Characteristics of the female athlete triad in collegiate cross-country runners

Menstrual Dysfunction in Adolescent Female Athletes

Despite the benefits of exercise on mental and physical health, excessive training loads can lead to health problems in the long term, including a wide spectrum of menstrual dysfunction (MD). This narrative review aims to analyze the relationship between physical exercise and MD in adolescent female athletes to support regular menstrual health monitoring and promote educational programs on reproductive risks. When dealing with MD in young athletes, several factors entangled with maturation of the hypothalamus-pituitary-ovarian axis should be considered. Firstly, some disciplines seem to have a higher prevalence of MD due to the high loads of training regimes and the early introduction of athletes to a competitive career. Moreover, low energy intake and a low body mass index appear to exacerbate existing MD. Lastly, disordered eating behaviors and psychological stress can contribute to MD in female athletes. The type of sport, influencing the intensity and duration of exercise, as well as individual psycho-physiological and environmental factors, may influence the role of physical activity in the manifestation of MD. Early recognition and management of MD, along with collaboration between sports organizations and health professionals, are crucial to minimize risks, ensure proper nutrition, and balance training with recovery. Keeping an open discussion on the topic may prospectively improve awareness, early diagnosis, and treatment strategies, as well as reduce injury risk and enhance sports performance.

A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating and associated factors among athletes worldwide

BACKGROUND

The purpose of this meta-analysis was to provide a pooled prevalence estimate of self-reported disordered eating (SRDE) in athletes based on the available literature, and to identify risk factors for their occurrence.

METHODS

Across ten academic databases, an electronic search was conducted from inception to 7th January 2024. The proportion of athletes scoring at or above predetermined cutoffs on validated self-reporting screening measures was used to identify disordered eating (DE). Subgroup analysis per country, per culture, and per research measure were also conducted. Age, body mass index (BMI), and sex were considered as associated/correlated factors.

RESULTS

The mean prevalence of SRDE among 70,957 athletes in 177 studies (132 publications) was 19.23% (17.04%; 21.62%), I2 = 97.4%, τ2 = 0.8990, Cochran's Q p value = 0. Australia had the highest percentage of SRDE athletes with a mean of 57.1% (36.0%-75.8%), while Iceland had the lowest, with a mean of 4.9% (1.2%-17.7%). The SRDE prevalence in Eastern countries was higher than in Western countries with 29.1% versus 18.5%. Anaerobic sports had almost double the prevalence of SRDE 37.9% (27.0%-50.2%) compared to aerobic sports 19.6% (15.2%-25%). Gymnastics sports had the highest SRDE prevalence rate, with 41.5% (30.4%-53.6%) while outdoor sports showed the lowest at 15.4% (11.6%-20.2%). Among various tools used to assess SRDE, the three-factor eating questionnaire yielded the highest SRDE rate 73.0% (60.1%-82.8%). Meta-regression analyses showed that female sex, older age, and higher BMI (all p < 0.01) are associated with higher prevalence rates of SRDE.

CONCLUSION

The outcome of this review suggests that factors specific to the sport affect eating behaviors throughout an athlete's life. As a result, one in five athletes run the risk of developing an eating disorder. Culture-specific and sport-specific diagnostic tools need to be developed and increased attention paid to nutritional deficiencies in athletes.

The Potential Role of Nutrition in Overtraining Syndrome: A Narrative Review

Competition between athletes and an increase in sporting knowledge have greatly influenced training methods while increasing the number of them more and more. As a result, the number of athletes who have increased the number and intensity of their workouts while decreasing recovery times is rising. Positive overtraining could be considered a natural and fundamental process when the result is adaptation and improved performance; however, in the absence of adequate recovery, negative overtraining could occur, causing fatigue, maladaptation, and inertia. One of the earliest forms of fatigue is overreaching. It is considered to be an accumulation of training that leads to reduced sports performance, requiring days or weeks to recover. Overreaching, if followed by adequate recovery, can lead to an increase in athletic performance. Nonetheless, if overreaching becomes extreme, combined with additional stressors, it could lead to overtraining syndrome (OTS). OTS, caused by systemic inflammation, leads to central nervous system (CNS) effects, including depressed mood, further inflammation, central fatigue, and ultimately neurohormonal changes. There are therefore not only physiological, biochemical, and immunological but also psychological symptoms or markers that must be considered, independently or together, being intrinsically linked with overtraining, to fully understand OTS. However, to date, there are very few published studies that have analyzed how nutrition in its specific food aspects, if compromised during OTS, can be both etiology and consequence of the syndrome. To date, OTS has not yet been fully studied, and the topic needs further research. The purpose of this narrative review is therefore to study how a correct diet and nutrition can influence OTS in all its aspects, from prevention to treatment.

The Prevalence of Menstrual Cycle Disorders and Menstrual Cycle-Related Symptoms in Female Athletes: A Systematic Literature Review

BACKGROUND

Menstrual cycle (MC) disorders and MC-related symptoms can have debilitating effects on the health and performance of female athletes. As the participation of women in sports continues to increase, understanding the prevalence of a range of MC disorders and MC-related symptoms may guide preventive strategies to protect the health and optimise the performance of female athletes.

OBJECTIVE

To examine the prevalence of MC disorders and MC-related symptoms among female athletes who are not using hormonal contraceptives and evaluate the assessment methods used to identify MC disorders and MC-related symptoms.

METHODS

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Six databases were searched until September 2022 for all original research that reported the prevalence of MC disorders and/or MC-related symptoms in athletes not using hormonal contraceptives, which included the definitions of the MC disorders examined, and the assessment methods used. MC disorders included amenorrhoea, anovulation, dysmenorrhoea, heavy menstrual bleeding (HMB), luteal phase deficiency (LPD), oligomenorrhoea, premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). MC-related symptoms included any affective and physical symptoms related to the MC that do not cause significant personal, interpersonal or functional impairment. The prevalence data across eligible studies were combined, and all studies were qualitatively synthesised to evaluate the assessment methods and tools used to identify MC disorders and MC-related symptoms. The methodological quality of studies was assessed using a modified Downs and Black checklist.

RESULTS

Sixty studies involving 6380 athletes were included. A wide range of prevalence was observed for all types of MC disorders, with a dearth of data on anovulation and LPD. Based on pooled data, dysmenorrhoea (32.3%; range 7.8-85.6%) was the most prevalent MC disorder. Studies reporting MC-related symptoms mostly examined the premenstrual and menstruation phases, where affective symptoms appeared more prevalent than physical symptoms. A larger proportion of athletes reported symptoms during the initial days of menstruation compared with the premenstrual phase. MC disorders and MC-related symptoms were retrospectively assessed using self-report methods in 90.0% of studies. Most studies (76.7%) in this review were graded as moderate quality.

DISCUSSION

MC disorders and MC-related symptoms are commonplace among female athletes, warranting further research examining their impact on performance and preventive/management strategies to optimise athlete health. To increase the quality of future studies, researchers should adopt standardised definitions of MC disorders and assessment methods such as a combination of calendar counting, urinary ovulation tests and a mid-luteal phase serum progesterone measurement when assessing menstrual function. Similarly, standardised diagnostic criteria should be used when examining MC disorders such as HMB, PMS and PMDD. Practically, implementing prospective cycle monitoring that includes ovulation testing, mid-luteal blood sampling (where feasible) and symptom logging throughout the MC could support athletes and practitioners to promptly identify and manage MC disorders and/or MC-related symptoms.

TRIAL REGISTRATION

This review has been registered in the PROSPERO database (CRD42021268757).

Exploring the Relationship between Micronutrients and Athletic Performance: A Comprehensive Scientific Systematic Review of the Literature in Sports Medicine

The aim of this systematic review is twofold: (i) to examine the effects of micronutrient intake on athletic performance and (ii) to determine the specific micronutrients, such as vitamins, minerals, and antioxidants, that offer the most significant enhancements in terms of athletic performance, with the goal of providing guidance to athletes and coaches in optimizing their nutritional strategies. The study conducted a systematic search of electronic databases (i.e., PubMed, Web of Science, Scopus) using keywords pertaining to micronutrients, athletic performance, and exercise. The search involved particular criteria of studies published in English between 1950 and 2023. The findings suggest that vitamins and minerals are crucial for an athlete's health and physical performance, and no single micronutrient is more important than others. Micronutrients are necessary for optimal metabolic body's functions such as energy production, muscle growth, and recovery, which are all important for sport performance. Meeting the daily intake requirement of micronutrients is essential for athletes, and while a balanced diet that includes healthy lean protein sources, whole grains, fruits, and vegetables is generally sufficient, athletes who are unable to meet their micronutrient needs due to malabsorption or specific deficiencies may benefit from taking multivitamin supplements. However, athletes should only take micronutrient supplements with the consultation of a specialized physician or nutritionist and avoid taking them without confirming a deficiency.

The Prevalence of Menstrual Cycle Disorders in Female Athletes from Different Sports Disciplines: A Rapid Review

The aim of this study was to rapidly review the literature on the prevalence of menstrual disorders in female athletes from different sports modalities. Articles were searched in the Web of Science and PubMed database in May 2022. A total of 1309 records were identified, and 48 studies were included in the final stage. The menstrual disorders described in the included studies were primary (in 33% of included studies) and secondary amenorrhea (in 73% of included studies) and oligomenorrhea (in 69% of included studies). The prevalence of menstrual disorders among the studies ranged from 0 to 61%. When data were pooled according to discipline (mean calculation), the highest prevalence of primary amenorrhea was found in rhythmic gymnastics (25%), soccer (20%) and swimming (19%); for secondary amenorrhea in cycling (56%), triathlon (40%) and rhythmic gymnastics (31%); and oligomenorrhea in boxing (55%), rhythmic gymnastics (44%) and artistic gymnastics (32%). Based on the results of this review, the study supports the literature of the higher prevalence of menstrual disorders in gymnastics and endurance disciplines. However, team sports modalities such as volleyball and soccer also presented a considerable percentage of menstrual disorders compared to the general population. It reinforces the importance of coaches and physicians paying attention to athletes' menstrual cycle as the occurrence of menstrual disorders can be associated with impairment on some health components.

Runner's health choices questionnaire: female collegiate cross-country runners' perspectives on health and eating

OBJECTIVE

To assess female collegiate cross-country runners' perspectives regarding sport-related health and the factors impacting eating behaviors.

PARTICIPANTS/METHODS

The Runner's Health Choices Questionnaire, a previously validated survey, was electronically distributed to female collegiate cross-country runners. Quantitative descriptive analysis was performed on all questions.

RESULTS

A total of 353 female collegiate cross-country runners completed the survey. The most common intrinsic factors that impacted overall diet type were makes you feel healthy, enjoyment of food, and athletic performance enhancement. Extrinsic factors such as practice/race that day, creating a balanced diet, and choices in the cafeteria were the top factors influencing daily meal decisions. Seventy-seven percent of athletes reported that they would be likely to apply information from a healthcare professional if they had access.

CONCLUSION

Female cross-country runners appeared willing to apply nutritional information; therefore, it is important that generalized nutrition education with an emphasis on intrinsic and extrinsic factors for food choices be considered for female collegiate cross-country runners.

The Female Athlete Triad-the impact of running and type of diet on the regularity of the menstrual cycle assessed for recreational runners

Background

The Female Athlete Triad (FAT) included three interrelated conditions including disordered eating, amenorrhea, and osteoporosis. The American College of Sports Medicine updated the definition of FAT to reflect the interdependence of low energy availability with or without eating disorders. The main aim of the study was to assess the impact of recreational running on potential disturbances in the regularity of women's menstrual cycles. Additionally, this work compared differences in the menstrual cycle between women runners and women who did not regularly practice sports. The respondents were also asked about the type of diet they consumed.

Methods

A total of 360 women took part in the research. This group included 217 runners and 143 control. The authors' questionnaire was used in the research.

Results

When compared to the control group, the runners had an increased frequency of menstrual cycles of <24 days (10.14% vs. 3.50%), fewer typical cycles of 25-31 days (75.58% vs. 86.71%), had fewer regular cycles per year (9.62 vs. 11.22), shorter duration of bleeding (4.79 vs. 5.27 days), and an increased frequency of painless menstruation (23.96% vs. 7.69%). A positive predictor of menstrual cycle disorders was the use of a 'special diet' (R:1.67; 95% C:0.47-2.87).

Conclusions

The runners had shorter and less regular monthly cycles and shorter and more often painless menstrual bleeding when compared to the control group. The frequency of menstrual disorders in runners was increased by following a 'special diet'. The frequency of menstrual cycle disorders in runners, however, did not differ significantly from the control group.

Prevalence of Female Athlete Triad Risk Factors among Female International Volunteers and College Age-Matched Controls

This study retrospectively compared the prevalence of factors related to the female athlete triad (low energy availability, secondary amenorrhea (SA), low bone mineral density (BMD)), and post-study BMD of female college students and female international volunteer missionaries (volunteers). Female college students (21–26 years) completed a survey that retrospectively assessed an 18-month study period (volunteer service or first 18 months of college); Diet History Questionnaire III (DHQ III) and Dual-Energy X-ray Absorptiometry (DXA) scan were optional. One-way ANOVAs and chi-squared distributions assessed group differences. Logistic regression assessed covariates of SA and BMD; corresponding odds ratios (OR) and confidence intervals (CI) were calculated. Statistical significance was set at p < 0.001. 3683 participants (58.8% volunteers, 31.5% non-volunteers, 9.8% others) provided complete survey data; 246 completed the DHQ III, and 640 had a post-study DXA scan. Volunteers had higher metabolic equivalent (MET) hours than non-volunteers and others (p < 0.001), and higher prevalence of food insecurity (p < 0.001) and SA (p < 0.001). Volunteers had higher odds of SA (OR = 2.17, CI = 1.75–2.62) than non-volunteers. Weight loss, body satisfaction, “other” weight loss methods, increased MET hours, and vomiting during the study period increased participants’ odds of SA. Participants’ average BMD Z-scores were within the expected range at all sites, with no significant group differences. Volunteers’ higher MET hours and higher prevalence of food insecurity and SA did not result in significantly lower post-study period BMD.

Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States

BACKGROUND

Menstrual irregularity (MI) is common in female athletes and is a component of the Female Athlete Triad (Triad). Many athletes with the Triad are started on hormonal contraceptives (HC) for MI, but this interferes with the ability to monitor menstrual cycle regularity and can mask other causes of MI. There are limited studies investigating the relationship between MI, HC use, and injury in female collegiate athletes.

OBJECTIVE

To examine the prevalence of and relationship between HC use, MI, and bone stress injuries in female collegiate athletes in the United States.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PARTICIPANTS

1020 U.S. female collegiate athletes (age ≥ 18 years).

METHODS OR INTERVENTIONS

Assessment of risk factors for menstrual irregularity and bone stress injuries was conducted via a one-time survey.

MAIN OUTCOME MEASURES

HC use, MI, history of stress fractures.

RESULTS

Current HC use prevalence was 65% (95% confidence interval [CI], 61.9%, 67.8%). Of all athletes, 47% reported past MI. Of the athletes who were not currently using HCs, 32% had current MI. Compared with athletes without past MI, more athletes with past MI reported current HC use (73% vs. 57%) and indicated menstrual cycle consistency as the primary reason for use (24% vs. 4%) (P < .001). Additionally, 25% of athletes reported a history of stress fractures, which was associated with lean/aesthetic sports participation (odds ratio [95% CI]: 1.9 [1.4, 2.5]; P < .001) and less oral contraceptive pill (OCP) use (0.7 [0.5, 1.0]; P = .043). Compared with OCPs, injectable HCs were associated with greater odds of a history of stress fractures (4.5[1.6, 12.3]; P = .004).

CONCLUSIONS

HC use was prevalent among this cohort of female collegiate athletes, and almost half of the athletes reported past MI. A goal of menstrual cycle regularity was cited by 24% of athletes as a primary reason to use HCs, which shows that more athlete education is needed to avoid masking MI and the Triad with HCs. Further studies elucidating the relationship between HC use, MI, and sports-related injury are warranted.

Are Elite Female Soccer Athletes at Risk for Disordered Eating Attitudes, Menstrual Dysfunction, and Stress Fractures?

OBJECTIVE

To determine the prevalence of stress fractures, menstrual dysfunction and disordered eating attitudes in elite female soccer athletes.

DESIGN

Cross-sectional descriptive study.

SETTING

Female soccer athletes were recruited from a national level youth soccer club, an NCAA Division I university team, and a women's professional team.

PARTICIPANTS

Two hundred twenty female soccer athletes with a mean age of 16.4 ± 4 years and BMI of 20.8 ± 2 kg/m(2) completed the study, representing all athletes from the included teams.

METHODS

One-time surveys completed by the athletes.

MAIN OUTCOME MEASUREMENTS

Height and weight were recorded, and body mass index (BMI) was calculated for each athlete. Athletes reported age of menarche, history of missing 3 or more menses within a 12-month period and stress fracture. The Eating Attitudes Test (EAT-26) was used to assess the athlete's body perception and attitudes toward eating.

RESULTS

Of the 220 soccer athletes, 3 athletes (1.6%) had a low BMI for their age, and 19 (8.6%) reported stress fractures of the lower extremity. Among athletes who had reached menarche, the average onset was 13 + 1 year; menstrual dysfunction were present in 21 (19.3%). On the EAT-26, 1 player scored in the high risk range (>20) and 17 (7.7%) scored in the intermediate risk range (10-19) for eating disorders. Athletes with an EAT-26 score ≥ 10 points had a significantly higher prevalence of menstrual dysfunction in the past year compared to athletes with an EAT-26 score of less than 10 (P = .02).

CONCLUSIONS

Elite female soccer athletes are susceptible to stress fractures and menstrual dysfunction and have delayed onset of menarche despite normal BMI and appropriate body perception and attitudes towards eating. Further studies are needed to better understand stress fracture risk in female soccer athletes and in other team sports to determine how these findings relate to long-term bone health in this population.

Female Athlete Triad: Past, Present, and Future

After the passage of Title IX in 1972, female sports participation skyrocketed. In 1992, the female athlete triad was first defined; diagnosis required the presence of an eating disorder, amenorrhea, and osteoporosis. However, many athletes remained undiagnosed because they did not meet all three of these criteria. In 2007, the definition was modified to a spectrum disorder involving low energy availability (with or without disordered eating), menstrual dysfunction, and low bone mineral density. With the new definition, all three components need not be present for a diagnosis of female athlete triad. Studies using the 1992 definition of the disorder demonstrated a prevalence of 1% to 4% in athletes. However, in certain sports, many female athletes may meet at least one of these criteria. The actual prevalence of athletes who fall under the "umbrella" diagnosis of the female athlete triad remains unknown.

Prevalence of individual and combined components of the female athlete triad

PURPOSE

The female athlete triad (Triad) is a syndrome linking low energy availability (EA) with or without disordered eating (DE), menstrual disturbances (MD), and low bone mineral density (BMD) in exercising women. The prevalence of Triad conditions (both clinical and subclinical) has not been clearly established.The purpose of this review is to evaluate the studies that determined the prevalence of clinical or subclinical Triad conditions (low EA, DE, MD, and low BMD) in exercising women and in women participating in lean (LS) versus nonlean sports (NLS) using self-report and/or objective measures.

METHODS

A review of publications using MEDLINE and PubMed was completed. Randomized controlled trials and observational studies that evaluated the prevalence of clinical and subclinical Triad conditions (MD, low BMD, low EA, and DE) in exercising women were included.

RESULTS

Sixty-five studies were identified for inclusion in this review (n = 10,498, age = 21.8 ± 3.5 yr, body mass index = 20.8 ± 2.6 kg·m; mean ± SD). A relatively small percentage of athletes (0%-15.9%) exhibited all three Triad conditions (nine studies, n = 991). The prevalence of any two or any one of the Triad conditions in these studies ranged from 2.7% to 27.0% and from 16.0% to 60.0%, respectively. The prevalence of all three Triad conditions in LS athletes versus NLS athletes ranged from 1.5% to 6.7% and from 0% to 2.0%, respectively. LS athletes demonstrated higher prevalence rates of MD and low BMD (3.3% vs 1.0%), MD and DE (6.8%-57.8% vs 5.4%-13.5%), and low BMD and DE (5.6% vs 1.0%) than the NLS athletes.

CONCLUSIONS

Although the prevalence of individual/combined Triad conditions is concerning, our review demonstrates that additional research on the prevalence of the Triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem.

Osteoporosis health beliefs of women with increased risk of the female athlete triad

Women with increased risk of the female athlete triad (Triad) are more susceptible to osteoporosis compared to other women. The study included 65 women with increased risk of the Triad who had their osteoporosis health beliefs measured to assess their concern for the disease. Participants were female collegiate cross-country runners at different levels of competition, including National Association of Intercollegiate Athletics (NAIA) and National Collegiate Athletic Association (NCAA) Divisions III, II, and I. Although these participants have an increased risk of the Triad and are more susceptible to osteoporosis, on a scale of 1 to 5, results showed that they had low to moderate perceived susceptibility to osteoporosis with a mean score as high as 2.81 and moderate perceived severity of osteoporosis with a mean score as high as 3.38. A statistically significant difference in perceived susceptibility to osteoporosis was found between female collegiate cross-country runners in the NAIA and those in the NCAA DIII. Reasons that could explain relatively low levels of concern for osteoporosis in female collegiate cross-country runners and reasons for significant differences in perceived susceptibility to osteoporosis are given, and recommendations for health education and intervention to help care for this population are provided.

Influence of a physical fitness course on menstrual cycle characteristics

AIM

Exercise is commonly cited as a remedy for menstrual symptoms. The purpose of the present study was to evaluate the effect of a period of exercise on physical and psychological symptoms of menstruation, dysmenorrhea, oligomenorrhea and amenorrhea.

METHODS

Participants of the study were 250 students of Shiraz University who enrolled in a fitness course. The study design was semi-experimental with one group. Prior and after 12 weeks of a physical fitness program, our subjects completed questionnaires on menstrual distress. The physical fitness training program included physical fitness exercises (cardiovascular endurance, muscular endurance, agility, speed, strength; duration: 90 min, frequency: twice weekly, intensity: 50 to 70% of maximum heart rate). The t test was used for analysis of the data.

RESULTS

Physical premenstrual symptoms (p = 0.005), psychological premenstrual symptoms (p = 0.019), dysmenorrhea (p = 0.0001) and oligomenorrhea (p = 0.034) were significantly reduced after the training program. There was no difference in the incidence of amenorrhea before and after the training program (p = 0.162).

CONCLUSION

Our findings indicate that selected physical fitness exercises positively influenced menstrual symptoms.

Associations of oral contraceptive use and dietary restraint with bone speed of sound and bone turnover in university-aged women

The associations of oral contraceptive use and cognitive dietary restraint with bone speed of sound (SOS) and bone turnover were investigated in 100 Canadian university-aged women (18–25 years old). Dietary restraint was assessed using the Dutch Eating Behavior Questionnaire (DEBQ) and daily calcium intake (Ca++) was assessed by the rapid assessment method. Quantitative ultrasound was used to measure SOS at the tibia and radius. Bone formation was estimated from plasma osteocalcin (OC), 25-OH vitamin D, and serum bone-specific alkaline phosphatase (BAP). Bone resorption was determined from serum cross-linked N-teleopeptide of type I collagen (NTx) and plasma C-terminal telopeptide of type I collagen (CTx). Weekly physical activity energy expenditure (WAeq) was assessed using a standardized questionnaire, and height, body mass, relative body fat (%BF), and chest, waist, and hip circumferences were also measured. Participants were divided into low and moderate to high dietary restrainers (LDRs and MDRs, respectively). These groups were further sub-divided into users and non-users of oral contraceptives. All groups had similar age at menarche, body composition, WAeq, and equally low levels of Ca++and vitamin D. Within the non-users of oral contraceptives, MDR exhibited a lower tibial SOS (p ≤ 0.024) and OC (p ≤ 0.009) than LDR. Moreover, amongst the LDR, the oral contraceptive users had a lower tibial SOS (p ≤ 0.015) and BAP (p ≤ 0.002) than non-users. These results show that bone SOS and bone turnover were influenced by oral contraceptives and cognitive dietary restraint among this population of young women independent of body composition and physical activity.