How does energy availability affect the
Did you know that 99 percent of women’s peak BMD is
attained by our early 20s? The opportunity to further increase
BMD is very limited after this time. Thus, the adolescent and
If female athletes and exercising women do not have sufficient
teenage years are a particularly important time for optimising
energy available for adequate hormonal production, it can affect their
bone mass and strength through nutrition and weight-bearing
menstrual cycle. The severity of abnormalities ranges from subtle or
exercise. Coaches and parents have a responsibility to ensure
non-observable changes to irregular and inconsistent cycles with the
young female athletes and exercising women are not experiencing
most severe presentation being complete loss of menstrual cyclicity.
an energy deficit, primary or secondary amenorrhea, and that they
When my monthly menstrual periods slowly
Other factors such as genetics and life-stress can also contribute
are conducting sufficient weight-bearing exercise.
disappeared a few years ago, I didn’t think too much
to the development of energy-related menstrual disturbances.
What are some of the signs and symptoms of low
of it. Lots of my friends had similar experiences, so we
And, it is important to note that body weight and fat, per se,
do not mediate the development of menstrual disturbances in
energy availability and Female Athlete Triad?
assumed it was normal. I regret not seeking advice
exercising women. Indeed, amenorrhea is observed in exercising
back then…” – 30-year-old recreational runner
women who have body fat levels the same or even higher than
their peers with regular menstrual cycles. There is much individual
variation between women, exercising women should be aware
Dr. Holly Thorpe, Senior Lecturer of Sport & Leisure Studies, University of
of their own unique energy requirements and avoid comparing
Waikato and Maria Bentley, PhD candidate at AUT University & endurance
athlete, are the directors of fuelaotearoa.co.nz, a new educational website for
Continuum of the Reproductive Disturbance
female athletes and exercisers. Here they respond to the query.
t Irregular or absent menstrual cycles and infertility
t Increased risk of musculoskeletal injuries and stress fractures
irstly, changes in the menstrual cycle is a common
of female athletes and exercising women. For this reason, the
concern in female athletes and other exercising women.
Triad is diagnosed in any exercising woman (no, not just thin,
t Increased cardiovascular disease risk factors
Research by leading experts at the University of Penn
elite athletes!) who exhibits signs or symptoms consistent with
t Impaired exercise training and sport performance
State (USA) has shown that four out of five recreational
the pathological end of any one or more of these spectrums (low
female runners who ran for two hours or 16 kilometres
energy availability, amenorrhea or low BMD).
per week for a year experienced mild reproductive abnormalities.
This is sobering because subtle menstrual disturbances are
t Eating less than needed in an effort to improve performance or
asymptomatic, and thus go unnoticed by female athletes and
exercising women. A further study suggests up to 46 percent of
Eumenorrhea > regular, consistent, ovulatory cycle (26 – 35 days)
similarly trained women may develop amenorrhea (a cessation of
menstrual periods). These reproductive abnormalities occur when
Image used with permission of Fuel Aotearoa
insufficient dietary energy is available to fuel exercise and all the
What can I do to minimise the risks?
I’ve heard the word before but what
Most importantly, if you are concerned about changes in
So why haven’t I heard of this before?
your menstrual cycle, you should consult with your GP or a
Amenorrhea is the most extreme of energy-related menstrual
Given the high prevalence of low energy availability, body image
health professional. Our website offers a list of nutritionists,
disturbances and is characterised by constant low levels of estrogen
concerns, disordered eating and exercise addictions among athletes
endocrinologists, psychologists and sports doctors who are
and progesterone that completely suppress the various stages of
and exercisers, it is a concern that the potential y harmful effects of
working with women across the country on these issues.
the ovulatory cycle. Put simply, it refers to hormonal changes that
energy deficiency in combination with exercise are rarely discussed
cause a cessation of the menstrual cycle.
t We also encourage you to take a proactive approach toward
in the media and by health professionals. Unfortunately, many
your own relationship to exercise, food, and your body:
Amenorrhea can be classified as primary or secondary. Primary
health providers are not up-to-date on the latest research
amenorrhea refers to girls whose menstrual cycles have not begun
t Make sure your body has enough calories to “fuel” and “refuel”
and do not refer or manage afflicted women appropriately.
by age 15 years, and secondary amenorrhea refers to previously
your daily exercise. It is very difficult to know what is needed,
Ongoing stigma and misinformation has lead to some confusion
so it is advised to get advice from a sports nutritionist to design
menstruating women who have an absence of menstrual periods
among exercising women: What happened to my period? Wil it
a balanced and healthy nutrition plan. Keep a journal of your
impact my chances of having children in the future? What will
exercise practices, nutrition and menstrual cycle.
Exercise without adequate energy availability can affect the
be the state of my bones in 20 years time? These are important
menstrual cycle. However, there are various other causes of
t Your menstrual cycle is a good indicator of health. If your period
questions, so we developed the Fuel Aotearoa website to make the
continuum between health and disease.
amenorrhea including pregnancy, pituitary gland tumours,
disappears for three or more consecutive cycles, consult your GP
scientific research accessible to female athletes, exercisers, coaches
chronic stress, and polycystic ovarian syndrome. Diagnosis is a
and ask them to recommend a specialist for further advice.
and parents. Our aim is to empower girls and women to experience Image used with permission of Fuel Aotearoa
complex process and we encourage women to seek professional
t Try to listen to your family or friends if they express concerns
the numerous benefits associated with exercise and sport while
advice if they have observed changes in their menstrual periods.
about excessive weight loss, or disciplined exercise regimes.
avoiding the negative consequences of the Female Athlete Triad
Refuel for life: What is the importance of
Sometimes family and friends see things you don’t, and most
often they are expressing their concerns because they love you.
What is the Female Athlete Triad? How does it
Energy availability is a key feature of the Female Athlete
Chronic low energy availability can have a direct negative
t While exercising and dieting might be important for
Triad. Low energy availability develops when insufficient calories
effect on bone mineral density (BMD) via effects on various
maintaining or achieving the body you want today, try
are consumed to meet the demands of exercise training. If the
metabolic and ovarian hormones, and also insufficient intake
to think about the long-term health of your bones and
In 1992, the American College of Sports Medicine (ACSM)
magnitude or duration of energy imbalance is too large, the body
of nutrients, vitamins and minerals that are important for
reproductive system. Ask yourself – do you still want to be
coined the term, “Female Athlete Triad” to illustrate the
must prioritise calories that are available. That is, energy is drawn
maintaining bone health. It is important to note that BMD
able to walk, run, or dance, well into your old age? Might you
unique risks facing female athletes. The Triad describes the
away from physiological processes and body systems that are not
may not be fully restored in exercising women when nutritional
three separate but interrelated spectrums of energy availability,
essential for immediate survival and towards those essential for
and hormonal status is once again optimised. Thus, chronic low
menstrual function and bone mineral density (BMD). Clinical
life. For some women, low energy availability is by accident but
energy availability poses a significant threat to the long-term
See fuelaotearoa.co.nz for more information on the Female Athlete Triad, energy deficiency, and how it
manifestations (see the purple triangle in the diagram) include
relates to recreational exercisers. Holly and Maria are available to provide educational seminars to groups
for many others, exercising and restricting caloric intake is done
health of exercising women by increasing the risk for fractures and
of female athletes, exercising women and coaches.
but are not limited to, disordered eating behaviours, amenorrhea
with the aim to lose or maintain a particular weight.
and bone mineral loss, which are detrimental to long-term health
Wissenschaft Neue Leitlinie zur Behandlung des Hörsturzes Bedeutung für Patienten und behandelnde Kassenärzte von Prof. Dr. Gerhard Hesse Die Leitlinie zur Behandlung des Hörsturzes ist gerade aktualisiert worden. Prof. Dr. GerhardHesse, Chefarzt der Tinnitus Klinik Dr. Hesse am Krankenhaus Bad Arolsen, ist Mitglied derLeitlinienkommission „Hörsturz“ und erläutert im folgende
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