Triad of the athlete

Edited by Dr. Giovanna Taranto

L "AMENORREA

The balance normally existing between the hormones that regulate the menstrual cycle can be easily interrupted by numerous factors of both physiological and psychological nature and each disturbing factor triggers reactions that differ from subject to subject and which manifest themselves in different pathological forms.
Amenorrhea is the manifestation of a severe disequilibrium of the hypothalamus-pituitary-gonadal axis which athletes can usually face going through intermediate phases such as oligomenorrhea, LPD (or luteal phase defect), anovulation or delayed menarche.
It has been shown that ovarian function often changes in relation to factors, such as the availability of food, the energy balance and energy expenditure, which can change as a result of seasonal or environmental factors.
Although there are different types of amenorrhea, classified according to their etiology, female athletes share the same type of disorder, which is hypothalamic amenorrhea - associated with the most severe estrogen deficiency, with chronically low levels of gonadotropins and ovarian steroids. circulating - also called hypogonadotropic hypothalamic amenorrhea.
Mainly there is a decrease in the pulsatile secretion of GnRH (hormone that acts on the pituitary to regulate the production of other hormones such as "LH: luteinizing hormone, and" FSH: follicle-stimulating hormone) which in turn limits the secretion from starts from the pituitary of LH and FSH. Low levels of LH and FSH lead to a lack of stimulation of the ovary which ceases to produce estradiol.
The definition of amenorrhea has varied over the years; classified as the lack of menstruation, it is divided into primary and secondary. Primary if menarche has not occurred within 14 years, in the absence of secondary sexual characteristics, or within 16 years in the presence of secondary sexual characteristics. Therefore primary amenorrhea is also called delayed menarche.
Secondary amenorrhea is characterized by the absence of menstruation after the establishment of regular menstrual cycles. The definition provides lack of a period for a period of 3-6 consecutive months or only one menstrual cycle per year.

PREVALENCE OF MENSTRUAL DISORDERS

The prevalence of the disorder among female athletes varies between 1% and 66%, while among sedentary women the percentage drops to 2-5%. As regards menstrual irregularity in general, the prevalence is 31.4% of female athletes against 24.5% of non-athletes with cycle disorders.
The highest prevalence of strenuous physical activity amenorrhea occurs in sports that emphasize low body weight such as figure skating, dance, long-distance running, and gymnastics, but studies have reported menstrual abnormalities in a "wide variety of sports. .

OTHER MENSTRUAL DISORDERS

Oligomenorrhea is defined as the succession of irregular and inconsistent cycles for a period ranging from 36 to 90 days; some studies have used the parameter of 4 or fewer cycles per year.
Since this type of disorder is closely correlated with a low level of estrogen, which leads to a difficulty of the dominant follicle to develop, oligomenoreal cycles can also be anovulatory and characterized by evident hypoestrogenism.

Anovulation is defined as the "absence of the ovulatory event when the levels of FSH and LH are low in association with reduced levels of E2 (estradiol) and the absence of luteinization. It is also characterized by low levels of E2 and progesterone during the cycle.

The luteal phase defect or LPD is a disorder that occurs following the secretion of an inadequate amount of progesterone that does not make it possible to implant the egg in the uterus. Women with LPD ovulate, but later than normal (normal ovulation between the 12th and 14th day of the cycle) showing a shortening of the luteal phase.
All of this is expressed in a low fertility rate and a high rate of spontaneous abortions. The defect of the luteal phase occurs with greater prevalence in athletes than in untrained subjects, representing the most frequent menstrual disorder related to sport.

LPD OVULATORY CYCLE ANOVULATORY CYCLES OLIGOMENORREA AMENORREA

Fig. 1: line of conjunction between the various disorders of the menstrual cycle of the athletes ordered by increasing severity from the normal condition of ovulatory cycles to amenorrhea.

Often there are ovulatory cycles alternating with anovulatory cycles during the year, it is good to take this into account to monitor the progress of the disorder.

This kind of disorder derives from excessive stress that triggers mechanisms by which the entire reproductive system, which needs the right amount of calories to function well, goes into a sort of stand-by, so as to leave the lack of energy resources for essential functions. to survival.
More recent research has revealed an additional health risk related to hypoestrogenism: increased cardiovascular risk factors such as unfavorable lipid and protein changes and decreased vascular function.
Estrogens have a vasoprotective function because they influence the functionality of the endothelial cells on which the health of the vascular system depends.
In the most severe cases of athletes affected by the Triad, therefore with severe hypoestrogenism, the risk of stroke and heart attack increases.
In fact, the health condition of athletes affected by the advanced triad is comparable to that of women in menopause!