female triad

Female Triad: Bone recovery after female athlete triad

Women whose bone development is interrupted in adolescence by the so-called ‘female athlete triad’ of disordered eating, delayed menstruation and osteoporosis can still catch up on bone growth well into their twenties.

That’s the encouraging implication of a single case history presented by researchers from Stanford University in California. They report on the case of an elite distance runner referred to the University’s sports medicine clinic at age 22 with primary amenorrhea (ie her periods had never started), low body weight (48.6kg) and low bone mineral density (BMD) in the spine and hip (74 and 80% of normal values respectively).

Like many elite runners she had started running competitively at age 12, before menarche (onset of menstruation). A year later she began to restrict her caloric and fat intake, leading to a failure to gain weight at the expected rate. She maintained an abnormally low weight for her height until age 25 through a combination of restrictive eating and high-mileage training.

When first seen at the clinic, the researchers commented on her bone density measurements, which ‘were roughly the values that would be expected for an average 13 year old, corresponding to the age of onset of disordered eating’.

Their initial strategy was to start her on calcium supplementation and oestrogen replacement in the form of the oral contraceptive pill, which induced normal menstruation. Despite this, one year later she had increased her weight by less than 1kg and there was little change in her bone density. A year after that the situation was essentially unchanged.

At this point, concerned about her long-term health, the woman decided to give up elite competition, reduce her weekly mileage and gain weight by adopting a less restrictive diet. Five years later she had increased her weight to 65.5kg, increased her bone density measures dramatically to within normal limits and was menstruating normally without the Pill.

‘This case shows’, the doctors report, ‘that large gains in BMD are possible for women who have recovered from the female athlete triad and that this recovery may occur into the third decade of life.’ However, they note that weight gain rather than calcium supplementation and oestrogen replacement therapy was the key to recovery.

Previous research had suggested that bone deficits in anorexia and the female athlete triad were not fully reversible unless the illness was short and recovery took place during adolescence. But this study suggests that the ‘window of opportunity for bone density recovery may be longer than previously expected… if full nutritional and weight recovery are achieved’.

However, because a single case study cannot serve as a reliable basis for treatment recommendations, the researchers call for further research following up groups of women with low bone density caused by anorexia or the female athlete triad.

Med Sci Sports Exerc 2005; 37(9):1481-1486

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