Is the pill the answer for patients with the female athlete triad

As a family and sports physician, I care for many young women affected by the female athlete triad. Typically, they present with low body mass index (BMI), oligomenorrhea or amenorrhea, and, oftentimes, low bone mineral density or stress fractures. Sometimes, the low BMI stems from intentional restriction of dietary intake; other times, it is a consequence of an unintentional mismatch of caloric intake relative to high calorie expenditure related to training and/ or sport participation. Menstrual dysfunction may take the form of delayed menarche, short infrequent menses (oligomenorrhea), or complete absence of menstruation (amenorrhea). In this setting, bone health alterations are thought to be related to changes in one’s hormonal milieu, in addition to nutritional deficiencies. The mainstay of clinical management for patients affected by the female athlete triad is to correct the negative energy balance or low energy availability that leads to menstrual dysfunction and alterations in bone health. However, as many clinicians know, this can be challenging. Competitive female athletes often are resistant to recommendations to increase dietary intake and body weight and/or reduce their exercise or training. A common practice has been to place amenorrheic women, especially athletes, on oral contraceptives (OCP) in an effort to provide estrogen replacement, in hopes of protecting against bone loss and/or stress fracture. However, there is emerging evidence that this practice is not beneficial and may even lead to harm. The amenorrhea that occurs within the spectrum of the female athlete triad is referred to as functional hypothalamic amenorrhea. It is an adaptive mechanism that reduces a woman’s fertility when the body perceives that there is inadequate energy to support the substrate, let alone a fetus (2). While this may seem beneficial to many athletes, as they may not be seeking pregnancy, the adverse effects of this hormonal disruption is manifest in negative impacts on bone health, 1) in the form of inadequate bone mineral acquisition, 2) in the loss of existing bone mineral density, or 3) in increased risk of stress fracture, even in the setting of normal BMD. Combined OCP, consisting of estrogen and progesterone, have been recommended for use in treating women affected by the female athlete triad (1). However, the evidence supporting a role for OCP in treatment is inconclusive at best (5). This likely is related to the fact that combined OCP containing only estrogen and progesterone cannot overcome the alterations in hormone levels associated with low energy availability, including decreased total triiodothyronine, leptin, insulin, insulin-like growth factors, glucose, luteinizing hormone pulsatility, and follicle-stimulating hormone, as well as an increase in growth hormone and cortisol (5). Not only are OCP unable to counter the impact these hormone alterations have on bone health; they may contribute, in fact, to worsening bone health. Exogenous estrogen replacement in young athletes may lead to premature closure of physes (growth plate) (4), and early OCP use has been associated with lower BMD in the spine and femoral neck among female distance runners (6). So what is a clinician to do when faced with the challenge of treating an athlete with the female athlete triad? The first step is to perform a comprehensive history and physical examination to confirm the diagnoses. Second, engage a multidisciplinary team, which often includes a physician, sports dietician, and mental health professional, to guide and support the athlete’s recovery. The cornerstone of treatment is to reverse the situation of low energy availability, which is typically a consequence of both inadequate stored energy (low BMI) and low energy intake relative to expenditure. The goal is to increase caloric intake above 30-kcalIkg fat-free mass (FFM); some would recommend upward of 45-kcalIkg FFM to produce changes in bone mineral density (3,7). What this translates into practically is approximately 1,912 cal for a 110-lb female distance runner with 15% body fat (110 lb 0.85 = 93.5-lb FFM Y 42.5-kg FFM 45-kcalIkg FFM = 1,912 kcal). Assuming she was continuing to train throughout this recovery period, adding additional calories to cover exercise-related expenditures would be required to replace the deficit (~100 kcalImile). The role of the sports dietician is to help the athlete consume the required amount of calories while minimizing INVITED COMMENTARY