Research In Action

Watching the elite female athletes during these Olympic games has been beyond exciting. But while the often extreme fitness and diet regimens of the athletes may suggest robust health, one topic parents should be aware of is that female athletes, through an imbalance of nutrition and hormones, are at both short- and long-term risk for poor bone health.

Naomi Brown, a Pediatric and Sports Medicine physician at CHOP, recently wrote about the "female athlete triad" (disordered eating, irregular menstrual cycle, and low bone mass) in the most recent CHOP's Health Tip of the Week. Dr. Brown writes that it is critical for parents to realize that, among teen girls who engage in rigorous athletic exercise, a typical healthy diet may not adequately balance the number of calories and energy spent during their athletic training. Inadequate nutrition disrupts the body's typical hormonal balance  and can lead to irregular menstrual cycles, as well as poor bone development. 

The reason why teen girls need to care about bone health in their teens and early 20s is that people reach skeletal maturity during these years and not beyond. With every missed period during this time of life, bone density decreases and risk of fractures increases. 

I recently had an opportunity to speak with Dr. Brown a bit more about this topic:

I can imagine that some teen female athletes might feel that not having their periods could offer a competitive advantage or feel pressured by coaches or others to maintain a certain diet. Do you encounter challenges when counseling families about the potential dangers of excessive exercise/inadequate nutrition?

Dr. Brown: Yes, we encounter challenges frequently. In general, athletes want to heal. Unfortunately, many athletes are resistant to reductions in training or alterations in their diet, for a variety of reasons, including beliefs that have been ingrained in them by coaches and the media. Treating the female athlete triad is a multidisciplinary approach, involving a clinician (either Sports Medicine, Primary Care or Adolescent Medicine), a nutritionist or dietician, a psychiatrist or therapist, the team coach, and of course, the parents.

Are there other symptoms or behaviors that precede menstrual irregularities that might clue a clinician into knowing that a particular patient could be at higher risk for the female athlete triad?

Dr. Brown: If the reason for menstrual irregularities is disordered eating, a clinician should look for other clues on physical examination for signs of bulimia or anorexia. This includes bradycardia (low heart rate), orthostatic hypotension (when blood pressure falls upon standing), and hypothermia. This can also be seen with hypothyroidism, another etiology for menstrual irregularities. Some women with eating disorders also can have callused knuckles from forced vomiting, gingival abrasions, parotid gland enlargement, and loss of dental enamel. You can also look for dry skin, hypercarotenemia, lanugo (fine, soft hair), and acrocyanosis (when hands, feet, or lips turn blue). It's important to look for clues for other etiologies of menstrual irregularities, such as hirsutism and acne to suggest Polycystic Ovarian Syndrome. 

Do males face any similar risk for fractures from inadequate nutrition?

Dr. Brown: Yes, males are at risk for low bone mineral density and stress injuries as well. The scientific evidence is still developing,so we do not know true data at this time. Male athletes who are involved in sports that emphasize and reward leanness, such as wrestling, may be at risk of similar symptoms to their female counterparts with the triad. At this time, symptoms to look for would be similar to those of anorexia nervosa or bulimia. Lab work may be helpful to screen for hormonal dysfunction. Often, stress injuries are the first sign that males might have impaired bone health and disordered eating.