Key Points

• An energy deficit is the primary cause of amenorrhea in athletic women, and treatment should focus on the restoration of a normal energy balance.

• Menstrual dysfunction or hypothalamic pituitary axis suppression caused by an energy deficit in exercising women is a diagnosis of exclusion, and workup should include evaluation for medical causes

Table 29-2 Common Apophyseal Injuries in Pediatric Athletes

Eponym/Common Injury

Body Part and Pathophysiology

Common Sports/Activity

Little League shoulder

Proximal humeral epiphysiolysis from repetitive microtrauma

Overhead sports: baseball, softball, tennis, swimming, volleyball

Little League elbow

Medial epicondylar apophysitis from traction to ulnar collateral ligament

Baseball (especially pitchers)

Lateral Little League elbow/ osteochondritis dissecans (OCD)

OCD of capitellum or less likely radial head from repetitive compression-rotation forces

Baseball, gymnastics, overhead throwing and arm weight-bearing sports

Osgood-Schlatter's disease

Traction apophysitis of tibial tubercle

Soccer, basketball, running/jumping sports

Sinding-Larsen-Johansson disease

Traction apophysitis to distal patella

Soccer, basketball, running/jumping sports

Sever's disease

Calcaneal apophysitis from traction on Achilles insertion

Soccer, gymnastics, running/jumping sports

Pelvis-ASIS apophysitis

Traction from sartorius origin

Sprinting, kicking, jumping, hurtling

Pelvis-AIIS apophysitis

Traction from rectus femoris origin

Sprinting, kicking, jumping, hurtling

Buttock-ischial apophysitis

Traction from hamstring origin

Sprinting, kicking, jumping, hurtling

Spondylolysis

Stress fracture of vertebral pars interarticularis

Gymnastics, figure skating, football lineman, sports with spine loading in extension

of amenorrhea, including a pregnancy test and determination of prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), dehydroepiandrosterone (DHEA), and testosterone levels. • Bone mineral density is adversely affected by menstrual dysfunction and, although treatment with hormone replacement (e.g., oral contraceptives) should be considered, this does not fully address the mechanisms of bone loss.

of amenorrhea, including a pregnancy test and determination of prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), dehydroepiandrosterone (DHEA), and testosterone levels. • Bone mineral density is adversely affected by menstrual dysfunction and, although treatment with hormone replacement (e.g., oral contraceptives) should be considered, this does not fully address the mechanisms of bone loss.

Exercise results in many benefits for both male and female athletes. In female athletes, exercise coupled with low energy intake can lead to a spectrum of disorders, culminating in the female athlete triad, strictly defined as the presence of an eating disorder, amenorrhea, and osteoporosis. It is important to recognize the precursors to the development of the female athlete triad when they may be more amenable to treatment, resulting in less severe long-term sequelae.

The menstrual cycle in the female athlete represents a complex and delicate interplay of hormones. The array of menstrual function seen in athletes ranges from normal ovulatory cycles to luteal-phase defects, to anovulation, to oligomenorrhea, and to amenorrhea. Menstrual dysfunction can exist even in women with normal cycle length, and various types of cycles are common in an individual athlete (De Souza and Williams, 2004).

Athletic amenorrhea is caused by hypothalamic-pituitary axis suppression and is a diagnosis of exclusion. Other causes of amenorrhea must be ruled out, including pregnancy, hyperthyroidism, hyperprolactinemia, primary deficiency of gonadotropin-releasing hormone, and hyper-androgenic anovulatory syndrome (polycystic ovarian syndrome) (Ahima, 2004). When amenorrhea occurs in the setting of exercise or weight loss and initial hormonal testing is normal, a diagnosis of athletic amenorrhea can be made. Recent research has established that energy deficit is the primary cause of amenorrhea in athletic women

(De Souza and Williams, 2004). Strenuous exercise alone in the setting of adequate energy intake does not disrupt the menstrual cycle. An energy deficit results in low concentrations of leptin and in changes in the neuroendocrine axis, including low levels of reproductive hormones, thyroid, and insulin-like growth factor-1 (IGF-1) and an increase in cortisol and growth hormone levels. Similar changes can be seen with psychogenic stress in sedentary women, and stress-induced changes may also contribute to menstrual dysfunction in both normal and underweight female athletes (Ahima, 2004).

The attainment of peak bone mineral density is adversely affected in both the short term and the long term by menstrual dysfunction (Keen and Drinkwater, 1997). The degree of menstrual dysfunction is related to the severity of osteo-penia or osteoporosis (Hartard et al., 2004). Initially, the low estrogen state associated with athletic amenorrhea was thought to be solely responsible for bone density problems similar to those seen in postmenopausal women. More recent research has indicated that micronutrient deficiency and low levels of leptin, IGF-1, and other bone trophic factors also contribute to bone mineral deficits (Chan and Man-tzoros, 2005).

Treatment of menstrual dysfunction and low bone density has traditionally consisted of hormone replacement therapy, most often with oral contraceptives. Oral contraceptives are not associated with complete bone recovery, most likely because of the multifactorial nature of bone metabolism. Bisphosphonates can increase bone density in adolescents with anorexia, although not as effectively as weight restoration (Golden et al., 2005). Bisphosphonates have extremely long half-lives and remain in the skeleton for many years. Because of concern about potential tera-togenicity, bisphosphonates should not be used in young women of childbearing age until further studies on their long-term safety.

The primary treatment for athletic amenorrhea should be restoration of a normal energy balance. Disordered eating patterns must be addressed. Anorexia nervosa and bulimia nervosa are common in women, particularly those competing in sports in which there is an emphasis on leanness or appearance, such as gymnastics, figure skating, and cross-country running. Eating disorders are best addressed with an interdisciplinary management team that includes both psychological and nutritional counseling (Otis et al., 1997).

Menstrual dysfunction, although common in female athletes, should prompt evaluation for medical causes and eating disorders. It is never normal or desirable for a female athlete to cease menstrual function, and this should not be seen as a marker of adequate training. Exercise alone should not be blamed for menstrual dysfunction. Treatment should focus on the restoration of energy balance and a safe continuation of activity.

References

The complete reference list is available online at www.expertconsult.com.

Web Resources www.ncaa.org/wps/ncaa?key=/ncaa/ncaa/legislation+and+governance/ eligibility+and+recruiting/drug+testing/drug_testing.html National Collegiate Athletic Association (NCAA): Drug-testing program. www.ncaa.org/wps/ncaa?key=/ncaa/NCAA/Sports%20and%20Champi onship/Wrestling/Playing%20Rules/index.html National Collegiate Athletic Association (NCAA): Wrestling 2005: Rules and interpretation. www.wada-ama.org/en/World-Anti-Doping-Program/Sports-and-Anti-Doping-Organizations/International-Standards/Prohibited-List/ World Anti-Doping Agency (WADA) list of prohibited drugs.

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