Female Athlete

   

  •

Introduction

•

Gynaecological concerns

•

○

Menstrual cramps

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Pre menstrual tension

Contraception ○

•

The oral contraceptive pill

Menstrual cycle and performance ○

Control of the menstrual cycle for athletes

○

Relationship between exercise and the menstrual cycle 

Delayed menarche



Menstrual dysfunction

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Oligomenorrhoea and Secondary Amenorrhoea

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Abnormal luteal phases

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Anovulatory cycles

○

Sequelae of abnormal luteal phases and anovulatory cycles.

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Contributing factors to Menstrual Dysfunction.

•

Female Triad

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Menstrual hygiene

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Pregnancy

•

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Important factors to consider about exercise during pregnancy

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Contraindications to exercise in pregnancy.

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Current Obstetric Status

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Symptoms upon which exercise should be ceased

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Benefits of Exercise

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Post Partum Exercise

Menopause ○

Osteoporosis 

Exercise



Calcium Intake

 ○ •

•

Coronary Heart Disease

The female athlete and nutrition ○

Iron Deficiency

○

Calcium Deficiency

Breast Injuries ○

•

Hormone replacement therapy

Management

Musculoskeletal Injuries ○

Shoulder injuries

○

Knee Injuries

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Illiotibial band tendinitis.

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Pes anserinus tendinitis

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Ankle Impingement.

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Stress Fractures

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Other injuries

•

Other Issues

•

Conclusion

Introduction We have come a long way from the time that Baron Pierre de Coubertin considered “women’s sports against the laws of nature”. At the 1996 Atlanta Games nearly 50% of the Australian Team were female. Women are now encouraged to participate in regular sporting activity. However, a number of health concerns specific to the female athlete have been described.

1 G Bryant C Mak K Foo 1997 The Female Athlete Chapter 17 in Manual of Sports Medicine Eds E Sherry D Bokor GMM London

Gynaecological concerns Menstrual cramps Menstrual cramps (dysmennorrhoea) occur during menstruation. The pain is abdominal and can range in severity from mild to severe. The pain is characteristically worst at the start of the cycle. Pathophysiologically, the pain is thought to be due to ischemia in the myometrium during uterine

contractions and is mediated by prostaglandin release by the endometrium. Severe symptoms may decrease athletic performance. Exercise may have a beneficial effect on dysmenorrhoea by the effects of beta-endorphins on the uterus. Treatment: Obtain a complete menstrual history and inquire about the severity of symptoms. For moderate to severe dysmenorrhoea, Ketoprofen, Naproxen Sodium or Ibuprofen, taken 24 to 48 hours prior to the onset of menses and for the duration of the discomfort, may be helpful as they work by limiting the release of prostaglandins. The oral contraceptive pill (OCP) reduces the severity of symptoms. Mild dysmenorrhoea may be treated with mild analgesics or even nothing. Pre menstrual tension Pre menstrual tension (PMT) refers to physical and emotional symptoms (Table 23.1) which begin with the onset of ovulation and decrease in intensity with the progression of menstruation. As with dysmenorrhoea, exercise may actually dampen the symptoms of PMT. This is thought to be due to the effects of bendorphins acting centrally or due to a decrease in the pulse frequency of gonadotrophin releasing hormone (GnRH).  

 

Table 23.1. Symptoms of PMT

Emotional Mood cravings

Physical Headaches

Anxiety

Fluid retention

Depression

Bloating

Irritability

Breast soreness

Insomnia

Breast enlargement

Alteration in libido

Appetite changes

  1 G Bryant C Mak K Foo 1997 The Female Athlete Chapter 17 in Manual of Sports Medicine Eds E Sherry D Bokor GMM

 

 

 

London

 

  Treatment: Oral Contraceptive Pill (OCP) can be used. The OCP can however cause an exacerbation of symptoms in some women. Pyridoxine (Vitamin B6, 200 to 600 mg/day) has been found to be effective in reducing fluid retention, breast tenderness and depressive symptoms. Diuretics can be used to treat fluid retention, but care must be taken to prevent dehydration and must not be prescribed for competitive sport (banned by the International Olympic Committee).

Contraception Choice of a contraceptive agent depends on the athlete’s fertility, medical history and coital frequency. Choices include diaphragms, condoms, and intra-uterine devices (IUD). Barrier methods (e.g. condoms) which don’t affect the normal hormonal balance of the body or alter athletic performance are to be preferred. They also prevent the transmission of sexually transmitted diseases. Condom usage should be encouraged to prevent transmission of genital herpes, genital warts, hepatitis B and HIV. Spermicidal (containing nonoxynol-9 and menfegol) creams improve the efficacy of condoms as a method of contraception. With respect to athletes, a diaphragm can be in place during training or competition and must be left in situ for at least 6 hours after the last sexual encounter. A smaller size diaphragm can be used if uncomfortable for the athlete during training periods. Other options include cervical caps and sponges impregnated with spermicidal creams. Intra uterine devices (IUD’s) can be used for athletes who have completed child bearing and have regular sex. IUD’s are also more reliable than barrier methods. Complications arising from IUD’s include an increased risk of pelvic infection and resulting subsequent infertility. In addition, heavier bleeding and increased cramping has been associated with IUD usage. Other contraceptive options include “natural” methods, (rhythm method, basal temperature and mucus viscosity status) but may be unreliable in females with menstrual irregularities. The oral contraceptive pill There are two types of oral contraceptive preparations. The combination pill which usually contains ethinyl oestradiol and a progesterone such as levonorgestrel. The other preparation is the Progesterone only pill (Minipill). The Combination preparation acts by inhibiting the hypothalamus-pituitary system and causes anovulation. The progesterone only pill acts by making the cervical mucus thicker and impenetrable to sperm. The combination preparation is available in monophasic, biphasic and triphasic formulations. In addition the OCP can be prescribed in low dose (decreased side effects) or high dose preparations. Side effects can include weight gain, fluid retention, breakthrough bleeding, carbohydrate metabolism changes, adverse clotting factor changes and changes in platelet function. Beneficial effects of the OCP, includes reduced premenstrual symptoms, reduced breast volume changes, and decreased menstrual flow (hence reducing menstrual iron deficiency anaemia). The OCP can preserve bone density in women with chronic amenorrhoea. The OCP is also associated with a reduced incidence of endometrial and ovarian cancers, as well as reduced incidence of benign breast lesions, pelvic inflammatory disease, ovarian cysts and ectopic pregnancies. The OCP is associated with lessening of symptoms of endometriosis and a reduction in the incidence of pelvic inflammatory disease and ectopic pregnancies. The effect on athletic performance (detailed in Table 23.2) appears to be minimal.  

Table 23.2 The oral contraceptive pill in athletes

Beneficial effects

Side effects

 

Reduced dysmenorrhoea Control of the menstrual cycle Oestrogen source for amenorrhoeic athletes

Water retention Altered glucose retention* Possible decreased VO2max

Reduced blood loss and hence reduced risk of iron deficiency anaemia.

 

* progestin component.

  Contraindications: (2-3% of the female population) •

Pregnancy

•

Endogenous depression

•

Otosclerosis

•

Smokers over 35 years of age

•

Undiagnosed abnormal uterine bleeding

•

History of thrombo-embolic events

•

Oestrogen dependent cancers (breast and uterine cancer and liver hepatomas)

•

Active liver disease

•

Intestinal malabsorption

•

Hypertension (moderate and severe)

•

Diabetes with vascular complications

•

Cardiovascular Disease Relative contraindications include:

•

Epilpesy

•

Hyperlipidemia

•

Sickle Cell Anaemia

•

Migraine

•

Oligoamennorrhea

•

Varicose Veins

Menstrual cycle and performance Studies are beginning to indicate that at an elite level of competition hormonal alterations due the ovulatory menstrual cycle may be of some impact. Athletes have felt that the premenstrual phase or the menstrual phase of the cycle coincides with a decrease in performance. Dysmenorrhoea and the premenstrual syndrome may also contribute adversely to athletic performance. However further study is needed in this area as Olympic medals and athletes have obtained world records at all stages of the cycle. Control of the menstrual cycle for athletes

 

Athletes who wish to avoid having their menses during competitive events can use monophasic OCP’s. A withdrawal bleed can be induced by stopping the pill 7 days before a competitive event, and then started again at the end of the menstruation or after the event. An alternate method is to induce a bleed by taking progesterone for 10 days, stopping 10 days prior to the athletic event. Skipping the 7-day sugar tablet and beginning the next packet prevents the withdrawal bleed and is another method of controlling menses. Relationship between exercise and the menstrual cycle The relationship between menstrual cycle disorders and exercise has been established. There is a wide spectrum of menstrual cycle disorders including delayed menarche, and menstrual dysfunction. Delayed menarche The onset of menses (menarche) can be considered delayed if there are no periods by age 16. The average age of menses in Australia is 12 – 13 years. Of the athletes with delayed menarche, there are two groups. One group being athletes, who exercised intensely before menarche and the other group which, did not. Factors contributing to delayed menarche include: •

Intense exercise

•

Low body weight

•

Genetic component.

The physiological mechanism involves the hypothalamic axis being affected by a combination of the above factors. Delayed menarche may confer an athletic advantage due to slower rates of maturation causing delayed closure of the epiphysial plates. These results in longer legs narrow hips and less body fat, which might be advantageous in certain sports. Menstrual dysfunction Menstrual dysfunction includes oligomenorrhea (irregular menstrual cycle length ranging from 35 to 90 days), amenorrhea (absence of menstrual bleeding), chronic anovulation and shortened luteal phase. Important sequelae of menstrual dysfunction include: •

Reversible infertility.

•

Skeletal demineralization1 (which might be rapid and not completely reversible). This might manifest

as stress fractures and premature osteoporosis. Major bone loss occurs early (first 2 years) and seems to affect trabecular bone more than cortical bone. •

Endometrial hyperplasia (with increased risk of adenocarcinoma of the uterus in females with

unopposed estrogen seen in chronic anovulation). •

Increased cardiovascular disease associated with the low estrogen levels (similar to post menopausal

women not receiving estrogen).

Oligomenorrhoea and Secondary Amenorrhoea Oligomenorrhoea (irregular menses) and secondary amenorrhoea (cessation of spontaneous menstruation for at least 6 months after normal menstrual cycles had been established) are examples of menstrual dysfunction that is relatively common with a 5% incidence in the general population. Overall the incidence in the athletic community is 10 – 20% with a peak incidence of 50% in endurance athletes. Etiology of amenorrhoea: The role of the hypothalamic – pituitary – adrenal axis is crucial in menstrual dysfunction. Intense exercise is associated with increases in catecholamines, cortisol, ð-endorphins, and decreases in Prolactin, LH and FSH concentration. Intense activity has been implicated in the activation of the adrenal axis, which in turn suppresses the pulse generation of GnRH. This inhibition leads to decreased gonadotrophin release and hence amenorrhoea. Common causes of secondary ammenorrhea include pregnancy, psychological stress, thyroid disorders, polycystic ovaries, medications, drugs, pituitary tumours and eating disorders.

1 G Barrow S Saha 1988 Menstrual irregularity and stress fractures in the collegiate female distance runners athletes Am J Sports Med 16 209-215

Abnormal luteal phases The luteal phase is a 14 day long period between ovulation and the onset of menstrual bleeding. Classically in athletes the luteal phase is shortened and associated with lower than normal progesterone levels. The cycles may however be normal due to longer follicular phases. Anovulatory cycles Anovulatory cycles can occur despite normal estrogen levels. In athletes, low progesterone levels due to changes in LH pulsatility during the luteal phase can cause these anovulatory cycles. Sequelae of abnormal luteal phases and anovulatory cycles. The main effect is infertility or sub-optimal fertility. There is also the theoretical risk of adenocarcinoma due to the inadequate endometrial protection afforded by the low progestrone levels. Contributing factors to Menstrual Dysfunction. •

Exercise level: Decreased exercise results in the restoration of the menses in athletes who had

amenorrhoea. Exercise is thought to act as a stressor which causes the release of hormones that affect the hypothalamic – pituitary axis. •

Low Body Fat: It was previously thought that a critical body fat percentage was required for normal

cycling. However considerable variability has since been noted in individuals. Increase in body fat has been associated with the return of menses in several cases. •

Diet: Calorie restricted diets have been associated with irregular menses. However it is not clear if the

menstrual irregularity is due to the low caoric intake or he resultant low body fat. •

Psychological Stress: Stress arising from the environment and family has been associated with

menstrual irregularity. Treatment of Menstrual Dysfunction. The principle concern must be to exclude non-exercise related causes of menstrual dysfunction. Thus pregnancy, polycystic ovaries, pituitary and thyroid conditions, psychological stress and medication related menstrual irregularities must be excluded. Delayed Menarche warrants investigation if no menstruation has occurred by the age of 16. It is also important to exclude endocrine, gynaecological, and genetic causes here. History and Examination •

Changes in weight

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Secondary sexual characteristics

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Virilization

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Pregnancy

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Visual acuity and visual fields

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Pelvic examination (which may include transabdominal ultrasound)

•

Prolactin and TSH levels, Pregnancy tests (human chorionic gonadotrophin).

•

Provera (medroxyprogesterone acetate) challenge test. Presence of estrogen will cause a withdrawal

bleed. No bleed indicates, low estrogen levels, or anatomical pathology. •

FSH/LH levels. Low FSH/LH levels is seen secondary to intense exercise or pituitary/hypothalamic

tumours. High FSH/LH levels might indicate ovarian failure or ovarian resistance. •

Family history.

•

Sexual History

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Medications including use of OCP.

•

Nutritional history Treatment

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Reduction in exercise and an increase in body fat.

•

Optimum nutrition and appropriate calcium intake (1200mg/day)

•

Cyclic oestrogen/progestin in women with low estrogen levels. Oestrogen supplementation can be in

the form of OCP or HRT (hormone replacement therapy which is composed of 0.625 mg oestrogen for days 1-25 and medroxyprogesterone acetate 5 mg from day14 – 25). •

Oestrogen supplementation is contraindicated in women with a history of deep venous thrombosis,

breast/endometrial cancer or abnormal liver tests. •

Counselling, education and a multidisciplinary approach.

The Female Triad This refers to a condition, which features disordered eating, amenorrhoea and osteoporosis. True prevalence is unknown and probably under reported. There is however an established link between disordered eating and intense exercise, which is classically seen in athletes for whom a lean physical appearance is a competitive factor. It is not known if the athlete begins high levels of exercise to help to

decrease body weight, or if the obsessive nature of the exercise attracts those individuals to whom are predisposed to eating disorders. Thus figure-skaters, gymnasts, divers and long distance runners seem to be prone to this illness. The disordered eating pattern can range in a continuum of severity with the most severe condition being Anorexia Nervosa (defined in DSM-IV). Bulimia (binge eating), unnecessary dieting, and, or purging can all be features of this condition. Weight control practices can include purging, laxative usage, diuretics, and diet pills. Conversely these behaviours usually lead to a decreased athletic performance. In some cases disordered eating lasts only as long as the competitive season Treatment •

Recognition of disordered eating patterns.

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Multi-disciplinary approach.

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Correction of the “body dysmorphic” syndrome. Improvement of self esteem

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Psychiatric and psychological consultation and therapy.

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Cognitive behavioural therapy.

1 A Nattiv R Agostini B Drinkwater KK Yeager 1004 The female athlete triad The inter-relationships of disordered eating, amenorrhoea and osteoporosis Clinics Sports Med 13(2) 405-418 April

Menstrual hygiene There is no known ill effect to training during menstruation and tampon usage is popular amongst athletes. Pregnancy and its impact on the female athlete. Exercise can be conducted during pregnancy. However this should be at mild to moderate level. High levels of activity may be possible in a highly conditioned athlete. In most cases, pregnancy is not an appropriate time to begin a new intensive exercise program or sport. Important factors to consider about exercise during pregnancy. Overheating: Studies have shown that maternal temperatures greater than 39 degrees Celsius are associated with neural tube defects (particularly failure of the neural tube 25 days post conception). Maternal hyperthermia is also associated with intra-uterine growth retardation, intra-uterine death and other abnormalities.

1 American College of Obstetricians and Gynecologists: Exercise during pregnancy and the Postpartum Period(Technical Bulletin #189) 1994 ACOG Washington DC

Recommendation: Advice should be provided indicating that exercise should be avoided during the hottest part of the day, and in addition loose light clothing should be worn. Mothers should be encouraged

to maintain an optimal fluid intake. Increased internal plasma volume may help fetomaternal heat transfer and dissipation. Exertion levels: Intense exercise during pregnancy might adversely affect fetal oxygenation. During exercise in excess of 80% of maximum heart rate may result in the diversion of uterine blood flow to exercising muscles. Hypoxic effects on the fetus are usually minimised due to the fact that uterine blood flow is maximal in the area of placental attachment. Despite this, changes in fetal heart rate have been observed during exercise (tachycardia and bradycardia). There is an additional risk of premature labour. While not common, this is thought to be due to an increase in noradrenaline levels which may lead uterine irritation and hence premature labour. Recommendation: Exercise levels to be maintained below 60% of maximal heart rate. Each period of exercise should not be longer than 45 minutes including an adequate warm up and cooling down period. Exercise routine should be resumed gradually over the 4-6 week postpartum period. Ensure adequate diet) as pregnancy requires additional 300kcal/day. Risk of Injury: During pregnancy, changes in body weight and shape may cause an alteration in the mother’s center of gravity. Hence the mother is at risk of losing her balance and having a fall. A fall could cause damage to the placenta. In addition during a pregnancy ligamentous laxity in the joints can develop increasing the chances of injury. A common complaint during pregnancy is lower back pain. This is thought to be due to circulating oestrogen and relaxin. Attention to posture, and muscle strengthening exercises (for the abdomen and back) should be commenced. Avoid even mild abdominal trauma. Nonweight-bearing exercises (cycling, swimming) are useful. Do not exercise in supine position after first trimester (as CO is reduced). Contraindications to exercise in pregnancy. Medical conditions such as cardiovascular disease, respiratory disease, infectious disease, anaemia, endocrine disorders, and obesity Obstetric complications in past history such as prior miscarriages, prematurely, and intra-uterine growth retardation Current Obstetric Status Factors including cervical incompetence, pre-term rupture of membrane, pre-term labour, persistent second to third trimester bleeding ,hypertension and intrauterine growth retardation are contraindications to intense exercise during pregnancy. Symptoms upon which exercise should be ceased1: •

Bleeding

•

Any “gush” of fluid from the vagina (premature rupture of membranes)

•

Unexplained abdominal pain

•

Excessive fatigue, palpitations, chest pain

•

Persistent tachycardia after exercise.

•

Uterine contractions(>6-8/hour query premature labour)

•

Severe headaches and/or visual disturbance; unexplained faintness or dizziness

•

Dyspnoea

•

Reduced weight gain(<1.0 kg/month during the last two trimesters)

•

Increasing oedema.

1 LA Wolfe et al 1989 Prescription of aerobic exercise during pregnancy. Sports Med 8 273-301

Benefits of Exercise2 •

Psychological and physical well being

•

Less weight gain

•

Less back pain from improved posture

•

Tendency for shorter labour and reduced time to recover.

•

Improves digestion and reduces constipation

•

Reduces ‘post partum” belly

•

Greater energy reserves

Post Partum Exercise The basic rule of thumb should be to reintroduce exercise gradually. Factors including ligamentous laxity and weight gain may predispose to injury. For the first 6 weeks post partum, exercise such as walking is recommended. Weight lifting and strenuous exercise is generally not advisable for the first 6 weeks post partum after a normal vaginal and 12 weeks after a caesarian section. Attention should be paid to fluid intake during exercise and optimal nutrition. The Menopausal Athlete. Menopause is defined as the cessation of menstruation. This generally occurs when the woman is about 50 years of age. It can however occur earlier or later than this age. Menopause is a stage of decreased oestrogen production and as such the two major concerns to a menopausal athlete are;

2 W Larry Kennedy et al Eds 1995 ACSM’s Guidelines for Exercise Testing and Prescription 5th Ed Williams and Williams PA p238 Table 11-7

•

Osteoporosis

•

Cardiovascular Disease

Osteoporosis

This illness results in the reduction of bone mass (osteopenia) and hence fractures due to minor trauma. This is an illness seen overwhelmingly in females. Risk factors for osteoporosis include: •

Athletic amenorrhoea

•

Slim build

•

High consumption of caffeine, tobacco, and alcohol

•

Family history

•

Caucasian race

•

Nulliparity

•

Older age

•

Corticosteroid use

•

Lack of weight bearing

Fractures in the wrist, hip, and the vertebral column are common in women with osteoporosis. It also tends to affect trabecular bone compared to cortical bone. Investigations. •

Bone density studies (dual energy x-ray absorptometry, DEXA)

•

Qualitative computed tomography

Treatment of Osteoporosis The major factors determining the course of the illness is the peak bone mass attained and the rate of loss. Hence the aim of treatment would be to maximize peak bone mass prior to menopause and then reduce the rate of bone loss. Peak bone mass is achieved at about 25 years of age. After this the amount of bone produced is eclipsed by the amount of bone mass being resorbed. Exercise Weight bearing exercise can reverse bone loss or reduce the rate of loss, which might occur during disuse. Exercise has been shown to increase mineralization of cortical and trabecular bone. Dynamic muscular pull is thought to have a positive effect on bone mass. This is indicated in women who supplement aerobic exercise with weight training, having greater spinal bone mineral densities than women who don’t use weight training or those that are sedentary. Calcium Intake Calcium intake in combination with oestrogen has been shown to be effective in the reversal of bone loss. Diets rich in calcium (dairy products, green leafy vegetables and fish) have been shown to be effective in restoring bone mass in ammenorrhoeic athletes. Hormone replacement therapy Hormone replacement therapy can have the dual effect of preserving bone mineralisation and decreasing the risk of cardiovascular disease. Oestrogen is thought to modulate calcium metabolism with the effect of increasing dietary calcium absorption and reducing calcium loss. A 50% reduction in the incidence of hip and arm fractures as well as an 80% reduction of vertebral compression fractures have been observed in

women who have taken oestrogen in the perimenopausal period. The therapy consists of oestrogen (0.625mg daily) and medroxyprogesterone acetate (10mg daily) for days 1 – 12 of the calendar month. The progesterone component reduces the risk of endometrial cancer, which has been attributed to the effect of unopposed oestrogen. The progesterone component is associated with withdrawal bleeds and side effects, which can lead to non-compliance. In women who have had hysterectomies, an oestrogen only preparation is recommended. In osteoporotic athletes who are already using HRT, the bisphosphonates can be useful.

Coronary Heart Disease Increased incidence of coronary heart disease is seen in postmenopausal women. This is thought to be due to the lack of oestrogen and its cardioprotective effects. Management Aerobic exercise can increase cardiovascular fitness, which results in a lower blood pressure and favourable blood lipid profiles. Favourable lipid profiles (i.e. HDL increase and decreased serum triglycerides) lower the risk of ischaemic heart disease. HRT has also been shown to decrease the risk of myocardial infarction. Guidelines to safe exercise for the menopausal athlete. Prior to the commencement of exercise, the menopausal athlete should complete a thorough medical examination. Significant points to be elicited in the history must include; •

Exercise history

•

History of any cardiovascular disease

•

History of any other medical illnesses which might influence further exercise patterns

•

Prior and current medications

•

Investigations that might need to be performed may include an exercise ECG, blood tests (screening

for Hb, glucose, and lipids), depending on the medical history of the patient.

Advice for commencement of an exercise program should include an initial moderate pattern of exercise. The general guidelines being to attempt 30 minutes of exercise 3 times a week at 40-60% of maximal heart rate (220 minus age). The exercise program should also include a warming up and cooling down period. This should improve cardiovascular fitness. If any symptoms such as chest pain, severe shortness of breath were to occur the patient should be advised to stop immediately and seek medical attention. As fitness attained the exercise intensity can be elevated to 70% of maximal heart rate. The female athlete and nutrition Of primary importance is the prevention of iron and calcium deficiency. Iron Deficiency This is a common condition in female athletes (20% - 30%). Iron loss can occur via menstruation, iron

poor diet, gastrointestinal loss, sweat, and urine. The deficiency can occur with or without anemia and with or without pseudoanaeima. Pseudo-anemia describes a condition peculiar to endurance runners and represents a physiological adaptation. Plasma volume expands and the haematocrit can drop. Iron deficiency can progress in three stages to an iron deficiency anemia. The first stage being iron depletion. This represents a depletion of body stores of iron in the liver, spleen and bone marrow. The next stage is an iron deficiency erythropoeisis. A fall in serum iron levels causes an increase in total iron binding capacity. The last stage is an iron deficiency anemia (Hb<120g/L). The effect of iron deficiency on the athlete depends on the stage of depletion. Anemia due to iron deficiency has been shown to decrease performance and associated lethargy and tiredness (due to lower clearance of lactate levels). However athletes with low ferritin alone haven’t been shown to have had their performance affected. However low ferritin levels can lead to anemia and must therefore be followed. Investigations: •

Full blood count (anemia indicated by low Hb and Hematocrit)

•

Iron studies. Serum ferritin will indicate iron stores. Levels below 50mg/L indicate absent iron stores.

Treatment Treatment is indicated if iron stores are low and the athlete is symptomatic. As well as specific dietary advice, iron supplementation is necessary. If there is no anaemia then do not use a slow release iron as it will not be absorbed. Make sure the iron is taken in the absence of cereals and coffee. The use of a vitamin C preparation at the same time will enhance the absorption. The athlete should be advised to eat lean red meat at least 3 times per week. Consultation with a sports dietitian is necessary if the athlete is vegetarian.15 mg of Iron may be indicated for in excess of 6 months to replenish body stores. Vitamin C supplementation may be considered as it increases iron absorption. OCP to combat menstrual loss Calcium Deficiency Calcium is an essential component in bone health and in the prevention of osteoporosis. In amennorrheic athlete’s intakes of 1,500mg/day, and 1200mg/day for women with normal menstruation is recommended. Maximum bio-absorption of calcium occurs after a meal due to stimulated gastric juices. Breast Injuries Discomfort during exercising is a common complaint. During the pre-menstrual period, fluid retention may cause breast tissue to swell. This may contribute to the discomfort. Nipple injuries can occur due to rubbing with clothing during exercise. This injury is often seen in males as well. Traumatic injuries to breast tissue are seen in contact sports such as martial arts. Management Large breasted women often find a well fitted sports bras to be comfortable. Generally larger breasted

women use a bra which limits breast motion, lifts and separates the breasts. Smaller breasted women often use pullover “compression” bra’s, that compresses the breast against the chest wall. Applying petroleum jelly on the nipple prior to exercise or taping it before sport can prevent nipple injuries. The use of plastic “cup” protection or the use of padding can prevent breast trauma. Musculoskeletal Injuries Studies indicate that injuries appear to be more sport specific than gender specific. However certain injuries have been noted to occur commonly in women. Shoulder injuries Rotator cuff injuries especially when the arm is placed overhead and pronated repetitively. Knee Injuries2 Anterior cruciate ligament injuries appear to be common in women involved in sport which involve jumping or pivoting such as soccer and basketball. Patellofemoral pain is also noted to be frequent in women. This is attributed to laterally placed patella and the wider pelvis of females. Illiotibial band tendinitis. Pain is felt at the point where the tendon passes over the greater trochanter. Females are thought to be more prone due to their greater pelvic span and the greater prominence of their greater trochanter. More commonly occurring problems tend to appear at the distal end of the Iliotibial band where it crosses the lateral femoral condyle. This is called iliotibial band friction syndrome and occurrs most commonly in runners and cyclists.

1 K Clarke W Buckley 1980 Women’s injuries in collegiate sports Am J Sports Med 8 187-191

2 J Powers 1979 Characteristic features of injuries in the knee in women Clin Orthop 143 120-124

Pes anserinus tendinitis The pes anserinus tendon is the common insertion of the gracilis, semitendinosus and sartorius muscles on the medial proximal tibia. It can become inflamed if there is excessive external rotation of the lower limb which can occur in some individuals due to the increased Q angle at the knee. It is best treated by strengthening the lower trunk stabilising muscles and the use of a foot orthoses to correct excessive foot pronation. Ankle Impingement. This injury appears to be due to forced plantar flexion causing irritation of the posterior ankle capsule, and trauma to the os trigonum as well as posterior tibial tendinitis. This injury is common in gymnastics,

dancing and diving. Stress Fractures Amennorheic women have an increased incidence of stress fractures (up to 4 fold). Primarily cancellous bone appears to be affected. Women on the OCP have fewer stress fractures. Other injuries Spondylolysis, vertebral body apophysitis (due to flexion-extension motion of the spine), and foot disorders such as bunions, corns and calluses occur and must receive appropriate treatment. Other issues •

Genital injuries: vulval injuries (bruising or lacerations) can occur due to falling astride.

• Cancer and exercise: athletes appear to have a lower rate of breast and reproductive system cancer due to later menarche and early menopause. •

Performance enhancing drugs: Anabolic steroids can have potentially damaging side effects and are

banned from international competition. Side effects can include virilisation (hirsutism, baldness, increased size of the clitoris) and hypertension. •

Gender Verification: Molecular biology techniques such as PCR techniques to detect the SRY gene of

male DNA or Barr body detection in cells can be used. •

Stress Urinary Incontinence: This can occur in multiparous women. However nulliparous women have

also been noted to suffer occasionally. Treatment can involve pelvic floor exercises, control of fluid intake prior to exercise or surgical correction of abnormal anatomy. Conclusion Women take part in many more sports than ever before. Data is available on established sports such as swimming and running; but less on new sports such as rowing and bodybuilding. The problem of the Female Triad is troubling. It is the question of how to maximise performance without causing serious health problems. Training programmes should be based on sound scientific principles. The future is promising-men’s and women’s world records are converging (as women’s progression is more rapid). Fig 4 shows the predicted times for the 200m and 1500 m events (already women outdo men on long distance swimming)

1 G Bryant C Mak K Foo 1997 Female Athlete Chap 17 in Sports Medicine Eds Esherry D Bokor GMM London Fig 3 p 246