exhibit these symptoms.
The use of steroids, smoke, alcohol, and hyperthyroidism can all speed up bone loss and should be checked for.

Anorexia, bulimia, avoidant/restrictive food intake disorder, and other mental health issues like low self-esteem, depression, and anxiety are all linked to eating disorders.
LBMD increases the risk of stress fractures in athletes and may be irreversible in some cases. Because of this, menopausal women may experience a rise in fracture rates.


Diagnosis 
Women should be screened for the female athlete triad at their yearly sports physicals, as well as during routine checkups and acute visits if they have any concerns.


Exhibiting Past Events 

Examine the patient's menstrual history (including use of hormonal contraceptives), fracture history, and depressive symptoms. Examine the person's eating habits, weight fluctuations, and nutritional routine. A sports dietitian's nutritional analysis and food diary might be useful tools. Evaluate feelings about one's body, worries about gaining weight, weight swings, a family history of eating disorders, and the use of laxatives, diet pills, or enemas.

Analyses in the Clinic 
Common signs and symptoms include bradycardia, orthostatic hypotension, hypothermia, cold or cyanotic extremities, lanugo, parotid gland enlargement or tenderness, epigastric tenderness, eroded tooth enamel, and knuckle or hand calluses (Russell sign); height, weight, and BMI 17.5% kg/m2; 85% of expected body weight in adolescents; 10% weight loss in 1 month.
● Patients experiencing amenorrhea should have a pelvic exam performed to check for uterine anomalies and evaluate the efficacy of the patient's ejaculatory system. When estrogen levels are low, vaginal atrophy can occur.

Diagnosis by Difference 
Test subjects against the DSM-5 criteria for anorexia, bulimia, avoidant/restrictive food intake, and rumination disorders. Patients with amenorrhea should be evaluated for the following.
In utero
Thyroid malfunction and Cushing syndrome are examples of endocrine disorders.
Hypothalamic dysfunction: amenorrhea due to psychological stress, amenorrhea due to medicine, and Kallmann syndrome
Ovarian dysfunction includes polycystic ovary syndrome, premature ovarian failure, menopause, gonadal dysgenesis, Turner syndrome, ovarian tumor, and autoimmune illness; pituitary dysfunction includes prolactinoma, Sheehan syndrome, sarcoidosis, and empty sella syndrome.
Asherman syndrome, a lack of a uterus, and uterine malfunction

Initial Tests and Results (Lab, Imaging)
Thyroid stimulating hormone (TSH), calcium, 25-hydroxyvitamin D, urine, and a complete blood count with differential
Tests for hCG in the urine and FSH, LH, prolactin, and TSH in the blood can help diagnose secondary amenorrhea.
Patients with multiple metatarsal fractures should have alkaline phosphatase levels checked to rule out hypophosphatasia.
Exclusion of polycystic ovaries and virilizing ovarian malignancies by pelvic ultrasonography in patients with hyperandrogenism.
Electrocardiogram to rule out prolonged QT interval

Additional Evaluations & Cautious Thoughts
DEXA screening for bone mineral density uses a risk-stratification methodology. In patients with a history of stress fractures or minimal impact fractures, risk factors include a history of disordered eating, hypoestrogenism, amenorrhea, oligomenorrhea, and/or a history of eating disorders lasting longer than 6 months.

Management 
A group of experts in several fields, such as medicine, nutrition, and mental health, working together. Establish regular communication with your loved ones, coaches, and trainers.
Cognitive-behavioral therapy (CBT) has shown promise as a potential treatment for low energy levels.
Active women should aim for an EA of >45 kcal/kg of fat-free muscle mass per day, and initial treatment should focus on nonpharmacologic methods and be monitored for at least a year.

● Increasing calorie intake is the first step in achieving the body weight associated with regular menstruation (demonstrating recovery of adequate estrogen levels). BMI >18.5 or >90% of the projected weight are typically associated with this.

● If you can, try to get people to eat whole, balanced meals instead than relying just on supplements.

Aim for a daily calcium intake of 1,000–1,300 milligrams (mg).
Promote calcium-rich foods; if dietary consumption falls short, supplementation can help.
Vitamin D intake/supplementation should be at least 600 IU per day; 1,500-2,000 IU per day may be necessary to maintain blood levels between 32 and 50 ng/mL. 
Iron may play a role, if not for all athletes then certainly those with iron deficiency anemia. Care for those with maladaptive patterns of behavior.


Treatment with Medication First
Nonoral estrogen, mainly transdermal estrogen with oral cyclic progestin, is the first-line medicine for unsuccessful dietary management and/or worsening symptoms (especially fractures).

Position Two
Due to the risk of teratogenicity, other postmenopausal medicines such as bisphosphonates and denosumab should not be suggested in women of childbearing age.

Medication trials include rhIGF-1 (recombinant human IGF-1) and metreleptin (a synthetic counterpart of the hormone leptin).


Admission 

Bradycardia, severe orthostatic hypotension, substantial electrolyte imbalances, hypothermia, arrhythmias, and prolonged QT interval are all life-threatening signs that should prompt an evaluation of people with eating disorders.

Maintenance Treatment. Patients should be monitored on a regular basis by a team of healthcare professionals. Periodized exercise (2 weeks on, 2 weeks off) may be a healthy and pleasurable technique to increase strength without aggravating the Triad's symptoms.

Low energy availability (with focus on disordered eating), body mass index (BMI), delayed menarche, oligo/amenorrhea, lumbar spine musculoskeletal disorder (LBMD), and stress fracture were all taken into account in the first evidence-based clearance and return to play recommendations offered by the Female Athlete TC consensus statement.

A clinical assessment tool (CAT) developed by RED-S and revised in 2015 takes into account the same sorts of things as the TC clearance guide does but rates them on a "green," "yellow," and "red" scale instead.
● There is ongoing disagreement about the reliability of each group's CATs.

Adequate diet, calcium and vitamin D intake, and regular weight-bearing activity should be stressed to all young female patients.
Short- and long-term consequences of LBMD should be discussed with patients who come with 1 triad components.


Long-term and short-term outcomes for female athlete triad patients are treatment- and time-sensitive.
Without treatment, it is predicted that amenorrheic women will experience a yearly loss in bone mass of 2% to 3%.
The prognosis for patients with the female athlete triad is good with early diagnosis and treatment employing a multidisciplinary team. Patients with a prolonged disease course may suffer from complications of decreased BMD throughout their adolescence and adult life due to the triad's common occurrence during the age window of optimal bone strengthening. Patients with disordered eating behaviors often require long-term therapy to manage their disease.