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PEDIATRICS Vol. 106 No. 3 September 2000, pp. 610-613
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ABSTRACT |
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Abstract
Recommendation
References
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Female children and adolescents who participate regularly in sports may develop certain medical conditions, including disordered eating, menstrual dysfunction, and decreased bone mineral density. The pediatrician can play an important role in monitoring the health of young female athletes. This revised policy statement provides updated and expanded information for pediatricians on these health concerns as well as recommendations for evaluation, treatment, and ongoing assessments of female athletes.
Exercise is good for female children and
adolescents. Special medical concerns should be considered, however,
when caring for young female athletes. Athletes can develop abnormal
eating patterns (termed disordered eating), which can be associated
with menstrual dysfunction (amenorrhea or oligomenorrhea) and
subsequent decreased bone mineral density (BMD), or osteoporosis. These
3 conditions Some physically active females, particularly adolescents, may
develop an energy deficit when the energy (calories) they expend exceeds their energy (calorie) intake.2 This deficit may
be unintentional, resulting from inadequate replenishment of the
caloric (energy) demands of training, or may be intentional Disordered eating behavior has been reported in young female athletes
and dancers.4-6 One study of young elite swimmers
revealed that 60.5% of average-weight girls and 17.9% of underweight
girls were trying to lose weight. Most of the girls were trying to lose
weight by decreasing their food intake7; however, 12.7%
were vomiting, 2.5% were using laxatives, and 1.5% were using
diuretics.7 Disordered eating can be seen in athletes
participating in all sports. Sports that may place athletes at higher
risk for the development of these behaviors include those in which
leanness is emphasized (eg, gymnastics, ballet dancing, diving, and
figure skating) or perceived to optimize performance (eg, long-distance running and cross-country skiing) and those that use weight
classification (eg, martial arts and rowing).3 A variety
of factors may contribute to the development of disordered eating
patterns in the young athlete, including pressure to optimize performance or meet inappropriate weight or body fat goals, social factors (eg, idealization of thinness in Western cultures),
psychological factors (eg, poor coping skills, unhealthy family
dynamics, and low self-esteem), and personality traits (eg,
perfectionism, compulsiveness, and high achievement
expectations).3
Disordered eating behaviors may impair athletic performance and
increase risk of injury. Decreased energy (caloric) intake and fluid
and electrolyte imbalance can result in decreased endurance, strength,
reaction time, speed, and ability to concentrate. Because the body
initially adapts to these changes, a decrease in performance may not be
seen for some time, and athletes may falsely believe disordered eating
practices are harmless. To the contrary, food restriction and purging
can result not only in menstrual dysfunction and potentially
irreversible bone loss but also in psychological and other medical
complications, including depression, fluid and electrolyte imbalance,
and changes in the cardiovascular, endocrine, gastrointestinal, and
thermoregulatory systems.8,9 Some of these complications
are potentially fatal.
Menstrual dysfunction in athletes may include primary amenorrhea,
secondary amenorrhea, oligomenorrhea, and luteal phase
deficiency.10-12
An adolescent is considered to have delayed puberty when breast
development has not begun by 13.3 years of age.13 Because
sports involvement or poor nutrition may be associated with a delay in
development, evaluation might be postponed until 14 years of age, as
determined by clinical judgment. Primary amenorrhea is defined as the
absence of menses by age 16 years. If menses have not occurred within
4.5 years after the onset of breast development, evaluation should be
considered. Secondary amenorrhea is typically defined as the absence of
at least 3 to 6 consecutive menstrual cycles in a female who has begun
menstruating. Oligomenorrhea refers to menstrual periods that occur at
intervals longer than every 35 days.11,12,14 Although
adolescents may have irregular periods or amenorrhea for 3 to 6 months
in the first several years after menarche, the cessation of menses for
longer than 3 months after regular cycles have begun or persistent
oligomenorrhea is considered abnormal.15
Menstrual dysfunction is more common in athletes than in the general
population. Athletes and dancers who begin training before menarche
occurs may experience a later menarche and have an increased incidence
of menstrual dysfunction when compared with girls who begin training
after menarche occurs.16-19 The prevalence of secondary
amenorrhea in adult athletes ranges from 3.4% to 66% (depending on
the sport studied and the criteria used to define
amenorrhea),10-12 compared with 2% to 5% of women in
the general population.12 The prevalence of secondary
amenorrhea in the young athlete is unknown.
Luteinizing hormone (LH) pulsatility and, therefore, normal menstrual
function are dependent on energy availability (dietary energy intake
minus energy expenditure from exercise).20 Low energy
availability causes a hypometabolic state characterized by a variety of
substrate and hormonal alterations, including hypoglycemia,
hypoinsulinemia, hypothyroidemia, hypercortisolemia, and the
suppression of the 24-hour mean and amplitude of the diurnal rhythm of
leptin.2,20-23 Amenorrheic and regularly menstruating
athletes display reduced LH pulse frequencies24 and
similarly low 24-hour mean leptin levels.25 However,
amenorrheic athletes are distinctive in having a more extreme
suppression and disorganization of LH pulsatility24 and a
complete suppression of the amplitude of the diurnal rhythm of
leptin.25 It is not known whether a particular threshold
of energy availability is required to maintain normal reproductive
function or whether the macronutrient composition of the diet is
important.
Menstrual dysfunction may lead to decreased BMD. Other long-term
consequences of a chronically estrogen-depleted state in young women
are unknown at this time.
Hypoestrogenism associated with amenorrhea may predispose to
osteoporosis.26,27 Osteoporosis is defined as premature
bone loss and/or inadequate bone formation resulting in low bone mass
and microarchitectural deterioration.1 Adequate levels of
estrogen slow bone resorption and improve or maintain bone
mass.28,29 The prevalence of osteoporosis in adult and
adolescent women is unknown.1 Studies of adult female
athletes have shown that premature osteoporosis may occur as a result
of amenorrhea and oligomenorrhea and may be partially irreversible
despite resumption of menses, estrogen replacement, or calcium
supplementation.27,30,31 Amenorrheic adolescents, both
athletes and nonathletes, have been found to have lower BMD
than eumenorrheic adolescents.28,32-34 This may be
attributable to decreased bone accretion as well as increased
bone loss.35 An overall increase in BMD is demonstrated
throughout adolescence. However, the amenorrheic teenager remains
osteopenic in comparison with regularly menstruating
teenagers.28,32-35
High-intensity exercise in some sports for many years may actually
increase BMD in specific skeletal sites despite amenorrhea. Elite
adolescent ice skaters and gymnasts have been found to have increased
BMD in the lower skeleton, compared with controls, despite menstrual
dysfunction.29,36,37
Girls who begin menarche at a later age and have a lower weight during
adolescence have been found to have the lowest BMD when compared with
their peers.34,35 An increased incidence of stress
fracture in dancers has been associated with older age at
menarche.38 Weight gain and the resumption of menses
result in increased BMD.33,35 Estrogen replacement therapy
may decrease bone loss and potentially increase BMD in the
adolescent with secondary amenorrhea.28,35,39
The physical examination that precedes participation in sports is
an ideal opportunity to screen for problems of disordered eating,
menstrual dysfunction, and decreased BMD.40 Signs
of disordered eating may be recognized by parents, coaches, athletic
trainers, teammates, or school nurses and brought to the physician's
attention. If an athlete shows signs of disordered eating behavior,
further evaluation by the physician, a nutritionist, and a mental
health professional may be necessary.3
The diagnosis of primary amenorrhea or secondary amenorrhea in an
athlete first requires a full evaluation to rule out pregnancy and
underlying pathologic conditions. Pathologic conditions that may cause
menstrual dysfunction include pituitary tumors (especially prolactinomas), thyroid dysfunction, polycystic ovary disease, premature ovarian failure, and other chronic illnesses.10
Evaluation of amenorrhea includes a complete physical examination and
pelvic examination when indicated. A pregnancy test is usually
indicated. Laboratory studies may include measurement of
thyroid-stimulating hormone, prolactin, and follicle-stimulating hormone (FSH). If the athlete shows signs of androgen excess (eg, hirsutism, acne) or if the pelvic examination reveals polycystic ovaries, a determination of levels of LH, testosterone,
dehydroepiandrosterone sulfate (DHEA-S), and 17-hydroxyprogesterone
may need to be done. A progesterone challenge may help determine if the
patient is hypoestrogenemic.10,15 The possible use of
anabolic steroids should also be considered.
In the athlete who has been amenorrheic, a study to evaluate
BMD may be helpful.29
The female athlete who has restrictive eating patterns because she
is unaware of her energy needs may require only nutritional counseling.
The female athlete who purposefully engages in disordered eating
behaviors is often best treated using a multidisciplinary team
approach: with a physician who monitors her medical status and ability
to participate safely in sports, a nutritionist who provides
appropriate nutritional guidance, and a mental health professional who
addresses any psychological issues.3
Increased dietary energy intake or decreased energy expenditure
(exercise) usually results in the development or resumption of menses
and ovulation in adolescent girls and women with exercise-associated amenorrhea.29,31 Daily requirements for calories,
carbohydrates, and protein are greater in athletes than in more
sedentary women and girls,41 and diet should be changed
accordingly. The recommended daily dietary allowance of calcium for
adolescents is 1200 mg. Amenorrheic athletes should be encouraged to
increase their calcium intake to at least 1500 mg daily. If intake of
dietary sources of calcium is inadequate, calcium supplements may be
recommended. If estrogen levels are deficient, the efficacy of calcium
supplementation in improving bone mass may be
impaired.10,29,42
In adolescents and young women with hypothalamic amenorrhea,
estrogen-progesterone supplementation may help maintain bone density,
protect the endometrium, and promote regular menses at predictable
times.10,28,35 The criteria for initiating estrogen
replacement therapy and the optimal dosing schedule have not been
determined. The minimum daily estrogen dose that has been shown to
prevent bone loss in postmenopausal women is 0.625 mg of conjugated
estrogens43; this dose, however, has not been shown to
increase BMD in young women with hypothalamic
amenorrhea.28 Supplementation with a low-dose oral
contraceptive (<50 µg of estrogen per day) is a readily available
source of estrogen and may be associated with an increase in total body
BMD.39
disordered eating, amenorrhea, and osteoporosisoften occur together and have been termed the female athlete
triad.1 Although these conditions may also be seen in the
nonathlete, this statement will concentrate on the physically active
and athletic female.
DISORDERED EATING
a
conscious attempt to lose weight or body fat in the interest of
improved appearance or athletic performance. These athletes often
restrict food intake but may develop other disordered eating behaviors,
such as binge eating and/or purging by vomiting or use of laxatives,
diuretics, and diet pills. Compulsive exercise, defined as excessive
exercise in addition to a normal training regimen, is another form of
"purging," or energy expenditure often overlooked in athletes. The
spectrum of disordered eating behaviors ranges from mildslight
restriction of food intake or occasional binge eating and purgingto
severesignificant restriction of food intake, as in anorexia nervosa,
or regular binge eating and purging, as in bulimia
nervosa.3 Disordered eating may result in adverse health
consequences, with the risk of morbidity and mortality increasing as
the severity of the behavior increases.
MENSTRUAL DYSFUNCTION
DECREASED BONE MINERAL DENSITY
CLINICAL EVALUATION
TREATMENT
RECOMMENDATIONS
Top
Abstract
Recommendation
References
COMMITTEE ON SPORTS MEDICINE AND FITNESS,
1999-2000
Steven J. Anderson, MD, Chairperson
Bernard A. Griesemer, MD
Miriam D. Johnson, MD
Thomas J. Martin, MD
Larry G. McLain, MD
Thomas W. Rowland, MD
Eric Small, MD
LIAISONS
Claire LeBlanc, MD
Canadian Paediatric Society
Carl Krein, AT, PT
National Athletic Trainers Association
Judith C. Young, PhD
National Association for Sport and Physical Education
Robert Malina, PhD
Institute for the Study of Youth Sports
SECTION LIAISONS
Frederick E. Reed, MD
Section on Orthopaedics
Reginald L. Washington, MD
Section on Cardiology
CONSULTANTS
Oded Bar-Or, MD
Anne Loucks, PhD
Suzanne Tanner, MD
STAFF
Heather Newland
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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BMD, bone mineral density; LH, luteinizing hormone.
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REFERENCES |
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Abstract
Recommendation
References
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Statement of reaffirmation:
This article has been cited by other articles:
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  M. P. WARREN and A. T. CHUA Exercise-Induced Amenorrhea and Bone Health in the Adolescent Athlete Ann. N.Y. Acad. Sci., June 1, 2008; 1135(1): 244 - 252. [Abstract] [Full Text] [PDF]
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 D. Bloomfield Secondary Amenorrhea Pediatr. Rev., March 1, 2006; 27(3): 113 - 114. [Full Text] [PDF]
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 J. F. Nichols, M. J. Rauh, M. J. Lawson, M. Ji, and H.-S. Barkai Prevalence of the Female Athlete Triad Syndrome Among High School Athletes Arch Pediatr Adolesc Med, February 1, 2006; 160(2): 137 - 142. [Abstract] [Full Text] [PDF]
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 D. M. De La Torre and B.J. Snell Use of the Preparticipation Physical Exam in Screening for the Female Athlete Triad Among High School Athletes The Journal of School Nursing, December 1, 2005; 21(6): 340 - 345. [Abstract] [PDF]
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 Committee on Sports Medicine and Fitness Promotion of Healthy Weight-Control Practices in Young Athletes Pediatrics, December 1, 2005; 116(6): 1557 - 1564. [Abstract] [Full Text] [PDF]
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 M. J. De Souza and N. I. Williams Physiological aspects and clinical sequelae of energy deficiency and hypoestrogenism in exercising women Hum. Reprod. Update, September 1, 2004; 10(5): 433 - 448. [Abstract] [Full Text] [PDF]
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R. T. Sherman and R. A. Thompson The Female Athlete Triad The Journal of School Nursing, August 1, 2004; 20(4): 197 - 202. [Abstract] [PDF]
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 J. Little AAP News, September 1, 2003; 23(3): 100 - 100. [Full Text] [PDF]
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 T. A. Roberts, J. Glen, and R. E. Kreipe Disordered Eating and Menstrual Dysfunction in Adolescent Female Athletes Participating in School-Sponsored Sports Clinical Pediatrics, July 1, 2003; 42(6): 561 - 564. [PDF]
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