Keywords

FormalPara Learning Objectives

Upon completion of reading this chapter, the reader will be able to:

  • Become aware of the estimated prevalence of disordered eating (DE) and eating disorders (ED) in female athletes

  • Understand reasons for and methods of screening for disordered eating and eating disorders in the female athlete in both informal and formal settings

  • Understand reasons for and methods of screening for disordered eating and eating disorders in the female athlete in both informal and formal settings

  • Become aware of screening tools that are utilized for disordered eating and eating disorders, in general, and specifically, in athletes

  • Become aware of the estimated prevalence of dysfunctional exercise (DysEx) in female athletes

  • Understand the different components of DysEx: Quantitative and Qualitative

  • Become aware of the limitations associated with the “diagnosis” and assessment of DysEx

  • Understand the methods for DysEx screening in the female athlete

  • Understand the importance of screening for menstrual dysfunction in the active female

  • Be able to list groups of athletes in whom screening for menstrual dysfunction is essential

  • Have a resource of potential screening questions for menstrual dysfunction

  • Understand the relationship of functional hypothalamic amenorrhea (FHA) with menstrual dysfunction

  • Understand the relationship of low energy availability (EA) and FHA causing menstrual dysfunction and the need to improve overall EA as the first step in management

1 Introduction

Throughout the lifetime of a female athlete, many health concerns may arise. A few pertinent ones include disordered eating, eating disorders, dysfunctional exercise, and menstrual dysfunction. There are a number of ways to screen for these conditions in order to review risks with athletes and develop management plans.

Disordered eating (DE) may occur as a sole entity or associated with eating disorder-type behavior. Some athletes are unaware of their disordered eating, which may occur in the form of inadequate fueling after exertion, creating low energy availability. Other forms of disordered eating) may include restrictive eating, skipping meals, overexercising, and laxative abuse [1].

Eating disorders (ED) are diagnosed as mental health illnesses, meeting defined criteria per DSM-V, characterized by pathologic eating behaviors which adversely impact health [2, 3]. ED impacts female athletes more regularly than males, but recent results indicate the window between the two is becoming smaller. With that, the risk of ED in the general population compared to athletes is also narrowing [4]. There is no clearly defined standard for the methods or timing of screening female athletes for DE or ED. Several screening tools are available, but no consensus exists yet, concerning the optimal tool with athletes. Various opportunities present themselves for screening athletes for (DE/ED), but no single time has proven most advantageous. Screening may be performed in various ways, but it is optimal to gather as many objective pieces of evidence as possible, since denial by the athlete is often a large component of DE/ED. Ultimately, ideal screening is specific to each athletic level and entity, whether recreational or competitive. This chapter covers various methods and timing options for the most effective screening of female athletes for DE/ED.

Relative to DE/ED, the phenomenon of dysfunctional exercise (DysEx) can be a paradox with regard to healthful activity engagement. Physical activity and exercise are considered by scientists as a critical tool to prevent chronic physiological and psychological pathologies [5,6,7,8]. Maintaining adequate physical activity levels has positive effects on physical and mental health [9]. However, exercise, as many other behaviors, can become dysfunctional. Thus, this chapter also covers ways to recognize, screen, and manage dysfunctional exercise in female athletes.

In light of the relationship between DE/ED and DysEx, menstrual dysfunction cannot be ignored and deserves attention. Menstrual dysfunction is a condition that can appear in the female athlete’s lifetime as a result of energy imbalance (either intentional or unintentional) and/or decreased energy availability. However, screening for menstrual disorders in athletes is more complicated than it might seem. Historically, the simple question was, do you have normal menstrual cycles or periods? If yes, then that was the end of the screening questionnaire. If no, the athlete was referred to the physician. With improved understanding of the female athlete triad and the components involved, screening has become more complex. In addition to menstrual status, those responsible for the health of the female athlete must also evaluate the other two components of the triad; bone health and optimal energy availability, or whether indications of DE/ED exist. Evaluation of one component of the female athlete triad should not occur in isolation from the other two components.

2 Definitions

2.1 Eating Disorders

Eating disorders, and disordered eating are similar phenomenon, but distinctly different. In athletes, DE encompasses various abnormal eating behaviors that can be inadvertent, such as inadequate refueling or they may be intentional. An ED is a clinical mental disorder, meeting diagnostic criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V); specifically, Anorexia nervosa, Bulimia nervosa, binge-eating disorder, and other specific feeding and eating Disorders. DE is defined as having disordered attitudes or behaviors toward food and eating (body dissatisfaction, shape and weight concerns, self-induced vomiting, dieting, and skipping meals). However, these behaviors do not amount to an ED diagnosis as per the DSM-V diagnostic criteria [10].

2.2 Dysfunctional Exercise

More than 30 terms have been adopted by researchers and clinicians to try to describe problematic or DysEx in mental health disorders [11]. Historically, the concept of addiction has been associated with the qualities and subsequent terminology related to DysEx [12,13,14,15,16,17,18]. However, most of the research has focused solely on populations having both DysEx and mental disorders. Therefore, insufficient research exists regarding DysEx in the general and physically active populations (recreational, amateur, or high-performance athletes). The most common terms found in the literature are exercise “addiction” [14], “dependence” [18], “abuse” [19], “obligatory” [20], “compulsive” [21], “morbid,” and “driven” [22] exercise or excessive exercise [13]. As a result of the multitude of proposed terms, “dysfunctional exercise” will be used to encompass each term. This lack of consistency has limited our body understanding of negative versus positive exercise behavior and its role in the development of LEA (low energy availability), DE or ED, and poor bone health [23].

It was not until 2015, when Rizk et al. attempted to analyze the different components, quantitative and qualitative, of DysEx behaviors, that we gained a distinctive understanding of the concept [23]. The quantitative component involves factors such as time, duration, intensity, or volume and can be defined as the amount of programmed exercise performed beyond the physical healthy limits; previously known as “Excessive Exercise.” The qualitative component of DysEx relates to mental health features such as compulsion, rigidity, and obsessiveness. Core features determining the quality of the exerciser’s relationship with exercise can be to control weight or shape [23] or due to features of addiction. Ultimately, the quality of the relationship is negative, thus creating both mental and physical distress [24].

Coverley Veale et al. proposed a classification for DysEx depending on the role of the exercise [25]: primary and secondary DysEx. Primary DysEx is the exercise that is an end in itself (i.e., exercise is the objective); hence, practitioners are intrinsically motivated to exercise. Secondary DysEx co-occurs with an ED or other compulsive disorders, where individuals are extrinsically motivated to exercise according to their self-image [i.e., weight loss is the objective] (Table 12.1). According to this classification, it is important to determine whether DysEx is primarily affecting the practitioner’s life or whether it emerges as a derived problem from another psychological disorder [25, 26].

Table 12.1 Primary and secondary dysfunctional exercise symptoms [25,26,27]
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2.3 Menstrual Dysfunction

Terms used when discussing menstrual screening include the following: primary amenorrhea, secondary amenorrhea, and functional hypothalamic amenorrhea (FHA). Although these terms have been described in previous chapters, a brief review provides a fuller understanding regarding screening and management recommendations. Amenorrhea is the absence of menstruation or a woman’s monthly period.

  • Primary amenorrhea occurs when a female has not yet started her monthly periods by age 15 but has gone through other normal changes that occur during puberty.

  • Secondary amenorrhea occurs when a woman who has been having normal menstrual cycles stops having her periods for 6 or more months (some sources state 3 months, although 6 months is more common). Note, however, this does not apply to women who are pregnant, breastfeeding, or in menopause.

  • Functional hypothalamic amenorrhea (FHA) is a reversible form of gonadotropin-releasing hormone (GnRH) deficiency, commonly triggered by stressors, such as excessive exercise, nutritional deficits, DE/ED, or psychological distress.

The Office on Women’s Health, Department of Health and Human Services suggests the physical and behavioral/emotional characteristics to detect eating disorders should be examined during the routine screening of adolescent and preadolescent patients by their primary care provider for the detection of issues related to the female athlete triad.

There is not yet an agreed upon optimal timing or method of screening for female athlete triad disorders. An energy deficit in a female athlete may cause a spectrum of menstrual dysfunction, either subtle or obvious, which may then have an impact on bone health. This leads to the realization that a comprehensive menstrual history may be needed in all athletes.

3 Research Findings in Disordered Eating/Eating Disorders, Dysfunctional Exercise, and Menstrual Dysfunction

The American College of Sports Medicine Position Stand on the Female Athlete Triad describes the interrelationships among energy availability, menstrual function, and bone mineral density. As these three entities are interwoven, an alteration in one can impact the others. Energy availability is the amount of energy remaining once exercise energy expenditure (EEE) is subtracted from energy intake (EI): (EA = EI-EEE). DysEx is a component of EEE and thus can impact EA which then can impair menstrual function and ultimately bone density. These are complicated relationships, but each entity is distinctly different, and in athletes, abnormalities can present alone or in combination. The longer these disorders go untreated, the greater the long-term consequences [28]. Thus, prevention and early detection of female athlete triad disorders are of utmost importance for the health of young female athletes [29, 30]. The following section will review the prevalence, current research, and screening procedures for each DE/ED, DysEx, and menstrual dysfunction.

3.1 Prevalence

3.1.1 Prevalence of Disordered Eating/Eating Disorders in Active Females

It is difficult to know the exact prevalence of DE/ED in female athletes as the majority of studies have various methodological flaws including the use of nonstandard diagnostic procedures, small sample sizes, lack of or inadequate control group(s), inadequate statistics, and/or heterogeneous athlete population [31, 32].

There have only been two, well-controlled studies utilizing DSM-IV criteria for diagnosis of EDs. These were conducted with elite athletes and demonstrated 31% prevalence in athletes compared to 5.5% in the control population for the first study and 25 versus 9% in the second study. Other studies have shown secondary amenorrhea to be as high as 69% in dancers and 65% in long distance runners versus 2–5% in the general population [31].

The first study to look at the combined prevalence of DE, menstrual dysfunction, and low bone mineral density in college females demonstrated that the number of athletes suffering from all three disorders of the triad was small (1–3 athletes out of 112). However, a significant number suffer from the individual disorders of the female athlete triad [3].

A more recent systematic review of 65 studies evaluating the prevalence of the individual and combined components of the triad verified that initial study. It showed a relatively small percentage of athletes (0–15.9%) exhibited all three components of the triad. The prevalence of any two triad conditions ranged from 2.7 to 27%. The prevalence of any one condition was the highest, from 16 to 60%. The recommendation from that review is that additional research on the prevalence of the triad using objective and/or self-report/field measures is necessary to more accurately describe the extent of the problem [28].

3.1.2 Prevalence of Dysfunctional Exercise in Active Females

The prevalence of DysEx, more specifically the addiction feature, is variable and uncertain due to the lack of comparable methodology in research of clinical cases, i.e., heterogeneity of the instruments used to assess addiction (qualitative component), insufficient sample size, and heterogeneity of the population studied. The most recent observational data available suggest a prevalence of 0.3–0.5% of the general population and 1.9–3.2% of individuals who are regular exercisers [26]. In this sense, Lejoyeux and colleagues analyzed exercise behaviors on 300 practitioners from a fitness room [18 years and older]. A total of 125 (42%) presented risk factors of primary DysEx. These participants spent more hours (h) each day in the fitness center compared with participants who had no risk [2.1 h/day vs. 1.5 h/day], and they went more often each week [3.5 vs. 2.9 days/week]. Moreover, those that presented addictive features smoked less and were significantly more compulsive buyers (63% vs. 38%) [33].

Prevalence of secondary DysEx is much higher. Typically, although not exclusively, DysEx is secondary to an ED. DysEx in those with EDs ranges from about 26.8–80% of clients [21]. In one study of 366 participants, researchers found that DysEx rates were 45.5% among 165 inpatients and 26.8% in 355 outpatients. The large range in prevalence rates can be a result of the presence of exercise dependence within each type of ED, with anorexia nervosa restrictive or purging subtype presenting with DysEx most commonly and eating and disorders not otherwise specified the least common.

3.1.3 Prevalence of Menstrual Dysfunctional in Female Athletes

In athletes, amenorrhea is much more common than in non-exercising controls with prevalence reported from 3 to 69% compared to 2–5% in the general population [3, 30, 34]. Prevalence is typically an estimate as it is difficult to gain accuracy due to inconsistencies in studies, including various definitions of amenorrhea, selection bias, underreporting, lack of education on what is normal versus abnormal, various competition levels, sports disciplines with varied intensity, and frequency of training [30, 35]. Despite this, research has shown that in adolescents, the current prevalence of the female athlete triad is 0–1.2% of athletes. When two factors of the triad are present, the prevalence of the triad is between 2.7 and 27% [28, 36].

3.2 Current Research in Disorder Eating/Eating Disorders, Dysfunctional Exercise, and Menstrual Dysfunction: Screening Tools

When choosing an appropriate screening tool, things to consider include the specificity of the tool, the feasibility of using one tool or another, and strengths and weaknesses of the instruments for measuring each of the components (DE/ED, DysEx, and menstrual dysfunction). Further considerations for choosing an appropriate screening tool include the following:

  • Applicability: It should be easy to apply and interpret.

  • Validity: The instrument should be capable of measuring what it was created for. Those instruments that have not been validated might not be the best. Those whose validation analysis is inconclusive should be avoided.

  • Reliability: If used for clinical practice, it is important that the instrument is reliable (precise) when measuring the same subject (intra-subject). In the case, if it is used for research, it is important to have both precision (intra-subject) and accuracy (inter-subject), so the changes detected are attributable to the intervention or the situation tested and not to the lack of reliability of the instrument.

  • Cost–benefits: For example, the sample size could reduce or increase the chance of using one or another instrument.

  • Objectivity: The most objective instrument has to be used. For example, if physical activity levels are assessed and both accelerometers and questionnaires are available, the most objective instrument will be the accelerometer.

  • Reactivity: Be aware that participants tend to change behaviors when being evaluated. Some instruments may be more sensitive to reactivity than others.

3.2.1 Current Research in Disorder Eating/Eating Disorders

There are multiple risk factors, which predispose an athlete to DE or ED. This list includes four major groups of factors as shown in Table 12.2.

Table 12.2 Risk factors for disordered eating/eating disorders [37, 38]
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Further evaluation of the sport-specific factors seems warranted given conflicting data. A review from 2001 [32] and a 2004 study [39] indicate that EDs are more likely to occur in athletes in aesthetic or leanness sports such as gymnastics, cross-country, and figure skating compared with athletes in non-leanness sports and controls. This was again verified in 2008 by Torstveit, Rosenvinge, and Sundgot-Borgen in a study with 186 athletes compared to 145 controls. EDs were more common in athletes in leanness sports (46.7%) compared to non-leanness sports (19.8%) and controls (21.4%) [29].

However, Beals provides evidence to question the long-held belief that EDs are more common in athletes in leanness sports in the small study of 112 athletes. She specifically notes that the percentages of individuals with DE and bone mineral density disorders, individually or in combination, were similar between lean build and non-lean build sports. The implication from this is that all female athletes, regardless of sport, should be screened for components of the female athlete triad and intervention should begin early to prevent development of the full triad [40, 41]. In any event, avoiding external pressure on the athlete to lose weight is essential to avert preoccupation with dieting, as it is considered to be the number one trigger for EDs [30, 31].

3.2.1.1 Screening for Disordered Eating/Eating Disorders and Pre-Participation Examinations

Screening recommendations for the female athlete triad or its components are based mostly on consensus, usual practice, or opinion. The most common times recommended are during pre-participation physical examinations (PPEs), during routine health visits, or if an athlete presents with a component of the triad [1, 30, 31, 42].

Screening can not only occur at a common entry point to athletic participation such as during pre-participation physical examinations (PPEs), but should also be an ongoing process throughout the span of an athlete’s participation. This ongoing process is particularly applicable to recreational athletes who participate in exercise clubs, individual activities, and “weekend warrior” activities. The screening process should be viewed as a two-step process [43, 44]. Once an athlete screens positively or if a concern exists, the athlete should be referred for further medical and psychological or psychiatric evaluation.

The main benefit of screening during PPEs is that medical personnel are able to quickly review the responses to the tool utilized, and potentially, they can immediately refer the athlete who screens positively. All new athletes are required to have a PPE, so all would at least be screened in this format. The disadvantage of screenings during PPEs is that they often occur in a station-centered setting, such as in an athletic training room. This provides minimal privacy and confidentiality in completion of questionnaires and in further discussions with the individual athlete. Although, in order to enhance confidentiality and improve efficiency, some universities are shifting to having athletes complete health histories either before arrival on campus or on web-based sites [40]. As technology and the patient-centered medical home (PCMH) advance, a web-based data center in an electronic health record may become the standard. The PCMH promotes organizing care around patients, working in teams, and coordinating and tracking care over time [45].

Another negative aspect of screening at PPEs is that there are typically multiple other forms to complete. The athlete may then rush through the DE/ED screening tool, not taking the time to answer accurately [34, 46]. Female athletes often feel uncomfortable discussing ED during PPEs and are more likely to withhold information [46]. This is another reason why screening females with a supplemental form within the first few weeks of arrival on campus may be a better method.

An additional concern arises in settings where PPEs are only required at entry and not yearly. In a study of the National Collegiate Athletic Association (NCAA) Division I universities, of the 257 (74%) schools that participated, only 32% require an annual PPE. In this case, if the athlete develops risk factors for DE/ED after her freshman year PPE, it may go undetected until a significant health event occurs, if at all [34].

When any of the informal signs and symptoms of DE/ED found at Table 12.3 are noticed among female athletes, areas of discussion that could be explored include: (1) eating behaviors such as binging, purging, eating in secret, recurrent dieting; (2) a history of or current mood disorder to include sadness, depression, or anger; and (3) the use of extreme weight control measure to manage weight or shape including starvation, diuretics, laxative, or saunas [30, 31, 47, 48].

Table 12.3 Informal signs and symptoms of disordered eating/eating disorders in athletes [30, 31, 47, 48])
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3.2.1.2 Reasons to Screen for Disordered Eating or Eating Disorders and Screening Practices

Screening helps to identify athletes who may be having issues with eating pathology or low energy availability who require further assessment. Screening can be a complex and challenging task, but the sports medicine team must keep in mind the reasons why screening is important. These include [30, 31, 46]:

  • Prevention of DE/ED; the most effective way to decrease the incidence of ED is to prevent them.

  • Early intervention when DE/ED exists to minimize impacts on health and performance; the longer an ED is allowed to persist and progress without treatment, the greater the health and performance detriments.

  • Athletes tend to deny or do not realize a problem exists.

  • Athletes are unlikely to come forward on their own, so complications from low energy availability can go unrecognized until a major event such as a stress fracture occurs. There are several reasons why the athlete may not come forward including guilt, shame, fear of losing a scholarship, or fear of losing playing time [30].

With no clearly defined standard for screening athletes for DE/ED, practices fall across a wide spectrum that includes: no specific screening, a few general questions at the time of PPE, utilization of a self-report questionnaire screening tool (SRQST) at PPEs, or the use of a SRQST combined with an interview by a trained mental health provider.

A 2012 study evaluated PPE forms utilized at 257/347 NCAA Division I universities for efficacy in screening for the female athlete triad. It compared those forms to the 12 items recommended by the Female Athlete Triad Coalition for screening females for the triad [49]. Only 25 universities (9%) had nine or more of the 12 recommended items on their forms [34]. Another study has shown that only 60% of Division I schools, which responded to the study, screened for ED during PPEs. Of those that did screen, <6% used a standardized SRQST [3].

Because the goal of the PPE is to facilitate optimal performance for athletes while ensuring the best possible health for the athlete both today and in her future, it has been suggested to implement a separate supplemental health questionnaire specific to female athletes. It is felt that this method would allow health care providers to narrow in on female-specific issues. It might be implemented before, during, or shortly after PPEs on campus [50].

An interesting innovation in screening female athletes for DE/ED is the physiologic screening test consisting of 18 items (4 measurements and 14 questions). It has been validated and has the potential to be combined with one of the athlete-specific questionnaires (see Table 12.4) to create a two-step screening process in an attempt to minimize false positives and false negatives prior to psychological referral [41].

Table 12.4 Athletic personal and barriers to recognition
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3.2.1.3 Functionality of Screening Tools for Disordered Eating or Eating Disorders

What makes a screening tool useful is functionality as well as validity. SRQSTs seem more functional than interviewer applied tools. However, they are subject to report bias, as athletes tend to be not as forthright with these as in a one-on-one interview [3, 51]. The interview tools are more appropriate for an in-depth evaluation, in search of a specific diagnosis, but they are time intensive and require education on the part of the interviewer. They are most useful as the second step in evaluation, once an initial screening tool is positive or when there is reason to suspect DE/ED in an athlete [52].

In the athletic arena, time is frequently an issue. It is essential for a screening tool to be focused and time limited. Formal screening tools are ideally brief, self-report questionnaires with simple cut-off scores that indicate a level of dysfunction concerning for pathology in the athlete [51].

One must be assured that the tool utilized, when interpreted as positive, truly indicates an issue for which further evaluation and time requirements will be needed. Once a screening tool is positive, the athlete should then have a more formal evaluation to determine whether true pathology exists or risk factors for pathology are present. This includes a detailed medical, nutritional, and reproductive history and physical examination with lab evaluation by a physician and referral to a psychologist or psychiatrist [1, 47]. An ideal tool for further evaluation is a structured interview. Eating disorders exam (EDE) has been identified as the gold-standard tool for identification of ED in general [41, 51, 53]. During the one-on-one interview, the athlete must feel secure and not threatened [30].

In organized sports, the PPE is a common entry point for evaluation of athletes. Screening at that time is of utmost importance, but it is not the only opportunity to diagnose DE/ED. Screening female athletes for DE/ED needs to by a dynamic, ongoing process, throughout the span of recreational and competitive activity. It should not occur in a vacuum, only at the time of a PPE. Recreational athletes can also fall into low energy availability from DE/ED. A less formal approach to screening may be applicable in their case.

3.2.1.4 Screening Settings for Disordered Eating or Eating Disorders

Screening for or DE/ED in athletes generally) occurs in three settings: (1) informal settings, mostly by observation and interaction with athletic trainers and coaches; (2) formal settings, typically with a team physician or primary care provider or when referred to a psychologist or psychiatrist; and (3) clinical settings.

Informal Settings: The informal setting occurs in the athlete’s day-to-day routine while interacting with athletic trainers, coaches, administrators, teammates, teachers, family, and friends. For recreational athletes, informal screening may occur with personal trainers, group exercise leaders, and gym personnel. The ideal is for all individuals interacting with athletes to be educated on recognizing concerning patterns of behavior and exercise (nutrition issues, over-exercising, etc.). Once educated on what to look for, he/she can feel empowered to approach the athlete in an effort to assist her. Written policies on dealing with suspected ED are recommended and adequate resources to assist the athlete are ideal [54, 55]. Each individual interacting with the athlete has the opportunity to informally screen the athlete for DE/ED. Whether they actually do, often depends upon their level of education and whether they are alert to a potential issue with the athlete [30, 56]. Direct questioning can be utilized; however, the nature of ED tends to be secretive. It is likely that the individual will not readily disclose the embarrassing symptoms of an ED, such as vomiting or laxative use. The intensity of questioning has to be balanced between the relationship of the athlete with the person inquiring and the athlete’s readiness to disclose her illness. Thus, the allied health professional sometimes must read between the lines and look for physical and behavioral characteristics that may signify an ED.

Formal Settings: The formal, structured setting occurs during pre-participation examinations and in the clinical setting. In the formal setting, SRQSTs are best utilized. A questionnaire tool is especially helpful as it can be difficult for the provider to remember the myriad of questions recommended for picking up on subtleties in order to discover DE or recognize an athlete attempting to hide an ED.

Clinical Settings: The other formal setting where the female athlete may be encountered is in the clinical setting when presenting for routine health care or for an acute illness or injury. The clinician then has the opportunity to screen for components of the female athlete triad, including those that set the athlete up for low energy availability (DE/ED). A full medical, reproductive, and skeletal health history should be taken as well as an appropriate physical examination looking for classic signs of ED [1, 47]. Questions to be asked during the history should also include nutrition questions incorporating weight and dieting history, current exercise regimen looking for any recent changes in intensity or amount, and mood-related questions. Physical complaints and findings such as amenorrhea, gastrointestinal disturbances, low body mass index, bradycardia, orthostatic hypotension, skin changes, and laboratory studies can help diagnose an ED [57]. However, during the early course of an ED, physical examination and laboratory findings may be normal. Again, there are time constraints in the clinical setting and the provider is likely to focus specifically on the illness, injury, or well woman examination at hand and not expand the history to include elements important in identifying ED/DE and female athlete triad disorders. Health providers (athletic trainers, team physicians, sports medicine fellows, physician assistants, and nurse practitioners) working with female athletes need to remember to focus on their medical roots to complete an entire history and physical examination looking for symptoms and signs of DE/ED and female athlete triad disorders.

3.2.1.5 Barriers to Recognition of Disordered Eating/Eating Disorders

Unfortunately, people close to the athlete can contribute barriers to recognition of the issue. This is often inadvertent but can also be intentional. These barriers are included in Table 12.4 [47].

In order to minimize barriers, it is critical to maintain an environment that promotes the clear expectation that DE/ED will be addressed with the intent to promote optimal health and performance for the entire team. This may minimize the concern for a “telltale” environment. It is a responsibility of those who are close to the athlete to help recognize DE/ED and initiate further evaluation and assistance [46]. Once it is recognized that assistance is needed, screening becomes formalized in the clinical setting with the team physician or primary care provider.

3.2.1.6 Screening Tools for Disordered Eating/Eating Disorders

There are multiple screening tools for DE and ED in the literature (Appendix 1). Some are specific to athletes, while others are more general nutritional, DE/ED screening tools. Most of the general tools are validated, but few of the tools specific to athletes have been validated in female athletic populations [31, 58].

A screening tool may save time obtaining the athlete’s history either before or as a part of a PPE or in the setting of a clinical visit with the physician. Questions may be incorporated into the PPE form or a supplemental screening tool. The American College of Sports Medicine Position Stand on the Female Athlete Triad and the National Athletic Trainers’ Association Position Statement on Preventing, Detecting and Managing Disordered Eating in Athletes make the recommendation for screening during PPEs, but provides no guidance on any one particular tool [30, 31]. It is generally felt that a supplemental tool directed specifically at female athletes may ultimately be ideal.

The SRQST is utilized as a first step. These tools are not designed to diagnose an ED so athletes who screen positively, should then be further evaluated by a physician for medical evaluation and referred to a psychologist or psychiatrist. During that visit it is likely that one or more interview-based tools will be utilized to determine if the diagnosis of an ED is appropriate.

3.2.1.6.1 General Screening Tools for Disordered Eating/Eating Disorders and Diagnostic Screening Tools for Eating Disorders (Table 12.5)

The clinical interview is the assessment tool of choice when diagnosing ED as it allows for more detailed questioning. Disordered eating is not included here as it is not a clinical ED. Use of an interview-based tool is part of the second step in evaluation when a screening tool is positive (Table 12.6.) [51].

Table 12.5 General screening tools for disordered eating/eating disorders not athlete specific
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Table 12.6 Interview-based tools—administered by qualified professional; second stage after screening
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3.2.1.6.2 Self-Report Questionnaire Screening Tools, Athlete Specific for Disordered Eating/Eating Disorders

There are a limited number of tools, which have been designed specifically for female athletes (Appendix 1). Some of the tools available screen both athletes and college students whether female or male. Another method of screening is through questions incorporated into a PPE form. In those, typically any nutrition questions will be directed at females and males. The following section of the form then has questions specific to females. Unless this is clearly delineated, this can be confusing for the athletes during completion of their history (Table 12.7).

Table 12.7 Self-report questionnaire screening tools, female athlete specific
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3.2.1.6.3 Non-Gender-Specific Eating Disorder Tools (Table 12.8)
Table 12.8 Self-report questionnaire screening tools, athlete specific
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3.2.2 Current Research in Dysfunctional Exercise Etiology

Theories regarding the etiology of DysEx are diverse and multifactorial, based on physiological (endorphins hypothesis and sympathetic arousal hypothesis), psychological (general theory of addiction), or psychobiological (personality traits or the anorexia analogue hypothesis) issues.

3.2.2.1 Physiological Hypothesis

During the 1980s and 1990s, some authors had reported regarding the intense exercise effect in the endogenous opioid system, resulting in significant higher concentrations in bloodstream and spinal fluids: The Endorphins Hypothesis. β-endorphin and catecholamine form part of the brain reward system, and it was thought to be related to exercise addiction due to their capacity to regulate physiological responses to stress and intense exercise [24, 75].

Endorphins are endogenous opioids derived from pro-opiocortin polypeptides. Moreover, endorphins originate in the hypothalamus, and regulate pain perception, increasing pain threshold, and showing a greater effort perception in trained people. Exercise intensity (performed above 60% of the maximal oxygen uptake) and duration (sustained for at least 3 min) are related to increases in plasma β-endorphin concentrations. However, plasma endorphins cannot cross the blood–brain barrier (BBB), whereby there is no evidence that changes in plasma levels could lead to simultaneous brain changes. Notwithstanding, some authors believe that endogenous opiates in plasma also operate in central nervous system activity [26, 76]. In spite of the lack of sufficient direct evidence of an association between exercise addiction and the endogenous opioid system, and knowing that aerobic exercise stimulates the release of β-endorphin [77], an animal study with rats reported opioid tolerance and dependence in chronic exercisers [78]. Steinberg and colleagues established that chronic exercise practice [61]:

  • provides an enjoyable effect that stimulates continuing practice;

  • triggers an excessive and compulsive behavior;

  • results in a reduced pain sensation dependent on the individual; and

  • causes the emergence of a psychological and physiological withdrawal syndrome.

The Sympathetic Arousal Hypothesis was first proposed by Thompson and colleagues in 1987. This hypothesis is based on the idea that increased concentrations of catecholamine (adrenalin, noradrenalin, and dopamine) are induced by intense physiological or psychological stress (exercise or tasks). In addition, researchers have reported 1.5–20 times greater concentrations of catecholamine, depending on exercise type, duration, and intensity [79]. Catecholamine produces increases in heart rate, blood pressure, and a general reaction of the sympathetic nervous system known as “fight-or-flight response” [75, 79]. However, endorphin concentrations seem to be attenuated affecting the sympathetic nervous system regulation. On the one hand, habitual practitioners show a central effect of exercise that reduces the sensitivity to stress, producing lower concentrations of catecholamine and an increased efficiency of energy utilization [80]. On the other hand, research also has shown that greater physical fitness resulting in attenuated concentrations of these hormones and could promote negative feelings such as lethargy, fatigue, depression, and decreased arousal [53, 64]. These findings suggest a possible association between addiction and catecholamine behaviors, due to the fact that habitual exercisers are motivated to engage in increased levels of exercise in order to achieve the same arousal levels and suppress symptoms [75, 81].

3.2.2.2 Psychological Hypothesis

Szabo et al. proposed a general theory of addiction or Cognitive Appraisal Hypothesis to explain the etiology of exercise addiction. This theory means that habitual exercisers use exercise as a way to cope with stress, learning to need exercise for this purpose (coping mechanism). When the amounts are exaggerated, the exerciser explains and justifies the practice, and slowly takes a principal role instead of normal daily activities. Negative psychological feelings (irritability, guilt, anxiousness, etc.) appear when the person is required to reduce or stop exercising; feelings that are believed to represent the withdrawal symptoms. There is also a loss of the coping mechanism where the exerciser loses control over stressful situations and feels the need to exercise to manage the stress. Exercise is used as a way to manage their stress. However, as it begins to have a greater toll on the human body, it can ultimately amplify and increase vulnerability to stress. The dysfunctional exerciser is trapped in a vicious circle, exercising more to cope with daily stress that partly is caused by itself [76].

3.2.2.3 Psychobiological Hypothesis

Personality traits or Anorexia analogue hypothesis has been the most utilized to explain DysEx despite the limited research support. Individuals engaging in DysEx share common personality traits and behavioral dispositions with anorectic patients such as compulsiveness [82], neuroticism [83], low self-esteem [84], perfectionism [18, 81, 85, 86], high trait anxiety [87], high self-expectations, denial of potentially serious debility, and tendency toward depression [77]. These traits and dispositions seem to be more pathological in patients with anorexia nervosa than in dysfunctional exercisers [88]. The main effects of DysEx in female are concern about body image and appearance, development of anxiety and depression disorders, as well as the emergence of other behaviors as compulsive buying [33]. However, males often report having an uncertain identity, low self-esteem, and anxiety about physical ineffectiveness [85].

3.2.2.4 Dysfunctional Exercise in the Active Female

Gender incidence remains unclear, although some researchers reported equal prevalence in both males and females, while others have shown a higher prevalence of primary DysEx in males, compared with an increased secondary DysEx in females [89, 90].

Villella et al. reported DysEx behaviors in adolescents and young adults using the Exercise Addiction Inventory [91]. However, this inventory was validated for university students, not high school students [92, 93]. Participants with scores of 24 or more were identified as at risk for DysEx. From a total of 2, 853 high school students (1142 girls—40%) ranging between 13 and 20 years old, 8.5% were at risk of DysEx. Segregating the sample into adolescents and young adults, both groups showed similar percentages (8.7% and 8.3% respectively), and females’ percentages were lower (6.3%) compared to males (10.1%) [91]. Exercise Addiction Inventory was used also by Griffiths et al. who identified 3% of the sample (n = 200) of adults between 18 and 40 years old at risk of DysEx scoring above 24, but no gender differences were reported [94].

Johnston et al. recruited 32 women (16–77 years old) from exercise facilities, weight-loss organizations, and school and university classes [13]. This study reported data of both quantitative and qualitative DysEx. Participants were engaged in a wide variety of activities (hockey, diving, exercise classes, running, weight training, etc.), where the weekly active time ranged from 1 to 16 h (mean of 5 h/week). A total of 18.75% scored above cut-off points of the Obligatory Exercise Questionnaire (OEQ), and half of them were defined as chronic dieters. They also showed that behavioral criteria such as frequency and amount of exercise (quantitative) are as important as psychological factors such as effort and enthusiasm (qualitative).

DysEx in adult runners has been previously reported showing that the more they exercise the greater their DysEx pathologies with no gender differences. In addition, these results were constantly significant in health club exercisers [90]. Edgar et al. recruited a total of 102 female athletes where 47 were dancers, 39 runners, and 16 hockey players. DysEx was lower in women who participated in collaborative sports (hockey, or soccer), followed by endurance practitioners (marathon or ultra-marathon), with higher rates in women practicing activities such as ballet or modern dance. The higher prevalence of qualitative DysEx behaviors in dancers and ballerinas could be explained by the different expectations related to technical demand, and aerobic and anaerobic fitness, intensity, body image, and weight control requirements [95, 96].

The prevalence of DysEx has been estimated in athletes; however, these studies are partly limited by confounding factors and small samples sizes, however, they can give provide an information on baseline prevalence. Despite this a most recent study of 234 Australian athletes of different sports and found a prevalence of 34% [92]. DysEx has been measured in varies levels of athletic competition finding higher levels of DysEx in high performance and professional athletes (64.3%) compared to amateur athletes (43.3%). One study demonstrated that 34% of athletes had an ED, and of those 34%, 50% of females, and 27% of males were dysfunctionally exercising. In female athletes specifically, the Obligatory Exercise Scale (OES) was used to assess DysEx in a group of 183 women age 26–71 year and found a mean prevalence of 3.3% across all ages [93]. Hence, we could expect DysEx prevalence to be the same across lifespan in active women. Hence, we could expect DysEx prevalence to be the same across lifespan in active women.

3.2.2.5 Dysfunctional Exercise Components

If the quantity of exercise is exclusively the defining feature of DysEx, this could be unnecessarily labeling athletes or others as pathologic. Many Olympic or high-level athletes are able to engage in high levels of activity without experiencing symptoms of DysEx such as reduced quality of life or depressive symptoms. Research has proposed that characteristics of DysEx go beyond the frequency or intensity of the exercise itself [97]. In a study of college females, the duration and frequency of self-reported activity were unrelated to DysEx. Rather motivations for exercise such as engaging in exercise to change weight and shape or experiencing negative affect like feeling guilt about missing a session was indicative of excessive exercise [37].

3.2.2.5.1 Qualitative Component

The above findings prompt us to consider a secondary component of one’s relationship with exercise: the “quality.” The quality of exercise can be conceptualized by contexts which may influence an individual to exercise in an unhealthy way. The contexts of exercise help us define the meaning, nature, and purpose of exercise engagement. Together, these contexts shape the quality of one’s relationship with exercise. Calogero and Pedrotty suggest several contexts which can shape our relationship with exercise, including, but not limited to exercise history, physical condition, emotional experiences, belief systems, social relationships, ecological factors, and sociocultural pressures [97]. For example, Claire is an 18-year old living in Los Angeles, USA. She feels compelled to run around the block four times before she has a snack for fear of gaining weight. Claire would be an example of the sociocultural context defining the quality of her relationship with exercise. This is because her motivation for activity is based on controlling her shape or weight which depicts the sociocultural pressure, she feels to be thin. This example helps illustrate that it is not simply the quantity of activity that characterizes DysEx. It may have only taken Claire 20 min to run around the block. However, the activity she engaged in was dysfunctional in nature due to the motivation underlying it. Together, we can conclude that it is quality and not simply the quantity of exercise that underlies DysEx. As such, it has been proposed that the quality of exercise mediates the relationship between healthful exercise and DysEx [95].

Interestingly, the origins of attempting to characterize and measure DysEx lie in understanding its quality. In fact, the first conceptualizations of DysEx were based upon the criteria for behavioral addiction, such as gambling [83, 98]. Many similarities exist between the two characterizations. Based on these characterizations, a number of scales were developed to assess DysEx. These assessment tools have, however, progressed with the evolving understanding of DysEx.

3.2.2.5.2 Quantitative Component

Since “health” is considered a state of complete physical, mental, and social well-being and not merely the absence of disease, physical activity levels could determine the health status of the population [99]. The benefits of moderate to vigorous physical activity (MVPA) and exercise have been well documented [100,101,102]. However, DysEx refers to negative effects of engaging in “too much” exercise. While sedentary lifestyle has been deeply researched using accelerometers, excess of physical activity has been poorly studied. In fact, there is substantial research that supports improvements of cardiovascular risk and reduction of all-cause mortality linked increased dose of exercise [98]. This generates two questions: the first, is DysEx determined by its quantity? The second, “how much is too much exercise?” The studies focused on finding a threshold to determine the limit for healthy versus DysEx have some limitations. For example, they generally chose a very conservative threshold based on the Metabolic Equivalent for Tasks (METS). So, more than 6 METS/day or more than 42 METS/week were found to be most protective or beneficial [103]. A study in 2001 reported a direct relationship between greater increases in physical health parameters and the number of weekly hours spent exercising (from 2 to 7 weekly hours). Lower cardiovascular risk of mortality was reported in those who practiced between 4 and 7 weekly hours of regular physical activity. However, some cardiovascular risks reported when more than 7 weekly hours where performed, may be due to undiagnosed cardiac conditions. By contrast, lower risk of cancer, respiratory disease, or other diseases were addressed when the practice was more than 7 h/week of MVPA [101]. Other authors show that physical activity benefits depend on the intensity of the practice, where greater benefits and lower mortality rates were associated with vigorous activity, not light activity [104, 105]. Based on this research, the Center for Disease Control and Prevention and American College of Sport Medicine recommended 30 or more min of MVPA almost every day [105, 106]. Currently, this recommendation has been increased, especially in children, where at least 60 min of MVPA should be performed 5 days a week and ideally every day. Another important limitation regarding to the quantitative component is that the definition of “How much exercise is too much?” is far below what many athletes perform. For example, endurance runner athletes and triathletes perform ~20 METS/session or ~20 h/week of exercise [107]. An athlete’s training level is unique to his/her discipline and each type of exercise is accompanied by unique physiological adaptations. Therefore, every discipline could have different cut-off points and health benefits.

In addition to the problematic thresholds, there is also an often-forgotten perceived positive psycho-physiological effect of exercise when it is part of the daily routine of an individual (i.e., habit). Habit is defined as a recurrent, often unconscious, pattern of behavior that is acquired through frequent repetition. Whether this is a positive elevated exercise practice or not, should be analyzed based on the characteristics (quantitative and qualitative) of the behavior. Remember that regular practice of exercise has been found to improve psycho-physiological parameters such as self-esteem, physical fitness, and social behavior, all of which contributes to maintain exercise behavior or habit [108]. But “what happens when you eliminate a habit from equation?” Researchers have reported that 1–2 weeks of practice deprivation can result in depression symptoms, negative mood states, or even fatigue [104,105,106, 109]. “Do these effects reflect that reduction of exercise levels is a positive decision?”

3.2.2.6 Thresholds for Dysfunctional Exercise: What We Know

Exercise thresholds (i.e., duration and intensity) have been primarily studied, but not validated, in populations with DysEx (i.e., Eds). Some authors suggest that engaging in more than 6 h of exercise per week during at least four consecutive weeks is an indicator of DysEx [19]. This threshold was proposed initially by Davis et al. in patients with Eds as a compensatory behavior; therefore, relating more to secondary DysEx [110]. This threshold (>6 h/week for at least 4 weeks) was further defined by Bratland-Sanda et al. in 2010 as MVPA. Therefore, performing more than 52 min/day of MVPA can be considered the threshold for secondary DysEx only in the context of those with an ED and not for the general population [111].

Due to a wide range of different characteristics of populations, establishing thresholds for healthy versus DysEx between the general population, those with Eds, and athletic populations may be unrealistic. A healthy population will be expected to perform at least 60 min of moderate to vigorous exercise every day for children and adolescents, and a minimum of 150 min/week for adults [112]. In this sense, there is a lack of knowledge and understanding about how to appropriately establish a threshold for each population. Research could help us understand how much activity should be performed by each group and set relevant thresholds for each. Establishing thresholds for each population is important, both for general knowledge and understanding, as well as to determine the most effective way to help an individual experiencing DysEx.

3.2.2.7 Screening Tools for Dysfunctional Exercise

Screening tools should be used to assess both quantitative and qualitative components of DysEx (Appendix 1). Quantitative features of the exercise behavior should assess duration (i.e., min, h), frequency (i.e., days/week, sessions/day), intensity (i.e., light, moderate or vigorous), or total volume. Therefore, qualitative features should be assessed through psychological measures such as mood state, depression, anxiety, compulsion, addiction, or eating disturbances. To further the complicate DysEx assessment, screening tools can be subjective or objective instruments. Daily logs, questionnaires, inventories, and observations are the most used subjective instruments due to their easy application and low cost. Nevertheless, there are important limitations associated to their validity and reliability [113]. When these screening tools are compared with gold-standard methods (i.e., accelerometry or GPS tracking devices) [114, 115], it results in either over-estimation in healthy populations [116], or under-estimate real levels in ED patients [117, 118]. Additionally, when the variables assessed are physiologic, it results in greater over-estimations, because the inability to analyze all dimensions of physical activity [116]. Regarding objective instruments, pedometers and accelerometers are the most common devices used to assess spontaneous activity during prolonged periods of time. Of these, the accelerometer is a practical, precise, and inexpensive device [119].

3.2.2.8 Classification of the Screening Tools for the Assessment of Dysfunctional Exercise

Choosing one screening tool over the other could give the researchers different validity levels of data from the most objective to the most subjective measurements. When is a screening tool considered objective or subjective? A screening tool is considered to be highly objective when it measures what it intends to, and when it approaches the fact. Subjective screening tools approximate the data by delayed information where the perception of researchers or participants could alienate results. Using objective or subjective screening tools depend on which characteristics of the excessive exercise are aimed to be analyzed: min per day, week or month, intensity of exercise, mood state, or eating disturbances. Researchers are more likely to use objective tools when the assessment does not need from the participation of individuals, or subjective tools when the participation of one or both researcher and individual is needed. Therefore, screening tools like mechanical devices are shown as objective tools, and inventories, questioners, self-report diaries, and interviews are shown as subjective tools [31, 120]. Both subjective and objective screening tools can be classified as qualitative (subjective instruments) and quantitative—including both subjective instruments and objective mechanical devices as accelerometers or pedometers, or other technologies such as mobile apps or sport-GPS tracking devices.

3.2.2.8.1 Qualitative Screening Tools for Dysfunctional Exercise

Qualitative screening tools report information about the characteristics of exercise related to psychological and physiological issues. The main characteristics of these instruments (QEQ, EDS-R, and EAI), as well as principal sources, can be found in the following Table 12.9.

Table 12.9 Screening tools for dysfunctional exercise
Full size table
3.2.2.8.2 Quantitative Screening Tools

Researchers have been using multiple movement devices successfully, including accelerometry, GPS-tracking devices, and pedometers to provide information about objective quantification of physical activity. Accelerometers and pedometers are the most popular and have been used not only in healthy children, adolescents, adults, and elders of both genders, but also in different pathologies, owing to their low cost, storage capacity (more than 20 days), programming, data download, validity, and reliability [132].

Subjective quantification of physical activity levels is also possible through self-administered questionnaires and interviews. For example, the International Physical Activity Questionnaire (IPAQ) is a free and self-administered questionnaire that has been validated and is used worldwide with adults from 18 years and older [133]. There are other questionnaires specially validated for children and adolescents, such as the Physical Activity Questionnaire for Children and Adolescents (PAC-C or PAC-A) [134]. When incorporated into clinical practice, the most appropriate self-administered questionnaires should be selected based on age, sex, and validation within the intended population group. However, we must keep in mind the over- or under-estimations associated to the instrument and the population group.

3.2.3 Current Research in Menstrual Dysfunction Types of Menstrual Dysfunction

Aside from pregnancy and menopause, causes of secondary amenorrhea are most likely due to the following:

  • Thyroid dysfunction

  • Elevated prolactin

  • Ovarian failure

  • Polycystic ovarian syndrome (PCOS)

  • Hypothalamic amenorrhea

Thyroid dysfunction and elevated prolactin are easily sorted out by blood testing for thyroid-stimulating hormone (TSH) and prolactin (PRL) levels. An athlete with ovarian failure will have elevated follicle-stimulating hormone (FSH) levels and very low or absent estrogen. PCOS and hypothalamic amenorrhea are typically differentiated based on clinical presentation, as they both may have normal FSH levels. The athlete with PCOS will usually be at or above a normal body as index (BMI) and will likely be hirsute and may show signs of insulin resistance [1, 35].

3.2.3.1 Functional Hypothalamic Amenorrhea

Loucks provides convincing evidence for the energy availability hypothesis related to menstrual dysfunction in athletes. Additionally, she provides evidence against the original theories concerning body composition and exercise stress. It is important to remember a series of events appears to be related to a deficit in energy availability causing menstrual dysfunction and subsequent issues with skeletal health. Exercise does not have an impact on LH pulsatility beyond the impact of its energy cost on energy availability [32, 47].

The energy availability hypothesis states if the brain energy requirements are not met, an alteration in brain function occurs which disrupts the GnRH pulse generator [50]. Regulation of puberty and reproductive function depends on interactions at specific levels of the hypothalamic-pituitary-ovarian (HPO) axis. The GnRH “pulse generator” neurons in the hypothalamus secrete GnRH every 60–90 min. This hormone causes release of gonadotropins (luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) from the pituitary gland. These, in turn, cause release of progesterone and estrogen from the ovaries. These two end hormones are key to regular, ovulatory menstrual cycles [1, 53, 54]. Deficiency in GnRH pulsatile secretion leads to hypothalamic amenorrhea. Since hypothalamic amenorrhea in the athlete becomes a diagnosis of exclusion, it is often termed functional hypothalamic amenorrhea (FHA), because it is a functional suppression of reproduction [1]. Because FHA is the typical menstrual abnormality seen in athletes, it will be the focus of discussion concerning treatment of menstrual disorders for this chapter.

3.2.3.2 Who Should Be Screened for Menstrual Dysfunction?

The main populations to screen for menstrual dysfunction include the following groups [41, 135]:

  • Adolescents involved in vigorous exercise with primary amenorrhea

  • No menarche within 5 years after breast development that occurred less than 10 years old

  • Failure of the thelarche (breast development) by 13 years old

  • Athletes with previously regular cycles, at any age, with secondary amenorrhea or the lack of menses for 3 continuous cycles after beginning menses

  • Athletes with oligomenorrhea, less than 9 cycles per year

  • An intensively exercising, reproductively mature woman interested in conception

3.2.3.3 When to Screen for Menstrual Dysfunction

The answers concerning when to screen athletes for menstrual disorders are similar for screening of DysEx and ED. Evaluation of one component of the female athlete triad should not occur in isolation from the other two components. There is not yet an agreed upon optimal timing or method of screening for any component of female athlete triad disorders [3, 58]. Screening should be economical and time-efficient and should create an environment that will not cause an athlete to minimize or deny certain medical conditions [58].

Timing of screening can include 1) during pre-participation examinations (PPEs) for competitive athletes, 2) during clinical presentation of the athlete for routine health care (i.e., well woman examination) or for illness or injury, and 3) incidental observation by an athletic trainer, parent, friend, coach, or administrator [3, 29]. Since menstrual dysfunction is often seen as related to sexuality, it can be a very sensitive topic and is not as likely to be incidentally discussed as energy availability might be. This leaves incidental observation the least likely scenario. Because of this, it is probably best to have a short screening tool utilized by those who interact on a routine basis with the athletes, such as athletic trainers, personal trainers or other gym personnel, and coaches who do not have availability of athletic trainers. The questionnaire tool could be distributed to all female athletes at specific times during the athletic year and would act as a first step to identify a possible disorder in menstruation. It ideally would also contain questions concerning nutrition and bone health. It would be easy to score and if the athlete screens positively with the tool, she would then be referred to a team physician or other designated intervention team for the second stage of screening, an in-depth evaluation.

3.2.3.4 Screening Questions for Menstrual Dysfunction

No validated tools to screen for menstrual dysfunction exist. Several pre-participation examination forms have from one to six questions included on the form [42, 55]. Tools used to screen for DE and ED may include a few questions about menstrual health. It is likely best to have a supplemental form, apart from the PPE form, in order to effectively screen for menstrual dysfunction. Screening should also include questions related to energy availability and skeletal health. Appendix 1.1 provides examples of tools used to screen female athletes for various components of the female athlete triad. The ideal will be to develop a standardized form to screen for the female athlete triad that is then validated. Any athlete who screens positively would need further evaluation by a physician [48].

3.2.3.5 Evaluation of Menstrual Dysfunction Beyond Screening

The in-depth evaluation with the physician or intervention team should include a routine health history, a comprehensive menstrual and obstetrical and gynecologic history, an appropriate examination, and an evaluation of bone mineral density. The physician could obtain the sexual history, in order to avoid an uncomfortable setting for the athlete and her athletic trainer and/or coaches [3, 29, 34, 44, 46, 58]. Some screening tools and PPE forms currently in existence already have a variety of questions concerning menstrual history. However, this varies from one question to several, to an entirely separate form [42, 55, 57, 77].

The question still remains concerning what makes up an adequate screening tool compared to an extensive obstetrical and gynecologic history. None of the existing forms have been validated for menstrual dysfunction screening. In a study done of NCAA Division 1 schools in 2003, 138 of 170 schools responded and 79% stated they did screen for menstrual disorders (MD). Only 24% of those used a comprehensive menstrual history questionnaire. A menstrual disorder treatment protocol was used by 33%. Of the responding schools, 60% screened for ED. However, less than 6% used a structured interview or a validated questionnaire. The conclusion from this study was there exists a pressing need for more standardized ED and MD screening, prevention, and treatment programs among NCAA Division 1 schools. A further conclusion was, at the very least NCAA member institutions should implement mandatory ED and MD education for all athletes and athletic personnel [28].

A study performed in 2012, involving menstrual irregularity in high school athletes, showed a high incidence of menstrual irregularity and an increased number of musculoskeletal injuries than in athletes reporting normal menses. More than half of the athletes reported a change in menses during training or competition. The recommendation from this study was for improved education of high school athletes to improve caloric intake to better balance their energy availability to prevent or correct menstrual irregularity [68].

3.2.3.6 Management of Functional Hypothalamic Amenorrhea

Once an athlete is identified as having a menstrual disorder, management becomes the next issue. In functional hypothalamic amenorrhea, there is insufficient energy availability. This then alters GnRH pulsatility in the hypothalamus and LH and FSH release. With limited pituitary secretion of LH and abnormal pulsatility, there is a lack of ovarian stimulation and thus an estrogen deficiency which impacts skeletal health from low sex hormones. There is also altered neuroendocrine function with low levels of insulin, glucose, leptin, triiodothyronine, and insulin-like growth factor-1 and elevated growth hormone and cortisol [53].

In adolescent girls, about 90% of total body mineral content is accrued by 15.5–18 years of age. Delayed puberty can compromise bone mass accumulation and low bone mineral density is a common finding in athletes with functional hypothalamic amenorrhea [53]. Twenty-five percent of bone mass accrual occurs in the 2 years surrounding menarche [34]. Due to this, the athlete becomes at risk for stress fractures, failure to achieve optimal peak bone mass density, and is thus at risk later in life for osteoporosis or delayed stress fractures [46]. Other risks from hypoestrogenism may include cardiovascular disease, dementia, depression, delayed post-exercise recovery, decreased immune function, and other neurodegenerative and psychiatric disorders [29, 47, 54, 126].

4 Contemporary Understanding of the Issues

Screening female athletes for disordered eating, eating disorders, DysEx, and menstrual dysfunction is a complex issue. Those involved with active females need to encourage screening on multiple levels, both formally and informally, utilizing a combination of timing and methods (observation, standardized questionnaires, interviews, etc.). Screening needs to occur as an ongoing process, not only occurring as an isolated event during pre-participation examinations. Education of those involved with female athletes, on all levels, will help in ongoing informal recognition of signs and symptoms of DE/ED, DysEx, and menstrual dysfunction. This is essential because the longer low energy availability is allowed to exist, the greater the health and performance impairments that occur and the more difficult they are to treat.

Screening for DysEx or menstrual dysfunction should not occur in isolation and need to include evaluation of total energy availability and bone health to be thorough in evaluating for the female athlete triad. Currently, there is no universally agreed upon timing or method to screen athletes for abnormal energy availability (DE/ED), DysEx, or menstrual dysfunction. Although, in association with PPE’s and during routine healthcare visits, or clinical evaluation when one portion of the triad presents, are the most common cited times for screening. Additionally, there are not clear guidelines about what should happen when an athlete does screen positively for menstrual dysfunction. A complete physician evaluation is recommended, to include past medical history, past surgical history, current medications, social history, family history, and a comprehensive obstetrical and gynecologic history. Comprehensive history taking will then guide the physician concerning appropriate physical examination, laboratory testing, and radiology studies.

A national standard should be encouraged, with a supplemental questionnaire specific to females rather than questions incorporated into a standard PPE form. The athletic trainer or team physician or both should then review the tools. Physicians need to be reminded to screen female athletes for risk factors for low energy availability during routine health visits and visits for acute illness or injury. If for some reason a female athlete-specific questionnaire cannot be utilized, consideration should be given to use of a general population screening tool that is inexpensive and easily accessible. Please see Chap. 5 for more discussion surrounding management and education for MD management in athletes.

5 Future Directions

The sports medicine community can serve its female athletes well by developing a consensus guideline related specifically to screening for DE/ED, DysEx, and menstrual dysfunction. The challenge has been twofold: to agree on questions needing to be asked on a survey tool, and to achieve validation of any such tool. A method of rapid assessment of that tool would then allow the healthcare provider to determine whether further referral should be made the same day, or if ongoing monitoring may be needed. Incorporation of physiologic variables into a screening tool shows promise and should be further evaluated.

Simplified education programs for all people who interact with athletes should be developed based on prior efforts, distributed nationally, and assessed to evaluate their effectiveness in detection and/or prevention. Methods of screening for these conditions should be covered in these programs so that screening will become an ongoing process in both informal and formal settings where female athletes are encountered. Further, programs of education and screening should be expanded into junior high and high schools to identify issues of low energy availability as early as possible.

6 Concluding Remarks

Low energy availability, as a consequence of DE or ED or DysEx in female athletes, is a significant health concern. It is a key component of the female athlete triad and can lead to menstrual disorders and changes in bone health. The athletic health care community needs to address this health concern beginning in junior high school and high school and continuing through the lifetime of the active female. The best method of management is through a combined approach with screening both informally through observation and formally during pre-participation examinations and other interactions of female athletes with health care providers, in order to prevent the consequences of DE, ED, and DysEx. Pathologic eating disorders can lead to significant health complications, including death.

There is a fine line between regular and healthy exercise and excessive practice. There is not a clear relationship between high levels of exercise and other mental disorders. Although other mental illnesses may be the source, there are no studies to confirm or deny it. DysEx is more common in high performance compared to recreational exercisers. When 15 years of experience are exceeded, the prevalence of DysEx decreases, likely because practice is highly integrated in daily life. When women display DysEx behaviors, the features are different compared to males. Features specific to women include weight preoccupation, appearance, body image, and body composition concerns. These features are closely related with DE and ED symptoms.

Menstrual dysfunction in athletes should be considered a medical issue needing further evaluation. Amenorrhea in the active female should no longer be viewed as a good thing. In addition to being a medical problem, it can be a symptom related to abnormal skeletal health. At one extreme, it may be the first warning sign of a potentially lethal ED. At the other extreme, it may be a sign of lack of proper nutritional education causing the athlete to exhibit DE, i.e., not taking in enough calories for the level of training. Prevention and early intervention are the key components to minimizing morbidity and mortality. The ideal method and timing for screening have yet to be determined. The best method is likely using a separate questionnaire-based screening tool during the pre-participation physical examination.

Screening for these disorders can be a sensitive issue. Initial screening by athletic trainers or coaches should include basic questions concerning menses, bone health, and energy availability. Once the athlete screens positively, she should be referred to medical personnel for a comprehensive evaluation. Screening tools need to be more specific and detailed, and validated for female population. Additionally, an in-depth analysis, using one or more screening tools, might be needed to prevent the female athlete triad and provide the best recommendations and/or treatment.