eMedicine Specialties > Physical Medicine and Rehabilitation > Medical Diseases

Low Energy Availability in the Female Athlete: Treatment & Medication

Author: Stacey Miller-Smith, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, UMDNJ-New Jersey Medical School
Coauthor(s): Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Contributor Information and Disclosures

Updated: Jan 8, 2009

Treatment

Medical Issues/Complications

Nutritional issues

Appetite and energy intake

Because appetite is not a reliable means of determining the energy needs of the female athlete and because exercise appears to suppress appetite, nutritional counseling is important for normally menstruating athletes and for athletes with menstrual disturbances.

Athletes need to eat by discipline, not by appetite. Studies have shown that a threshold of 20-30 kcal/kg LBM/d is needed for reproductive function and bone health, and a diet comfortably greater than 30 kcal/kg LBM/d is recommended. Counseling should focus on how a patient's diet can provide close to 45 kcal/kg LBM/d in order for the patient to maintain reproductive and skeletal health. A balanced, nutrient-rich sample diet of 45 kcal/kg LBM/d tailored to individual weight or a general sample diet for weights of 55, 60, 65, and 70 kg on either a poster in the training room or a handout would be helpful. In addition, an estimation of the energy expenditure during a typical daily training regimen and the replacement of this expenditure are important.

Tables of energy expenditure in various athletic activities can be used for this calculation. For instance, a track coach could estimate the approximate energy expenditure during 1 practice (miles run), determine how many power bars or containers of yogurt are needed to replace the expended energy, and encourage his/her athletes to eat these snacks after practice. A poster of snacks that replace, for instance, the energy lost during 1 hour of intermittent running (eg, during soccer practice) or after a run of a certain number of miles (eg, during track practice), could be displayed in the training room.

Athletes should be counseled that if they underconsume, they are actually slowing their metabolic rate and that an increase in energy intake helps to restore their metabolic rate, prevent deleterious effects on reproductive and skeletal health, and even improve performance. Therefore, if the athlete's weight increases while her metabolic rate is adjusting, at least part of it is likely due to an increase in LBM, which even further improves performance.

For athletes with menstrual disturbances, energy intake should be even more closely monitored to ensure that it approximates 45 kcal/kg LBM/d along with the replacement of energy used during exercise. While intake is increased over a period of 1-2 weeks, electrolytes and hematocrit values should be monitored at least once a week during the transition.

Monthly measurement of acetoacetate

Monthly measurements of urinary acetoacetate in times of increased training in normally menstruating athletes could be performed by the athlete herself or by the athletic trainer. The goal should be a complete absence of urinary ketones before and after a meal as well as before and after training. In amenorrheic athletes or in those who are positive for ketones, daily keto-stick measurements can be made before and after meals, as well as before and after training, and energy intake can be increased until no evidence of acetoacetate is present in the urine and normal reproductive function is observed.

Eating disorders

If disordered eating patterns are suspected, a therapist or psychiatrist familiar with treating eating disorders should be consulted immediately. For more information on the workup and treatment of eating disorders, please refer to the eMedicine article Female Athlete Triad.1,2

Optimum bone health

Calcium intake is a key determinant of peak bone mass in adolescent women.27 Supplementation of calcium from adolescence through young adult life, with a recommended daily allowance of 1200 mg/d, is advised. In women aged 25-50 years, 1000 mg/d is recommended.27

Vitamin K is a cofactor necessary for the gamma carboxylation of several bone matrix proteins, one of which is osteocalcin. In one study of elite amenorrheic athletes, vitamin K supplementation induced an increase in bone formation markers and an even greater decrease in bone resorption markers.45 Therefore, supplementation with a multivitamin containing vitamin K might optimize bone health in female athletes. A multivitamin also contains other vitamins and minerals (eg, vitamin C, manganese, copper, zinc) that serve as cofactors in the modification of the bone matrix.

Physical activity

Amenorrhea or oligomenorrhea

If no evidence suggests musculoskeletal injury (eg, stress fracture) in an amenorrheic or oligomenorrheic patient, discontinuing or decreasing physical activity is not necessary to restore menstrual function. Animal studies have shown that an increase in energy intake is sufficient to restore menstrual function.20 Future studies on refeeding in amenorrheic humans are needed to confirm that this is the safest and most effective treatment.

Optimum bone health

Athletes who perform weight-bearing exercise have higher bone mineral densities than those that do not, but the advantage in bone mineral density tends to be site specific, depending on where the load has been applied. Studies have shown conflicting results in terms of the magnitude of force required to function as an osteogenic stimulus. Whether the bone mineral density increase from weight-bearing exercise persists into adulthood after the cessation of exercise is unclear, and studies have shown mixed results.

The first published follow-up study of a 7-month, high-impact exercise program in prepubertal children after 7 months of detraining showed a persistent skeletal effect at the femoral neck.46 Follow-up studies of childhood exercise intervention after detraining will clarify this issue.

The addition of 50 vertical jumps per day has been shown to increase femoral and trochanteric bone mineral density by 2-3% in premenopausal women after 5 months47 and might prove valuable in creating an osteogenic stimulus in athletes, such as swimmers, who do not regularly load their skeleton during training.48

Oral contraceptives

The issue of whether a female athlete should take oral contraceptives is a personal one; the importance of a drug's contraceptive and regulatory effects should be balanced against possible performance effects. Athletes should discuss this issue with their health care provider.

Studies have not shown that oral contraceptives have a major impact on performance, but several studies on monophasic and triphasic low-dose oral contraceptives have found a decrease in VO2max in females from all athletic backgrounds after more than 1 month's use of these drugs. Athletes should be educated regarding this effect.9,49 Because these same studies have shown a reversal of this effect within 1 month of the cessation of oral contraceptives, women who choose to take an oral contraceptive should be counseled that the decrease in VO2max is likely reversible.

Because oral contraceptives might mask symptoms of amenorrhea induced by low energy availability, ketone measurements are even more essential in athletes taking oral contraceptives than they are in others.

Related eMedicine topics:
 Anorexia Nervosa [Emergency Medicine]
Anorexia Nervosa [Psychiatry]
Bulimia [Emergency Medicine]
Bulimia [Psychiatry]
Eating Disorder: Anorexia
Eating Disorder: Bulimia
Nutrition for the Female Athlete

Consultations

  • A nutritionist can make recommendations for a balanced, nutrient-rich diet.
  • An obstetrician/gynecologist may be helpful for patients whose amenorrhea is resistant to refeeding.
  • A psychiatrist or counselor may be consulted in cases involving disordered eating (intentional energy [caloric] restriction).
  • The team physician and athletic trainer should work together in obtaining keto-strip measurements and in administering or monitoring refeeding interventions.

More on Low Energy Availability in the Female Athlete

Overview: Low Energy Availability in the Female Athlete
Differential Diagnoses & Workup: Low Energy Availability in the Female Athlete
Treatment & Medication: Low Energy Availability in the Female Athlete
Follow-up: Low Energy Availability in the Female Athlete
References
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References

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Further Reading

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Keywords

anorexia, anorexic, eating disorder, eating disorders, osteoporosis, menstrual cycle, anorexia nervosa, athletic women, menstruation, bone density, women exercise, amenorrhea, bone loss, female athlete, women athletes, athletic woman, chronic energy deficit, menstrual dysfunction, stress fractures, sports performance, energy expenditure, athletic training, athletic performance, energy intake, disordered eating, female athlete triad, anovulation, oligomenorrhea, unintentional underconsumption, athlete's diet, musculoskeletal disturbances, reproductive disturbances, menstrual-cycle irregularities in the female athlete, primary amenorrhea, secondary amenorrhea, delayed menarche, exercise energy expenditure, luteal suppression

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Contributor Information and Disclosures

Author

Stacey Miller-Smith, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, UMDNJ-New Jersey Medical School
Stacey Miller-Smith, MD is a member of the following medical societies: American College of Sports Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Elizabeth A Moberg-Wolff, MD, Associate Professor and Pediatric PM&R Fellowship Director, Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin; Program Director, Tone Management and Mobility, Department of Physical Medicine and Rehabilitation, Children's Hospital of Wisconsin
Elizabeth A Moberg-Wolff, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Medtronic Neurological Grant/research funds Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching

 
 
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