Osteoporosis risk real for female athletes

Evidence suggests it can hit elite and amateur athletes alike.

By Victoria Stagg Elliott — Posted March 6, 2006

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Elizabeth Joy, MD, a family physician in Salt Lake City, has often had to deliver bad news to 20-something females with long athletic histories. After years of hard training and irregular menstrual cycles, some have the bones of old women.

"It's been very hard to tell them that they have the bone mineral density of 60-year-olds because they were told that not having menstrual periods was normal," said Dr. Joy, an associate professor in the Dept. of Family and Preventive Medicine at the University of Utah. "And the bone loss to some degree is irreversible."

The fact that her experiences are not isolated has led physicians and official sports bodies to increasingly recognize that, although sports participation is vital for women, it can also be detrimental and lead to the "female triad" of eating disorders, dysmenorrhea and osteoporosis.

The International Olympic Committee Medical Commission issued its first related position statement in November 2005 terming this condition a serious problem and recommending ways that physicians and other professionals can handle it. On the heels of this statement, a paper was published in the February International Journal of Eating Disorders mapping out how the IOC statement could be used by physicians.

"You have to ask the right questions because we're more concerned about [an athlete's] health than their athletic performance," said Ron A. Thompson, PhD, one of the paper's authors and a member of the panel that wrote the IOC directive.

Experts praised these efforts for focusing attention on the triad and providing a tool that could be used to address it.

"We are thrilled that the IOC has stepped up to the plate and is reminding us that athletes are in high-pressure situations and that there can be consequences if they are training in unhealthy ways," said Ellen Rome, MD, MPH, head of the adolescent medicine section at the Cleveland Clinic Foundation, who was speaking on behalf of the Academy for Eating Disorders. "We don't want [athletes] striving to get [to the Olympics] at the expense of their bodies."

A problem for more than the elite

There is also growing awareness that this problem extends far beyond women athletes who compete at the Olympic level. Early signs may be detected at a point when more can be done to prevent some of the dire implications, especially osteoporosis. According to a study published in the Archives of Pediatric and Adolescent Medicine last month, a survey of 170 female high-school athletes from six high schools in southern California found that, although only a small number fit the full definition of the triad, about 20% had at least one aspect of it.

"This is not just a problem of professional athletes," said Sarah Sams, MD, a family physician from Hilliard, Ohio. "It can happen to weekend warriors, the mom down the street and high-school students."

American Medical Association policy states that adolescent athletes should be assessed for eating disorders and amenorrhea during the preparticipation physical. And the Archives study suggests that the sports physical may be the time to intervene even if all three elements of the triad are not completely present.

"We need to try to catch things early on before there's potential damage," said Jeanne F. Nichols, PhD, lead author and professor of exercise and nutritional sciences at San Diego State University.

Experts say, however, that there are numerous barriers to addressing the triad. The IOC position statement advised physicians to be particularly alert for subclinical eating disorders that may be endangering an athlete, but these are not always as easy to detect as bulimia or anorexia nervosa. The reasons for the lack of nutrition among athletes, such as a belief that a lower weight may lead to improved performance, are often different from those for nonathletes, who are more likely to have eating issues because of self-image problems. Also, many physicians may be more worried about obesity and less concerned with the weight or nutritional status of lean and active patients.

"Physicians are so used to their patients being overweight that they may not know how to respond to their patient who is undereating," said Dr. Thompson, a consulting psychologist with the athletic department at Indiana University in Bloomington.

Some physicians as well as many athletes and coaches may also believe that the cessation of menstruation is not a concern.

"Many of the symptoms may be thought of as just normal consequences of their training," said Boone Barrow, MD, a sports medicine and family physician with the Scott and White Clinic in College Station, Texas.

But both eating problems and menstrual irregularities -- what many regard as the first two prongs of the triad -- may lead to the third prong, osteoporosis, about which experts are sounding the loudest alarm. With girls building most of their bone density in their teens, those who work with athletes are particularly concerned that the skeletons of some girls will never reach their full potential.

"Not being able to reach your peak bone mass can cause lifelong problems," said Heidi Prather, DO, a physiatrist and associate professor at Washington University in St. Louis.

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Tips to topple the triad

Identifying disordered eating should go beyond the strict criteria that are used for nonathletes to identify subclinical problems that could lead to dangerous energy deficits. For instance:

  • Athletes suspected of having food issues should be referred to a licensed dietician with experience working with this population.
  • Those who refuse appropriate treatment should not get the go-ahead to participate in their sport.
  • Detailed questions should be asked about menstrual cycles.
  • The absence of menstruation should not be thought of as a normal result of training.
  • Osteoporosis should be considered a possibility in girls who have missed more than six periods.
  • Oral contraceptives may be prescribed if changes in nutrition and training do not restore menstruation.

Source: International Olympic Committee, Position Stand on the Female Athlete Triad, Nov. 9, 2005

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External links

International Olympic Committee consensus statement on the female athlete triad (link)

"Practical use of the International Olympic Committee Medical Commission position stand on the female athlete triad: A case example," International Journal of Eating Disorders, published online Feb. 9 (link)

"Prevalence of the Female Athlete Triad Syndrome Among High School Athletes," abstract, Archives of Pediatrics and Adolescent Medicine, February (link)

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