Use of the Preparticipation Physical Exam in Screening for the Female Athlete Triad Among High School Athletes

INTRODUCTION

For centuries, women were considered too frail or fragile to participate in sports. For example, riding a bicycle was considered too taxing for the Victorian woman (Donaldson, 2003). However, since President Nixon signed Title IX into law in 1972, there has been a 10-fold increase in the number of female athletes (Donaldson). Title IX is part of the Education Amendment Act of 1972 that mandates that any institution that accepts federal funding must provide equal opportunities for men and women to participate in all athletic programs (Kirchner & Cohen, 2002). Over the past 30 years, female athletes have experienced several benefits, such as improved health and fitness, increased self-esteem and self-confidence, and improved psychological and social outlook (Smith, 1996). Despite the benefits women have experienced, there has been an increase in health problems specific to female athletes. According to many authors, the most worrisome is the triad of medical problems that includes disordered eating, amenorrhea, and osteoporosis (Donaldson, Thrash, & Anderson, 2000). The American College of Sports Medicine (ACSM) has named this trio of medical conditions the “female athlete triad” (Otis, Drinkwater, Johnson, Loucks, &, Wilmore, 1997). The female athlete triad has been termed the “new epidemic” (Yurth, 1995, p. 149), which can result in short- and long-term health problems for women, such as stress fractures, irreversible bone loss, infertility, and osteoporosis (Lo, Hebert, & McClean, 2003). Each of these individual conditions is of medical concern, but when found within the triad, they can have serious and potentially life-threatening medical consequences (Beals, Brey, & Gonyou, 1999; Burney & Brehm, 1998; Otis et al.).

LITERATURE REVIEW

Disordered eating is the main aspect of the triad and has been reported to affect 15–62% of female athletes versus approximately 5% of women in the general population (Donaldson, 2003; Hobart & Smucker, 2000; Kirchner & Cohen, 2002). Disordered eating can range in severity from relatively benign behaviors, such as limiting caloric intake and skipping meals, to true eating disorders, such as anorexia nervosa and bulimia nervosa (Yurth, 1995). Researchers believe disordered eating behaviors cause hypothalamic dysfunction in female athletes with normal menarche, leading to secondary amenorrhea. Secondary amenorrhea is defined as the absence of at least three consecutive menstrual cycles in a girl who has begun menstruating (American Academy of Pediatrics [AAP], 2000; Nattiv et al., 1994). The prevalence of amenorrhea in athletes has been reported to be 3–66% (depending on the sport), compared with 2–5% in the general population (AAP; Burney & Brehm, 1998; Hobart & Smucker). According to researchers, prolonged amenorrhea or menstrual dysfunction in female athletes leads to decreased levels of estrogen, which inhibits adequate bone formation (AAP; Kirchner & Cohen). This increase in premature bone loss and inadequate bone formation leads to osteopenia and premature osteoporosis in female athletes, resulting in increased bone fragility and risk of fractures (Burney & Brehm). The prevalence of osteoporosis in female athletes is unknown, although it is evident that bone loss in amenorrheic athletes is rapid and may not be reversible (Burney & Brehm). This is especially relevant to young girls, due to the fact that 60–70% of peak bone mass in women is acquired before age 20 (Donaldson).

This triad of conditions is of growing concern for girls involved in athletics. However, according to the American Academy of Family Physicians (AAFP) and the ACSM, “the triad is often denied, not recognized, and underreported” (AAFP, 1997; Otis et al., 1997, p. ii). The ACSM calls on all individuals who work with female athletes to learn about the triad and to develop plans to prevent, to recognize, and to treat this disorder (Otis et al.). According to experts, prevention should be the highest priority for these individuals (Nattiv et al., 1994; Otis et al.). Educational programs should be the basis for this prevention, with these programs targeting coaches, athletes, parents, athletic trainers, and school administrators; programs should focus on the importance of sound nutrition and the short- and long-term consequences of the triad. Unfortunately, few high school or collegiate athletic programs include such education.

The recognition of athletes at risk or those athletes who already have developed one or more components of the triad is of utmost importance in order to prevent further health problems. Many experts recommend that the best time to screen for the female athlete triad is during the preparticipation physical exam (AAP, 2000; Beals et al., 1999; Hobart & Smucker, 2000). According to Yurth (1995), “preparticipation physical examination is the ideal time to identify athletes who already have or are at risk of the triad developing” (p. 149). Preparticipation history and physicals are required for participation in a majority of high school sports, yet many schools do not use forms designed specifically for girls. As a result, these exams fail to screen girls for the triad and, more specifically, for disordered eating and menstrual dysfunction.

In one study, Beals (2003) surveyed 138 Division I college athletic programs for the nature and scope of their screening, education, and treatment of eating disorders and menstrual dysfunction in female athletes. The study demonstrated that only 24% of programs used a comprehensive menstrual history questionnaire and less than 6% used a structured interview or a validated eating disorder questionnaire. The study also showed that disordered eating and menstrual dysfunction education was provided by 73% of schools; however, less than 41% made such education a requirement (Beals). These statistics demonstrate the lack of effectiveness of collegiate athletic programs to screen women for disordered eating and menstrual dysfunction and to require education on the subject. There is a lack of data about the effectiveness of similar screening and educational programs among high school athletic programs. The purpose of this study was to evaluate the effectiveness of the preparticipation history and physical forms in high school athletic programs to screen for the components of the triad and to determine the prevalence of educational programs related to the female athlete triad in a large urban school district in a western state.

METHOD

A descriptive study design was used to determine if preparticipation screening forms included characteristics of the female athlete triad and if schools had educational programs for female athletes on issues concerning the triad. This project determined whether the triad-related guidelines recommended by the ACSM were being implemented in high school athletic programs.

RESULTS

Statistical analyses were performed using SPSS (Statistical Package for the Social Sciences, Version 11.0 for Windows, Chicago, IL). Frequency tables were completed for each question. A total of 76 surveys were mailed, and 34 (45%) were returned (25 public schools and 9 private). Of the surveys completed, 97% were completed by the girls’ high school athletic director. Results indicated that a majority of high schools (67%) do not screen female athletes for menstrual dysfunction. Only 33% of the schools that do screen reported using one or two limited questions on the pre-participation exam form related to menstrual history (e.g., Is your period regular? Have you ever skipped a period?). Three percent of schools reported having a standard treatment protocol for athletes with menstrual dysfunction, which usually consisted of referring the athlete to her primary physician, and 30% of schools would restrict an athlete from participation if recommended by a physician.

Twenty-two percent of schools reported screening female athletes for disordered eating during the pre-participation exam, which consisted of weight-loss history, weight for height measurements, or reports from coaches and teammates. Only 18% of schools reported having a standard treatment protocol for confirmed cases of eating disorders. This treatment was usually on a case-by-case basis and consisted of a referral to a physician (42%), psychologist or counselor (42%), eating disorder specialist (24%), or registered dietitian (15%), and/or a talk with the athlete’s parents (12%). Multiple responses were allowed. Thirty-two percent of schools reported restricting athletes with confirmed cases of eating disorders from participation.

Thirty-three percent of schools reported having educational programs (e.g., individual counseling, group seminars, videos/films, written materials) for female athletes regarding the disorders of the female athlete triad, yet less than 9% of these educational programs required student attendance (Figure 1). Similarly, education regarding the female athlete triad was provided for 24% of coaches, but only 15% of schools made the education a requirement (Figure 2).

DISCUSSION

The results of this study suggest that high school athletic programs are not adequately screening girls for the different components of the female athlete triad. The AAP (2000) recommends that the following be reviewed for each female athlete: (a) dietary practices, (b) exercise intensity, duration, and frequency, and (c) menstrual history. Of the high schools surveyed, only three reported the inclusion of this information on the preparticipation history and physical form. With a lack of this information, high schools are failing to screen female athletes for disordered eating and menstrual dysfunction. In order to effectively screen for menstrual dysfunction, the medical history should include questions about age of menarche, frequency and regularity of periods since menarche, frequency and duration of amenorrhea, and changes in menstruation during the summer when athletic participation diminishes (Beals, 2003; Donaldson, 2003; Rumball & Lebrun, 2004). Disordered eating should be screened through a complete nutritional and body weight history. Questions should include a food log, the usual number of meals and snacks, list of forbidden foods, highest and lowest weights since menarche, weight satisfaction, and weight-control behaviors (Beals; Donaldson).

As previously stated, educational programs should be the basis for preventing the female athlete triad, and experts agree that these programs should target coaches and athletes (Burney & Brehm, 1998; Hobart & Smucker, 2000; Lo et al., 2003). However, only one third of high schools reported having educational programs and a majority of these programs did not make attendance a requirement. The ACSM recommends that every physically active girl be educated about proper nutrition, safe training, and warning signs and risks of the triad (Otis et al., 1997), yet the results of this study suggest that high schools are failing to implement such programs.

IMPLICATIONS FOR SCHOOL NURSING PRACTICE

With a growing population of female athletes who are at risk for the female athlete triad, nurses have the potential to play a vital role in the prevention and treatment of young athletes. According to Nattiv and colleagues (1994), adolescent female athletes are at the greatest risk for developing the triad, and therefore “school nurses are in the best position to identify signs and symptoms of the Female Athlete Triad in middle- and high-school-age athletes” (Sherman & Thompson, 2004, p. 201). As stated previously, the highest priority for individuals working with girls in athletics should be prevention. Educational programs designed to target female athletes are a tangible way to help prevent the triad. School nurses are a key component in implementing educational programs, such as seminars, workshops, and physical education classes designed for young female athletes (Burney & Brehm, 1998). These educational programs should be required for these athletes and coaches, and should focus on dispelling myths and misconceptions about dieting, body weight, and nutrition. They also should stress the importance of good nutrition and responsible exercise in promoting health and performance (Beals et al., 1999). There are a variety of available resources regarding the female athlete triad to help school nurses, coaches, and administrators implement educational programs in their high schools (Table 2). It also is essential for school nurses to become familiar with community resources necessary for athlete referrals, such as local registered dietitians, psychologists, medical providers with expertise in adolescent gynecology, and eating disorder specialists.

Another opportunity for school nurses to participate in the prevention of the triad is through the education of school athletic directors and administrators about the importance of implementing preparticipation history and physical forms designed specifically for girls (Lo et al., 2003; Rumball & Lebrun, 2004). According to Rumball and Lebrun, the medical history portion is the most important aspect of the preparticipation physical, and should include questions regarding gynecological and nutritional information (Table 3). These questions are essential for adequately screening female athletes for disordered eating, menstrual dysfunction, and osteopenia. Through the use of uniform guidelines for preparticipation physical examinations, schools can begin to adequately screen female athletes for the different components of the triad. For example, The Preparticipation Physical Evaluation (3rd ed.) has been published recently and has been endorsed by six major medical societies in an attempt to develop uniform guidelines for athletic trainers, coaches, and school athletic directors (AAFP and others, 2004). This book is considered the “gold standard” in screening exams and contains sample history, physical, and clearance forms. It also contains information pertaining specifically to female athletes, including disordered eating, the female athlete triad, gynecologic disorders, and pregnancy.

SUMMARY

Girls can enjoy a variety of benefits from high school sports. Adolescent girls who participate in sports are less likely to become pregnant as teenagers or to become involved in abusive relationships, and are more likely to finish high school and to go to college (Ireland & Ott, 2004). However, when the pressure to achieve success in athletics overcomes the excitement and pleasure of participation, serious health problems can develop, the most serious of which is the female athlete triad. Only through educational programs and effective preparticipation history and physicals specific for female athletes can young women continue to experience optimal performance and health.