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The Female Athlete Triad: winning competitions but losing bladder control

It is the last leg of the race. Victory is in sight. Just have to kick it to the finish and ... What just dribbled down my leg?

The female athlete triad is described by the Women’s Task Force as a collection of three separate but interrelated conditions (Nazem and Ackerman 2012). Separately, the conditions in the female athlete triad are s e r i o u s ; c o m b i n e d , t h e y b e c o m e substantially more dangerous. One of the less frequently discussed conditions stemming from the triad is stress urinary incontinence. This article will review the female athlete triad and stress urinary incontinence, their relationship to one another, how to recognize the signs and symptoms, and how to intervene.

The female athlete triad is the union of disordered eating, amenorrhea, and osteoporosis in an athlete who has two “X” chromosomes. Disordered eating is a nonpsychiatric condition (not to be confused with an eating disorder) in which a person either restricts or binges food—typically, s p e c i fi c m a c r o n u t r i e n t s s u c h a s carbohydrates (Hinton and Beck 2005). Most of us have been disordered eaters at some point without realizing it. As a broke college student, you may recall binging ramen noodles when pulling an all-nighter.

In an athlete with disordered eating, the low nutrient intake relative to the high energy demand may result in amenorrhea—the absence of a period for longer than three months (Eguiguren and Ackerman 2016). Athletes with disordered eating are at higher risk for functional hypothalamic amenorrhea due to decreased leptin—a hormone found in fat tissue. A disrupted menstrual cycle leads to decreased levels of estrogen—a hormone heavily involved in regulating bone mineral density, which is related to bone strength. Maintaining uninterrupted bone mineral regulation in the young female athlete is crucial since a majority of bone mineral content is achieved by 18 years of age. Decreased bone mineral density, osteoporosis, leaves athletes prone to injury (Eguiguren and Ackerman 2016).

The cycle of the female athlete triad is now complete. But what about that urine dribble? Stress urinary incontinence is the involuntary loss of urine during physical exertion (Petrou 2010). How can two conditions that are so vastly different be related? There is a dearth of research into the connection between the female athlete triad and stress urinary incontinence. So I decided to connect the risk factors for stress urinary incontinence that coincide with aspects related to the female athlete triad: female gender, decreased estrogen, amenorrhea, high impact-sports and weight-class sports, and heavy exertion (Luber 2004). Two risk factors of stress urinary incontinence are uniquely associated with female athlete triad patients compared to their eumenorrheic (regularly menstruating) counterparts: decreased estrogen and amenorrhea. Due to the aligning risk factors, someone fitting the criteria of the female athlete triad is more l i k e l y t o d e v e l o p s t r e s s u r i n a r y incontinence.

Now that we know what the female athlete triad and stress urinary incontinence are and understand their relationship to one another, let’s look at how we identify that any of this is happening in an athlete.

None of us has X-ray vision to see an athlete’s bone composition, nor psychic powers to tell us she is wetting herself. (If you do please contact me immediately.) Fortunately there are other identifiable factors. Parents and coaches will be surprised at how much information they can get about an athlete’s eating habits from the athlete herself. I have found that athletes of any gender and age are often willing to openly discuss eating habits when asked. To recognize malnourishment in athletes taking part in weight-class sports, be alert to alterations in energy level and demeanor outside of their sporting activities.

As for identifying amenorrhea, it is time for the dreaded period talk. Not all parents are comfortable speaking to their children about topics related to sexual development, and the children are often uncomfortable too. It is beneficial for the female athlete to u n d e r s t a n d w h a t t o e x p e c t past menarche (the first period) so she can recognize when something is not right. But more important than recognizing a problem is seeking help.

If I suspect one of my younger patients has a problem they may not want to disclose to me personally, I encourage them to tell an adult they are comfortable with—perhaps a parent, guardian, teacher, or coach. Physical therapists can use outcome measures such as the Pre-Participation Gynecological Examination (PPGE) and Eating Attitudes Test (EAT). The PPGE is a validated questionnaire that can be used for the recognition of physical alterations often underestimated by the athletes themselves; this information permits referral to the appropriate practitioner (Parmigiano et al. 2014). The EAT is an acceptably reliable questionnaire for the identification of potential disordered eating in adolescents (Gleaves et al. 2014). Once the threeheaded beast known as female athlete triad is identified, how can you intervene as a coach, parent, or practitioner?

In the Disney movie Hercules, you may recall a mythical creature called the hydra. Hercules had a particularly difficult time defeating the hydra as its number of heads increased. Eventually our hero was overcome and swallowed whole. Had Hercules intervened before the hydra’s heads multiplied, defeating the beast would have been significantly easier. Stress urinary incontinence and the female athlete triad are very similar in that way.

Early intervention for the female athlete triad and stress urinary incontinence is imperative due to the increased likelihood of bladder dysfunction occurring again in adulthood (Heron et al. 2017). Thankfully, Our mighty heroes and heroines at Canadian Sport for Life proposes a multidisciplinary approach using the “Attention to Prevention” protocol from the beginning of an athlete’s career to ensure positive long-term athlete development (Harber). Well-educated coaches, school counselors, and physical education teachers make a winning combination to keep the female athlete triad at bay. Teaching and implementation of positive eating habits should begin in infancy and continue into early childhood. Beyond 8 years of age, child athletes should begin learning specific nutritional fueling practices when preparing for, during, and after sport. Female athletes should also be taught about the connection between menstrual function, energy intake, and bone health.

Athletes can begin learning technique as soon as age 6, such as batting stance in baseball or foot position for kicking in soccer. Between the ages of 11 and 15 years it is considered safe to initiate strength and agility training. Should the female athlete triad show any of its three heads, it is imperative to refer the athlete to a primary care or sports physician (Eguiguren and Ackerman 2016). I suggest physical therapists make the same referral if stress urinary incontinence becomes apparent in a pubescent female athlete, before treating the incontinence as its own entity.

As parents, coaches, and physical therapists, it is our duty to diligently combat all components of the female athlete triad in our athletes before any become a reality. Should disordered eating, amenorrhea, and osteoporosis evolve into the three-headed opponent known as the female athlete triad, remember that it can be defeated. Keep your wits about you, and do not be afraid to refer out so the multidisciplinary attack on the female athlete triad can begin.

References: {1} Nazem, Taraneh Gharib, and Kathryn E. Ackerman. (2012) “The Female Athlete Triad.” Sports Health 4 (4), 302–311. http:// doi.org/10.1177/1941738112439685. (Nazem and Ackerman 2012) {2} Hinton, Pamela S. and Niels C. Beck. (2005). “Nutrient Intakes of Men and Women Collegiate Athletes with Disordered Eating.” Sports Science and Medicine, 4 (3), 253–262. Retrieved September 6, 2017. (Hinton and Beck 2005) {3} DuffyPaiement, Christy. 2009. Disordered Eating Among Collegiate Female Athletes: The Role of Athletic Seasonal Status and Selfobjectification. In PsycEXTRA Dataset. Albany: ProQuest Dissertations Publishing. https://doi.org/10.1037/e627862010-001. (Duffy-Paiement 2009) {4} Eguiguren, Maria L., and Kathryn E. Ackerman. 2016. “The Female Athlete Triad.” In The Young Female Athlete, edited by Cynthia J. Stein et al., 57–71. Contemporary Pediatric and Adolescent Sports Medicine. Cham: S p r i n g e r . h t t p s : / / d o i . o r g / 10.1007/978-3-319-21632-4_5. (Eguiguren and Ackerman 2016) {5} Petrou, Steven P. 2010. “An International Urogynecological A s s o c i a t i o n ( I U G A ) / I n t e r n a t i o n a l Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.” International Brazilian Journal of Urology, 36 (1), 116. https://doi.org/ 10.1590/s1677-55382010000100032. (Petrou 2010) {6} Luber, Karl M. 2004. “The Definition, Prevalence, and Risk Factors for Stress Urinary Incontinence.” Reviews in Urology, 6 (Supplement 3), S3–S9. (Luber 2004) {7} Miller, Michael G., Christopher C. Cheatham, and Neil D. Patel. 2010. “ R e s i s t a n c e T r a i n i n g f o r Adolescents.” Pediatric Clinics of North America, 57 (3), 671–682. https://doi.org/ 10.1016/j.pcl.2010.02.009. (Miller et al. 2010) {8} Parmigiano, Tathiana Rebizzi, Eliana Viana Monteiro Zucchi, Maíta Poli de Araujo, Camila Santa Cruz Guindalini, Rodrigo de Aquino Castro, Zsuzsanna Ilona Katalin de Jármy Di Bella, Manoel João Batista Castello Girão, Moisés Cohen, Marair Gracio Ferreira Sartori. 2014. “Preparticipation gynecological evaluation of female athletes: a new proposal.” Einstein (São Paulo), 12 (4), 459–466. https:// doi.org/10.1590/s1679-45082014ao3205. (Parmigiano et al. 2014) {9} Gleaves, David H., Crystal A. Pearson, Suman Ambwani, and Leslie C. Morey. 2014. “Measuring eating disorder attitudes and behaviors: a reliability generalization study.” Journal of Eating Disorders, 2 (1), 6. https://doi.org/ 10.1186/2050-2974-2-6. (Gleaves et al. 2014) {10} Harber, Vicki. (n.d.). The Female Athlete Perspective. Canadian Sport for Life. Retrieved June 11, 2017, from http:// sportforlife.ca/portfolio-view/the-femaleathlete-perspective/. (Harber) {11}Heron, Jon, Mariusz T. Grzeda, Alexander Von Gontard, Anne Wright, and Carol Joinson. "Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study." BMJ Open 7, no. 3 (2017). doi:10.1136/bmjopen-2016-014238. (Heron et al. 2017)

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