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NEDA TOOLKIT for Coaches and Trainers • Disordered eating • Menstrual irregularity is not usually detectable by a coach, but it is important to let your athletes know that missing menstrual cycles is not normal and they should feel comfortable going to student health or a specialist to have this addressed. Missed cycles in athletes are not always an indication of the Triad, so it is important to have the athlete evaluated by a doctor for other medical problems that may cause amenorrhea (e.g., polycystic ovarian syndrome or a pituitary tumor). This evaluation involves various laboratory tests and sometimes imaging. Once other causes are ruled out, treatment can proceed with dietary and exercise adjustments. Female athletes taking oral contraceptive pills (OCP) may be unaware of menstrual irregularities or think the artificial period created by the pills will protect her from decreased bone density. More recent studies show that this is not the case. Only natural menstruation produces the right hormones at the right levels to build bone mass. Sample Female Athlete Triad scenarios, with potential responses A college freshman cross-country runner increases her mileage abruptly but does not increase her caloric intake to compensate for increased training. She is also experiencing stresses in school. She suffers a tibial stress fracture. • Changes in routine and new stresses, both mental and physical, can take a toll on an athlete. Talk to new team members early on about the changes they may experience and how to cope with them. If you know an athlete is under mental or physical stress, encourage her to make use of your school’s counseling services and/or suggest sports nutrition counseling, both of which can help improve physical and mental well-being. • Prevent this situation by gradually increasing training during the preseason, as well as stressing the need for dietary adjustments and increases to account for the increase in caloric expenditure. • Send the athlete to a medical professional to assess her fracture as well as review her diet, menstrual history and fracture history. A doctor may decide a DXA scan is warranted, depending on other risk factors present. You overhear some seniors on your high school volleyball team discussing one of their teammates, who has never gotten her menstrual cycle. • Send the athlete to a sports medicine specialist for evaluation. No cycle by the age of 16 is considered primary amenorrhea (versus secondary amenorrhea, where a female has begun menses that later stop). • If a medical cause such as a tumor or polycystic ovarian syndrome is discovered, it can be managed by a doctor such as primary care doctor, endocrinologist or OB/GYN. • If delayed menses due to extreme exercise and/or diet (the Triad) is diagnosed, the athlete’s physician and a dietitian should address the problem immediately, as she is missing important estrogen exposure and dietary support for skeletal development and bone density. What are the Triad treatments? Therapy for the Female Athlete Triad involves a multidisciplinary approach that includes the coach, parents, medical professionals, dietitians, psychological support (e.g., psychiatrist, psychologist, therapist) and sometimes teammates. The basis of all Triad treatment is diet and exercise modification. If the athlete is underweight, energy balance and weight gain are crucial to treatment success. The athlete needs to gain an understanding of the relative number of calories she is burning and the types of nutrients her body needs. She may also need counseling to help return to healthier eating and exercise habits and coping with the range of emotions that this entails. She may also benefit from therapies that challenge unhealthy ways of thinking and promote developing better coping skills. The most important help you as a coach can provide is to recognize the warning signs and know where to go to for help. Page  | 21