Transcript Eating disorders in Adolescents

The Female Athlete Triad
Keren Kazis, M.D.
Adolescent Medicine
Department of Pediatrics
New York Medical College
Female Athlete Triad
 Syndrome consisting of Disordered Eating,
Amenorrhea, and Osteoporosis
 1.9 million female athletes in HS and College
level sports with 3800 females in the Olympics
 Imbalance in energy intake vs expenditure (low
cal, high ex) leading to dysregulation of the HPO
axis causing amenorrhea
 Low estrogen levels can cause low BMD leading
to osteoporosis and inc fracture risk
Disordered Eating
 Prevalence of ED in athletes 15-62%
 Can be a spectrum from abnormal eating habits
to AN/BN
 Female athletes consume 20-30% less than
RDA and expend 700Kcal/day
 Unrealistic expectations placed on female
athletes to maintain low body weightsgymnastics, ballet dancers, figure skating
Amenorrhea
 Spectrum – primary and secondary amenorrhea
and oligomenorrhea
 Incidence of amenorrhea5% in pop
10-20% in athletes
30-50% in elite athletes
 Amenorrheic athletes initiate training earlier than
eumenorrheic athletes, even prior to menarche
 Ballet dancers- menarche of 15.4 yrs vs controls
at 12.5 yrs
Amenorrrhea
 Mechanism- Hypothalamic dysfunction
suppressing HPO axis- dec pulse freq of GNRHdysfunction of LH and FSH -ovarian suppression
and low estrogen
 Secondary to excessive exercise and/or dieting
 Bullen et al –excessive exercise even without
weight loss can cause menstrual irregularities
 Hormonal changes in athletic women with NL
cycles-Shortened luteal phase(dec
progesterone), dec LH pulse frequency
Bone Mass
 Peak bone mass obtained in adolescence
 Only minimal increases in BMD 2yrs after
menarche
 PBM determined by- gender, genetics, diet,
exercise, hormones
 PBM in women 30% lower than in men
 Estrogen deficiency in adolescence may cause
a decrease in PBM
Osteoporosis
 Def: reduction in the quantity of bone, resulting
in bone that is thin or brittle
 Estrogen def inc bone turnover and bone
resorption, causing a reduction in trabecular and
cortical bone
 Dec BMD leads to an increased fracture risk
 Drinkwater et al- comparison of Vertebral BMD
of A vs E athletes- found A athletes had BMD
equiv to women 51.2 yrs of age
Osteoporosis
 Biller et al- BD lower in women with HA, women
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with primary HA lower BD than women with
secondary HA
BMD lower in women who develop AN pre vs
post-menarchal
Drinkwater et el- BMD after resumption of
menses- inc but not as high as eumenorrheic
group – not completely reversible!!!!!
Warren et al- as age of menarche inc in ballet
dancers there is a higher incidence of stress fx
50% of A. college runners reported stress fx.
Diagnosis, Prevention and Treatment
 Identify the female adolescent at risk – pre
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participation physical
History, physical and blood work similar to ED
DEXA scan if amenorrheic > 6 mths
Prevention- Education of athletes, trainers,
coaches, and family of the dangers of the Triad
Multidisciplinary approach
Increase caloric intake and dec intense exercise
Treatment- Oral Contraceptives
 AAP recommendations – over 16 with HA should
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receive hormone replacement
Seeman et al-Inc BD in adult AN on OCP’s
Gibson et al- small but not sig benefit of OCP’s
on BD in runners with HA
Klibanski et al-no sig change in BD in adult AN
on OCP’s, but inc in BD with very low weight
(70% of IBW)
Golden et al- no sig difference in BD of Ad AN on
OCP’s, difficult to determine resumption of
menses
Conclusion
 Higher incidence of Female Athlete Triad is
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being seen
Components of the Triad- ED, amenorrhea and
osteoporosis can lead to increased fracture risk
Cause of dec in BD is multifactorial and
exogenous estrogen alone may not be beneficial
Further investigation of treatment modalities for
osteoporosis in the ad age group are being
conducted- use of Alendronate
Prevention is key!!