The female athlete triad: review of current literature

Osteoporosis in premenopausal women

The development of osteoporosis and fractures in young premenopausal women is infrequent and is usually associated with secondary causes of osteoporosis. Therefore, it is recommendable to perform a clinical evaluation and a thorough laboratory study searching for possible causes of bone loss in these patients. Treatment depends on the cause of osteoporosis and the associated processes as well as the future gestational desire of the patient, all of which should be taken into account when evaluating the most adequate diagnostic and the therapeutic approach in these patients.

Organized Sports for Children and Teenagers

Organized sports participation for youth has been growing across the nation. Much of this is fueled by the excitement surrounding collegiate, professional, and Olympic sports competitions, as women and athletes of color are specifically being recognized. There is also increased motivation due to the potential for financial success if elite skill levels can be achieved early on. Primary care clinicians play a major role in children and teenager participation in organized sports by carrying out the sports physical visit and by being a source of support in times of injury. With this responsibility, clinicians need to be aware of the risks for overuse injuries and burnout and the disparities that exist for youth athletes from racial and ethnic minority communities. Sports specialization, parental involvement, and inequi- ties in access are all factors affecting youth organized sports participation. Clinicians can educate and maintain awareness of these elements as a part of their preventative medicine practice. [Pediatr Ann. 2025;54(4):e119-e122.].

Reproductive Health Management of Female Adolescent Athletes With Relative-Energy Deficiency in Sport

The objective of this document is to guide the screening, diagnosis, and management of Relative Energy Deficiency in Sport (RED-S) in Adolescent/Young Adult (AYA) athletes to treat symptoms and reduce long-term sequelae with a focus on gynecologic aspects of the disorder. RED-S is a more comprehensive term for the condition previously known as the Female Athlete Triad. An overview of the clinical presentation, evaluation, and management of the reproductive health aspects of RED-S for female athletes is provided. For the purposes of this document, "female" refers to those designated female at birth, and "athlete" is defined as an individual who participates in regular physical activity. This document is intended for use by healthcare providers who care for female AYA athletes with RED-S.

How Does Physical Activity Modulate Hormone Responses?

Physical activity highly impacts the neuroendocrine system and hormonal secretion. Numerous variables, both those related to the individual, including genetics, age, sex, biological rhythms, nutritional status, level of training, intake of drugs or supplements, and previous or current pathologies, and those related to the physical activity in terms of type, intensity, and duration of exercise, or environmental conditions can shape the hormonal response to physical exercise. The aim of this review is to provide an overview of the effects of physical exercise on hormonal levels in the human body, focusing on changes in concentrations of hormones such as cortisol, testosterone, and insulin in response to different types and intensities of physical activity. Regular monitoring of hormonal responses in athletes could be a potential tool to design individual training programs and prevent overtraining syndrome.

Structure-function relationship of the pituitary gland in anorexia nervosa and intense physical activity

Patients with Anorexia Nervosa (AN) and athletes share intense physical activity and pituitary hormonal disturbances related to absolute (AN) or relative (athletes) undernutrition. Pituitary gland (PG) structure evaluations in those conditions are scarce, and did not differentiate anterior from posterior lobe. We evaluated the structure-function relationship of anterior and posterior PG in AN and athletes, and potential reversibility of this alteration in a group of weight-recovered patients (AN_Rec). Manual delineation of anterior (AP) and posterior (PP) PG was performed on T1-weighted MR images in 17 women with AN, 15 women with AN_Rec, 18 athletes women and 25 female controls. Anthropometric, hormonal, and psychometric parameters were explored and correlated with PG volumes. AP volume (APV) was lower in AN (448 ± 82 mm3), AN_Rec (505 ± 59 mm3), and athletes (540 ± 101 mm3) vs. Controls (615 ± 61 mm3, p < 0.00001, p < 0.00001 and p = 0.02, respectively); and smaller in AN vs. AN_Rec (p = 0.007). PP volume did not show any differences between the groups. APV was positively correlated with weight (R = 0.36, p = 0.011) in AN, and luteinizing hormone (R = 0.35, p = 0.014) in total group. In AN, mean growth hormone (GH) was negatively correlated with global pituitary volume (R = 0.31, p = 0.031) and APV (R = 0.29, p = 0.037). Absolute and relative undernutrition led to a decreased anterior pituitary gland volume, which was reversible with weight gain, correlated with low bodyweight, and blockade of gonadal hypothalamic-pituitary axis. Intriguing inverse correlation between anterior pituitary gland volume and GH plasma level could suggests a low storage capacity of anterior pituitary gland and increased reactivity to low insulin-like growth factor type 1.

Elevated IL-1β and Comparable IL-1 Receptor Antagonist Levels Are Characteristic Features of L-PRP in Female College Athletes Compared to Male Professional Soccer Players

Autologous platelet-rich plasma (PRP) therapy has been becoming popular for the treatment of musculotendinous injuries among athletes. However, for individual and practical variations, clinical success is hardly predictable. To overcome this difficulty, we have been exploring possible criterion candidates for monitoring its clinical effectiveness. In this study, we focused on sex-based differences in young elite athletes and compared the biochemical compositions of their PRP. Leukocyte-rich PRP (L-PRP) was manually prepared from blood samples collected from male professional soccer players (mPSPs) (n = 25) and female college athletes (fCAs) (n = 36). Platelet-derived growth factor-BB (PDGF-BB), transforming-growth factor-β1 (TGFβ1), platelet factor-4 (PF4), interleukin-1β (IL-1β), and IL-1 receptor antagonist (IL-1RA) were quantified using an enzyme-linked immunosorbent assay. The levels of PDGF-BB, TGFβ1, and PF4 in L-PRP were significantly higher in mPSPs than in fCAs. Conversely, IL-1β and IL-1RA were detected at significantly and slightly higher levels, respectively, in fCAs than in mPSPs. Our findings suggest that, even though L-PRP from fCAs may have lower potential to induce cell growth and differentiation than that of mPSPs, due to the latter's higher capacity to control inflammation, it does not necessarily imply that PRP treatment in fCAs is less effective. Thus, these cytokine levels should be checked before PRP therapy.

Characterization of Leukocyte- and Platelet-Rich Plasma Derived from Female Collage Athletes: A Cross-Sectional Cohort Study Focusing on Growth Factor, Inflammatory Cytokines, and Anti-Inflammatory Cytokine Levels

Platelet-rich plasma (PRP) has been increasingly used in sports medicine owing to its various advantages. The purpose of our project was to standardize the parameters before performing large-scale clinical trials in the near future to precisely evaluate individual PRP quality. To examine the effects of regular exercise on PRP quality, this study focused on young female athletes, who have been relatively less studied. Blood samples were obtained from female college athletes (n = 35) and ordinary healthy adults (n = 30), which were considered as controls, and leukocyte-rich PRP (L-PRP) was prepared manually. Body composition indices were determined using a bathroom weight scale equipped with an impedance meter. Growth factors and cytokines were quantified using ELISA kits. Platelet-derived growth factor-BB (PDGF-BB) and Transforming-growth factors β1 (TGFβ1) levels (per platelet) in L-PRP were significantly lower in female athletes than in controls. In contrast, Interleukin-1β and Interleukin 1 receptor antagonist (IL-1RA) levels (per platelet and L-PRP) in L-PRP were significantly higher in athletes, and this difference was more prominent in IL-1RA. These findings suggest that L-PRP from athletes may facilitate the inflammatory phase of the healing process by regulating the pro-inflammatory and anti-inflammatory balance. These chemical compositions can be adopted as "must-check" parameters to characterize individual PRP preparations prior to clinical trials.

Bone Health in Young Athletes: a Narrative Review of the Recent Literature

PURPOSE OF REVIEW

The aim of this review is to discuss the most recent published scientific evidence regarding bone health in the pediatric athlete.

RECENT FINDINGS

Pediatric athletes commonly suffer from overuse injuries to the physes and apophyses, as well as bone stress injuries, for which magnetic resonance imaging grading of the severity of injuries may be useful in guiding return to sport. Adolescent athletes, particularly those who train indoors and during the winter season, are at risk for vitamin D deficiency, which has important implications for bone mineral density. However, the relationship between vitamin D status and traumatic fracture risk is still unclear. While the female athlete triad is a well-established condition, the current work has led to the recognition of parallel pathophysiology in male athletes, referred to as the male athlete triad. Recent evidence suggests that transdermal 17β-estradiol treatment in amenorrhoeic female athletes is an effective adjunctive treatment to improve bone mineral density in treatment of the female athlete triad. Young athletes are at risk for musculoskeletal injuries unique to the growing skeleton. Optimizing nutritional intake, particularly related to adequate vitamin D intake and prevention of the athlete triad, is critical to optimize bone health in the young athlete.

Bone health in Norwegian female elite runners: a cross-sectional, controlled study

Objective

The primary objective was to compare bone mineral density (BMD) in Norwegian female elite long-distance runners with a control group of inactive females. Secondary objectives were to identify cases of low BMD, to compare the concentration of bone turnover markers, vitamin D and symptoms of low energy availability (LEA) between the groups, and to identify possible associations between BMD and selected variables.

Methods

Fifteen runners and fifteen controls were included. Assessments included dual-energy X-ray absorptiometry measurement of BMD in the total body, lumbar spine and dual proximal femur. Blood samples included endocrine analyses and circulating bone turnover markers. The risk of LEA was assessed through a questionnaire.

Results

Runners had higher Z-scores in the dual proximal femur (1.30 (0.20 to 1.80) vs 0.20 (-0.20 to 0.80), p<0.021) and total body (1.70 (1.20 to 2.30) vs 0.90 (0.80 to 1.00), p<0.001). The lumbar spine Z-score was similar between groups (0.10 (-0.70 to 0.60) vs -0.10(-0.50 to 0.50), p=0.983). Three runners had low BMD (Z-score <-1) in the lumbar spine. Vitamin D and bone turnover markers showed no differences between the groups. Forty-seven per cent of the runners were at risk of LEA. Dual proximal femur BMD showed a positive correlation to estradiol and a negative correlation to LEA symptoms in runners.

Conclusion

Norwegian female elite runners had higher BMD Z-score in the dual proximal femur and total body compared with controls, while no difference was observed in the lumbar spine. The advantages of long-distance running on bone health seem to be site specific, and there is still a need for the prevention of LEA and menstrual disorders in this group.

Athletic children: Guidelines and monitoring in pediatric orthopedic surgery

In day-to-day practice pediatric orthopedic surgeons often come up against the question of sport. The aim of the present study was to analyze the relationship between sport and childhood, with 3 questions: (1) What are the benefits of sport for children? (2) How to manage high-level child athletes? And (3) What sports are possible after major orthopedic surgery? Sports provide many benefits for children, and are to be encouraged. Sixty minutes' moderate to intense physical activity per day benefits motor development and bone mineralization and reduces the risk of obesity. On the other hand, excessive sports activity, as encountered in high-level sport, can be harmful for the child's development. The amount of training should not exceed a certain threshold in terms of hours per week according to age. Surgical treatment of sport-related traumatic lesions does not necessarily accelerate return to sport: indications need to be reasonable, despite pressure from the patient's circle. Sports are possible after major orthopedic surgery, although return to sport tends to be delayed and the level is lower than preoperatively.

Irisin and Bone in Sickness and in Health: A Narrative Review of the Literature

Irisin is a hormone-like myokine produced by the skeletal muscle in response to exercise. Upon its release into the circulation, it is involved in the browning process and thermogenesis, but recent evidence indicates that this myokine could also regulate the functions of osteoblasts, osteoclasts, and osteocytes. Most human studies have reported that serum irisin levels decrease with age and in conditions involving bone diseases, including both primary and secondary osteoporosis. However, it should be emphasized that recent findings have called into question the importance of circulating irisin, as well as the validity and reproducibility of current methods of irisin measurement. In this review, we summarize data pertaining to the role of irisin in the bone homeostasis of healthy children and adults, as well as in the context of primary and secondary osteoporosis. Additional research is required to address methodological issues, and functional studies are required to clarify whether muscle and bone damage per se affect circulating levels of irisin or whether the modulation of this myokine is caused by the inherent mechanisms of underlying diseases, such as genetic or inflammatory causes. These investigations would shed further light on the effects of irisin on bone homeostasis and bone disease.