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CDR Steven M. Kriss, FP/Sports Med, FHCC Lovell 1

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Disclaimer This presentation does not represent the opinions of the U.S. Government, the U.S. Navy, the Veterans Administration or the Federal Health Care Center James A. Lovell (FHCC Lovell) There are no financial relationships or unapproved or off-label product uses to disclose 2

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Objectives To understand 3 aspects of the Female Athlete Triad To understand that the triad is a spectrum To understand basic endocrinology of the condition To understand the sports at risk for the triad To understand physical exam findings in the triad To understand the basic treatment for the triad To understand the multi-disciplinary approach To understand Title IX and its effects on sports 3

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Chief Complaint R. Foot Pain 4

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HPI 16 yo USN dep female Runner (runs 50 miles/wk) presents with R. Foot Pain since 21 NOV 2009. Pain started while running in a X-Country race on a hill. The next week she ran a second race; had more pain. 5

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PMed Hx No Hx Fxs or Surgeries Primary Amenorrhea Diet: Lacto-Vegetarian Acne Hyperhidrosis 6

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Medications NKDA Ibuprofen 600 mg Benzoyl Peroxide, Topical 5 % Gel Clindamycin, Topical 1 % lotion 7

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Soc Hx No Tobacco No Alcohol Iced Tea 8

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Fam Hx Not significant 9

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Physical Exam General: A/O x 3 Well-Hydrated Thin for age NOT well-developed NOT well-nourished 10

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Patients Height/Weight Age: 16 years Height: 60 inches Weight: 95 pounds 11

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Weight for Age Chart 12

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Stature for Age Chart 13

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Musculoskeletal Exam Slightly antalgic Gait, favoring L. Foot R. Foot: +Ecchymosis +TTP over dorsal aspect R. Second MT Pain with ROM of R. Second MT 14

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Imaging AP/LAT/Oblique Foot/Toes : 1. Step-off Fx of distal second phalanx 2. Stress Reaction in diaphysis of second MT 15

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R. Foot X-Rays 16

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Diff Dx Fractures (2) Problem Summary List 17

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A Triad 18

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The Female Athlete Triad 19

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The Female Athlete Triad Historically (defined by ACSM in 1992): Anorexia, Amenorrhea, Osteoporosis New: Disordered Eating, Menstrual Dysfunction, Low Bone Mineral Density Why the difference ? Well discuss later 20

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Background Title IX was signed into law in 1972, increasing funding for female sports at all levels and increasing female participation in sports. This increased the incidence of a particular syndrome more common in female athletes than in the female non-athlete population. ACSM developed first position statement in 1997 ACSM developed second position statement in 2007 21

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ACSM Position Statement The Female Athlete Triad refers to the relationships between energy availability, menstrual function and bone mineral density. The clinical manifestations include eating disorders, functional hypothalamic amenorrhea and osteoporosis. Energy availability is defined as dietary energy intake minus exercise energy expenditure. Low energy availability is the factor that impairs reproductive and skeletal health in the Triad. 22

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Components of the Triad A spectrum of pathology: Decreased food intake to eating disorders Eumenorrhea to Amenorrhea Osteopenia to Osteoporosis 23

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Hypothalamic-Pituitary Axis (HPA) 24

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Diagnosis This is largely a clinical diagnosis Must exclude other causes of Amenorrhea and Osteopenia More common in Sports which emphasize leanness: Gymnastics, Figure-Skating, Ballet, Cheerleading, Cross-Country Running 25

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Sports at risk for Triad 26

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History Detailed screening history. Endocrine problems: pituitary, thyroid, PCOS, DM II Menstrual history: Menarche, length, cycle Drugs/Meds/OTC/Herbals: Anabolic Steroids Psycho-Social: Tobacco, Alcohol, Illegal, Abuse, Depression, Anxiety, SI, Significant life stressors Exercise history: Sport, other work-outs, total hours Eating Disorder Inventory 27

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Physical Exam Vital Signs: Temp, HR, RR, BP (ranges per ped charts) Growth Charts (Pediatric and Adult), BMI General appearance Basic Pre-Participation Exam: MS, HEENT, Cardiac Gynecologic, PAP and Breast exam after rapport developed (R/O CA, Congenital issues, STD-s) Pelvic US if necessary 28

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Abnormal findings Thyroid palpation: R/O Goiter Parotid glands: R/O hypertrophy from purging Bulimia: bloodshot eyes and petechiae of sclera/cheeks. Dental exam: dental caries from stomach acid. Anorexia may cause bradycardia and hypotension. ECG for above and for baseline. Dermatologic exam: lanugo and hypercarotenemia 29

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Russells Sign 30 Callous formation on distal extensor surface of finger used to induce vomiting

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Fractures Often the first manifestation of the Triad. May have a history of past fractures. Bone Mineral Density (BMD) can be affected. A result of amenorrhea, decreased estrogen and poor nutrition. 31

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Labs UA and Urine HCG: Volume status; R/O Pregnancy CBC: R/O Anemia ESR and CRP: Check for Inflammation and Infection CMP: electrolytes, liver and kidney function Thyroid panel: R/O Hypo, Hyperthyroidism (TSH) FSH and LH: Eval Pituitary and Ovarian function Prolactin: Eval Pituitary function Testosterone and DHEA: R/O Androgen excess, tumor Estradiol: Check levels for ovarian function 32

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Imaging X-Rays: R/O Fx if pain present DEXA scan: R/O Osteoporosis and baseline bone density MRI: If clinical/labs suggest Pituitary tumor Pelvic US: Presence of uterus and ovaries, morphology Bone Scan: R/O Fx if X-Rays not definitive 33

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Treatment A Multi-Disciplinary treatment team: Team Physician (FP, ER, IM, Peds) Nutritionist Orthopedic Surgeon Psychiatrist or Psychologist Cardiologist Athletic Trainer Coach Parents Friends 34

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Treatment Immobilization of Fractures Rest or Relative Rest from Sport Exercise reduction Increase caloric intake Supplements (Vit. D, Ca, K, Fe) Make a contract with athlete to set goals Temporary removal from team/sport if necessary Hospitalization (often long-term) 35

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Medications Medications are NO substitute for increasing energy availability,the cornerstone of restoring normal menstrual, reproductive and bone function OCPs in those whose BMD declines after NL diet, wt Progesterone to prevent endometrial hyperplasia SSRI-s for those with depression, anxiety or OCD 36

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Complications Osteoporosis Fractures Infertility Cardiac Arrhythmias Possible Cardiovascular effects (adverse lipid profile) Death 37

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Prevention Early detection with Pre-Participation Exam, quest. De-emphasize weigh-ins Education of physicians, coaches, trainers, parents and athletes Maintain energy availability of 30 kcal/kg /day 38

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New Discoveries Leptin, a hormone secreted by fat cells in proportion to body fat stores may have effects on reproductive function. Rodents deficient in leptin do not have NL pubertal development Other neuro-hormones like ghrelin may influence menstrual function 39

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Young Female Runner Pt Diagnosis: The Female Athlete Triad Treatment: 1. Fracture immobilization in a Walking Boot x 4 wks 2. No Running or biking; may swim 3. Rec Nutrition consult and increase caloric intake 4. Rec Psychiatry consult 5. X-Rays of Foot before next appt 6. F/U with Orthopedics Cast Room in 4 wks 7. D/W Parents and Athlete 40

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Summary The Female Athlete Triad is more prevalent nowadays A continuum of Disordered Eating, Menstrual Irregularities and Decreased Bone Density Certain Sports are at higher risk A Multi-Disciplinary Treatment Team is key Treatment aimed at increasing caloric intake to roughly 30 kcal/kg/day Sometimes, Hospitalization is necessary Complications can be serious, including Death Prevention through education and screening 41

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References 2007 ACSM Position Stand The Female Athlete Triad 2008 E-Medicine article Female Athlete Triad 2009 Up to Date article Amenorrhea and Infertility associated with Exercise The Little Black Book of Sports Medicine Clinical Sports Medicine by Brukner 42

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Thank You 43