Female Athlete Triad spells triple trouble

With passage of Title IX legislation in 1972 came an influx of women participating in diverse athletics. Title IX came about when school funding for sporting programs was an issue. It mandated that any secondary or collegiate school receiving federal funding must offer equal opportunity for both men and women to receive scholarships to participate in athletic programs. Currently, approximately 12 million women compete in a variety of sports at many levels. As young girls, they may use the athletic experience as a social outlet. When young women demonstrate a high level of skill in their sports, the dynamics change. Practice becomes more like work, with its associated demands, both spoken and unspoken. Female Athlete Triad — which consists of disordered eating, amenorrhea, and osteoporosis — is an unfortunate side effect of the highly driven side of women in competitive sports.

We have moved from a society in which women were inadvertently doing physical fitness to no exercise to exercising again. In the early 1800s, women performed manual labor, such as hauling water from the stream or well, and did laundry by hand. In the beginning of the 1900s, women were erroneously informed that physical activity would decrease their ability to bear children. As the century progressed, the 1920s spawned the "modern" woman, who was allowed to dance the Charleston, a lively activity. During the war years, women were sent to work in steel mills. Over the second half of the last century, women's exercise and physical activity have increased steadily.³ Whereas the baby boomers may not have had many participatory sports options when they were growing up, their young daughters have many.

Female athletes now compete more heavily than ever. Numbers of young women with dreams of Olympic glory or at least college scholarships are growing. Parents see a will to compete and foster it; coaches recognize talent and hone it. One of the inherent side effects of this competitive drive is Female Athlete Triad, which was first designated as a distinct entity in 1991.

Female Athlete Triad is becoming an epidemic, according to Dr. Michelle Cameron, an orthopedic surgeon from Cheyenne, Wyo., and head of the Female Athlete Triad summit. She says the problem is unacceptable and that "we have known about it for a long time." Dr. Cameron is attempting to get the message out about the destruction of a woman's body through eating disorders and the additional medical sequelae. "Alone, each disorder is of significant medical concern, but when all three components are present, there is the potential for a more serious impact on one's health and risk of mortality."¹ Dr. Cameron has been working with medical groups, including the American Academy of Orthopaedic Surgeons (AAOS), the National Association of Orthopaedic Nurses (NAON), and the Academy of Eating Disorders, in addition to several school, physical therapy, and coaching organizations, to address this growing problem. Now dentistry can become involved.

According to Dr. Cameron's research, the incidence of eating disorders in the normal population is 5 to 10 percent, but female athletes exhibit a 16 to 72 percent incidence. Menstrual irregularities occur in the normal population at a rate of 2 to 5 percent, whereas for female varsity athletes, the rate can be as high as 28 percent. Other statistics demonstrate that 3.4 to 66 percent of female athletes, depending on the sport, can experience amenorrhea that is related to athletic training and weight changes from eating disorders.⁷ Premature osteoporosis is a direct consequence of these two predisposing factors, possibly due to estrogen loss.

Amenorrhea can be defined as loss of the menstrual cycle in a young woman. Primary amenorrhea occurs when a girl has not experienced a menstrual cycle by age 16. Secondary amenorrhea is exhibited by a six-month or longer absence of the menstrual cycle.² The hypothalamus regulates the menstrual cycle. With hypothalamic amenorrhea — which is the most common form of athletic amenorrhea — there is a decrease in pulsatile gonadotrophin-releasing hormone (GnRH).4,5 Highly intense physical activity appears to cause this menstrual dysfunction.⁸ A concomitant decrease in estrogen occurs with the decrease of GnRH. There is a correlation with lowered estrogen to a decrease in bone mass and an increase in cardiac risk.

Eating disorders fit easily into the pattern of training, competition, and stress. With pressure on athletes to win, eating may not be a priority. Most athletes do not consume enough calories needed for intensive sports training.¹ "Appearance" sports — such as running, ballet, gymnastics, and swimming — uphold a slender physique as a standard. In part due to the media and its constant body-image projection that associates thinness with success and the "perfect life," the lithe, sculpted body of an elite athlete has become a desire in the minds of many young women.

To achieve this image, many athletes do not eat properly. Some practice poor nutrition in response to pressure from misguided coaches who insist on specific weight standards for competition. Athletic training involves many hours of sport-specific activities, weight training, and psychological focus. The physical stresses on the body usually require an increase in caloric intake. However, due to the demands of training and the mental image of the "ideal body," nutrition often falls by the wayside.

Many eating disorders begin at an early age. Parents and coaches are often aware of these problems; and sometimes they are unable or unwilling to do anything about them. My daughter, who just completed a four-year NCAA Division I collegiate swimming career, said there were many who suffered from anorexia and bulimia among her team members, especially on the women's team. The coach, in contrast, stated there were possibly one or two cases of anorexia, but that the teammates usually "turn them in" and they receive treatment. My daughter corroborated this "turning in." She said, "It is up to the teammates, more than the coaches, to see what is going on; the coaches are blind to everything." Female athletes, especially on the college level, rarely go to the coaches to tell them they have a problem; they will first approach their teammates. In the earlier stages of intense training, that network may not be available, and eating disorders will be more circumspect.

Disordered eating can run the gamut of restricting caloric intake and occasional binging and purging, to severely restricting food intake and recurrent episodes of binging and purging.¹ The two main categories of eating disorders are anorexia nervosa and bulimia. Anorexia nervosa is a morbid refusal to maintain body weight. Bulimia involves recurrent episodes of binging and purging, with or without use of laxatives, diuretics, or enemas. Other eating disorders exist that do not fit these specific criteria: individuals who purge but do not binge, women who do not experience amenorrhea but who do meet other criteria for anorexia nervosa, and individuals who binge less than twice a week but who meet other criteria for bulimia. Studies have shown that 10 percent or more of college-age women report symptoms of disordered eating.

Osteoporosis is a disease of brittle bones due to mineral loss. Peak bone mass is usually attained by age 35; 80 percent of bone mass is attained by age 20. Bone mineral levels in athletes with more than six months of amenorrhea have been demonstrated to be as low as postmenopausal levels.4 With increased training time and decreased estrogen levels and bone mineral content, the occurrence of stress fracture incidences in athletes has increased.5 Studies have shown an increase in musculoskeletal injuries and interrupted training time in women with combined disordered eating and menstrual dysfunction.7 Insufficient caloric intake negatively affects wound healing, which means stress fractures take longer to heal.

What does this all mean for dentistry? How can we help these young athletes? Treatment involves a multidisciplinary approach. A variety of health-care professionals may be called into action in the treatment of this triad: the dental team in combination with a medical team of physicians, nurses, psychologists, psychiatrists, and nutritionists, in addition to parents, athletes, and coaches. We may not be able to discuss menstrual cycles or request bone density scans, but we can offer a vast amount of assistance.

The most important thing we can do is to listen. Listen to the female athlete discuss her training regime. Listen to her complaints about the time spent in the weight room and away from the table. Understand that she may casually discuss more with you about her sport than with her own parent. A constant preoccupation with food and eating, eating alone, overconcern about weight and body image, or frequent bathroom visits, especially after eating, should send up red flags.

Signs and symptoms of disordered eating are evident in routine intraoral and extraoral examinations. These signs include erosion of lingual enamel from purging, halitosis from constant purging, increased caries rate, enlargement of parotid gland, sore throat, traumatic ulcerations of the soft palate from forced vomiting, xerostomia, irritation to the lips and other soft tissues, and dentinal sensitivity. Some of these signs could be falsely assumed to be a result of poor personal dental hygiene care. Additional physical assessment keys include signs of malnutrition (thinning hair, always cold, fatigue, hypothermia, facial hair or lanugu, carotenemia), decreased ability to concentrate, depression, and low body weight. Abrasions or calluses on the dorsal surfaces of the fingers and hands due to friction from self-induced vomiting also will be present.

A 24-hour dietary diary that includes what was eaten, when, and where the food was consumed will assist in the evaluation of nutrient intake. Further examine a high carbohydrate diet, very low caloric intake, or a diet heavy with proteins and little else. Food-frequency questionnaires can help assess the monthly intake of a variety of foods, because bone density responds to long-term food intake.⁹ Recommend 1,200 to 1,500 mg of calcium per day, in addition to eating a healthy variety of all foods, not just "sports diets," which consist mainly of liquids and fiber-rich components that have accelerated passage through the digestive system.⁶

Instruct patients to brush immediately after purging, encourage rinsing with water to decrease the acidity in the oral cavity, recommend the use of a daily fluoride treatment to remineralize the enamel, and suggest the use of a desensitizing toothpaste to decrease dentinal sensitivity.

Make appropriate referrals to medical personnel if either the physical or dietary evaluation highlight major concerns. In addition, try to make parents, coaches, and athletic trainers more aware of the overt signs and symptoms of the triad, such as disordered eating.

Female Athlete Triad is a complex issue. Awareness of its signs and symptoms may help young women minimize their risks. Overcoming the silence and becoming aware of certain myths (i.e., that loss of a menstrual period is not an indication of optimum training, or that a low amount of body fat ensures athletic performance) will help to open communication. Dentistry can easily fit into the multi-disciplinary approach needed to combat this problem. We are often the first to evaluate and assess distinct dental abnormalities. Let us join in the battle to help these women athletes; their future bone health is dependent on it.

The author wishes to thank Dr. Michelle Cameron for her invaluable research assistance.

Sheri B. Doniger, DDS
Dr. Doniger has been in private practice of family and preventive dentistry for almost 20 years. She is currently focusing on women's health and well-being issues. She can be contacted at (847) 677-1101 or donigerdental @aol.com.

References —

1. "Female athletes at risk for triad of medical disorders." www.aaos.org/wordhtml/press/event1.htm
2. Hobart J, Smucker D. The Female Athlete Triad. Am Fam Phys 2000;61:3357-3367. www.aafp.org/afp/20000601/3357.html
3. Smith A. The Female Athlete Triad: causes, diagnosis and treatment. Phys Sports Med 1996; 24-27. www.physsportsmed.com/issues/1996/07_9/smith.htm
4. Teitz C, Hu S, Arendt E. The female athlete: evaluation and treatment of sports-related problems. J Am Acad Orthop Surg 1997;5:87-96.
5. Marshall L. Clinical evaluation of amenorrhea in active and athletic women. Clin Sports Med 1994;13;371-387.
6. Cree C, Vermuelen A, Ostyn M. Are high-performance young women athletes doomed to become low-performance old wives? A reconsideration of the increased risk of osteoporosis in amenorrheic women. J Sports Med Phys Fitness 1991;31:108-114.
7. Henriksson GB, Schnell C, Hirschberg AL. Women endurance runners with menstrual dysfunction have prolonged interruption of training due to injury. Gynecol Obstet Invest 1000;49:41-46.
8. Athletic women, amenorrhea, and skeletal integrity. Ann Intern Med 1995;102:258-259.
9. Frederick L, Hawkins S. A comparison of nutritional knowledge and attitudes, dietary practices, and bone densities of postmenopausal women, female college athletes and nonathletic college women. J Am Diet Assoc 1992;92:299-305.

Additional references, suggested reading —

• Warren M, Stiehl A. Exercise and female adolescents: effects on the reproductive and skeletal systems. JAMWA 1999;54:115-120.
• Amenorrhea in adolescent athletes. Pediatrics 1989;84:394-395.
• Lauder T, Williams M, Campbell C, Davis G, Sherman R, Pulos E. The Female Athlete Triad: prevalence in military women. Milit Med 1999; 164:630-635.
• Cline A, Jansen R, Melby C. Stress fractures in female army recruits: implications of bone density, calcium intake and exercise. JAm Coll Nutr 1998;17:128-135.
• Gibson J, Mitchell A, Reeve J, Harries M. Treatment of reduced bone mineral density in athletic amenorrhea: a pilot study. Osteoporosis Int 1999;10:284-289.
• Jones K, Ravnikar V, Tulchinsky D, Schiff I. Comparison of bone density in amenorrheic women due to athletics, weight loss, and premature menopause. Obstet Gynecol 1995; 66: 5-8.
• Warren M. Health issues of women athletes: exercise-induced amenorrhea. J Clin Endocrinol Metab. 1999;1892-1896.
• Drinkwater BL. Exercise and bones: lessons learned from female athletes. Amn J Sports Med 1996;24:S-33 – S-35.
• Keen AD, Drinkwater BL. Irreversible bone loss in former amenorrheic athletes. Osteoporosis Int 1997;7:311-315.
• Callahan L. Stress fractures in women. Clin Sports Med 2000;19:303-314.
• Constanti NW, Warren MP. Menstrual dysfunction in swimmers: a distinct entity. J Clin Endocrinol Metab 1995; 80:2740-2744.
• www.aaos.org
• www.aedweb.org
• www.anad.org

Signs of disordered eating

• Erosion of lingual enamel from purging
• Halitosis from constant purging
• Increased caries rate
• Enlargement of parotid gland
• Sore throat
• Traumatic ulcerations of the soft palate from forced vomiting
• Xerostomia
• Irritation to the lips and other soft tissues
• Dentinal sensitivity
• Signs of malnutrition (thinning hair, always cold, fatigue, hypothermia, facial hair or lanugu, carotenemia)
• Decreased ability to concentrate
• Depression
• Low body weight
• Abrasions or calluses on the dorsal surfaces of the fingers and hands due to friction from self-induced vomiting

How to help your patients

• Recommend 1,200 to 1,500 mg of calcium per day, in addition to eating a healthy variety of all foods
• Instruct patients to brush immediately after purging
• Encourage rinsing with water to decrease the acidity in the oral cavity
• Recommend the use of a daily fluoride treatment to remineralize the enamel
• Suggest the use of a desensitizing toothpaste to decrease dentinal sensitivity
• Make appropriate referrals to medical personnel if either the physical or dietary evaluation highlight major concerns