The Female Athlete
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Transcript The Female Athlete
Antoin Alexander
Maj USAF MC
Adapted from Dr. Terry Adirim
Overview
General Differences
Injury Patterns
Menstrual Cycle
Female Athlete Triad
General Differences
Females
Males
Prepubertal Capabilities
Equal
Equal
Growth Spurt
11
13
Maximum Height
16-17
20-21
Weight Difference
Minus 11-14 kg
Bone and muscle
mass
Body Fat
26%
14%
Body Shape
Wide Hips
Wide Shoulders
Limbs
Shorter
Longer
Strength
Equal relative to lean mass
Muscle Hypertrophy
Due to testosterone
General Differences
Females
Males
Upper Extremity Strength
40-75% of men
Lower Extremity Strength
60-80% of men
Average VO2 Max
Minus 40%
VO2 Max vs Lean Body wt
Minus 10%
Cardiac
Size and output
Heart rates
Pulm
Thoracic cage
Vital Capacity by 10%
Distance Events
By 5-15 %
Injury Patterns
Common injuries in women/girls include:
Anterior cruciate ligament (ACL) injuries
Patellofemoral pain syndrome
Stress fractures
ACL Injuries
Women have an increased predisposition to ACL
injury
Many theories, but no one proven definitive cause
ACL Injury
Intrinsic factors:
Joint laxity
Hormones
Limb alignment
Ligament size
Intercondylar
notch size
Extrinsic factors:
Conditioning
Experience
Skill
Strength
Muscle
recruitment
patterns
Landing
techniques
ACL Injury
Intercondylar notch width well studied
Some studies have shown differences in size between
the sexes; others have not
Smaller notch may mean smaller and weaker ACL
Same size ACL, but smaller notch may cause
impingement on the ligament
ACL Injury
What to do?
Teach preventative skills
Learn how to fall, jump and to cut
Plyometric training
Reduce landing forces and improve strength ratios
Increase hamstring activation
Patellofemoral Pain Syndrome
Probably more than one etiology
Chondromalacia
Malalignment of patella
Patellofemoral Pain Syndrome
Causes of PFPS
Anatomical
Larger “Q” angle
Leads to abnormal tracking
of the patella
Patellofemoral Pain Syndrome
Other causes
Muscle imbalances
Foot type (either pes planus or pes cavus)
Shoes
Overuse
Stress Fractures
Chronic, overuse injury
Most common in weight bearing bones
Feet, tibia, femoral neck
Seen commonly in Female Athlete Triad
Menstrual Cycle
Average Age Menarche : 12.8 years
Average Cycle Length : 28 days (20-45)
Well-Defined Pattern of hormonal changes
Follicular or Proliferative phase
Menses through Ovulation
FSH causes overies to make estrogen
Follicle Forms and lining proliferates
Follicle ruptures and Ovum formed
Luteal or secretory phase
Ovulation through menstruation – 14 days
Estrogen LH Surge Ovulation Estrogen/Progesterone
If no fertilization Estrogen/Progesterone Menstruation
6
3
Menstrual Cycle
9
5
1
2
4
7
8
Menstruation
Studies fail to show decreased performance
Luteal Phase 7 beats per minute ≠ Δ in performance
? Asthmatics Vulnerable during perimenstrual phase
Peak expiration flow rates reported 30-40%
ER visits 4 times
Progesterone bronchoconstriction
? Performance Impact of increased core temperature
Unclear impact on ACL injuries, cognition, aerobic
and anaerobic capacity, and performance
Female Athlete Triad
Definition
ACSM 1992 – Disordered eating, amenorrhea, and
osteoporosis
Current- Energy Availability, menstrual function, and
bone mineral density interrelationship
Belief that lower body weight needed for athletic
success and social acceptance
Prevalence of all components = 1-3%
Disordered eating 18-25%, Menstrual dysfunction 25%
Energy Availability
Availability = Dietary intake – exercise expenditure
Key dysfunction underlying triad is disordered eating
manifesting as low energy availability
May be inadvertent
DSM-IV eating disorders
Anorexia nervosa
Bulimia Nervosa
Eating Disorders not otherwise specified
Energy Availability
Affects cascade of metabolic hormones
Insulin, cortisol, growth hormone, triiodothyronine,
leptin, glucose, fatty acids, ketones
Leptin regulates basal metabolic rate
Level of 1.85 mg required for normal menstruation
Low levels in athletes with disordered eating and amenorrhea
Energy Availability
Risk Factors
Dieting or restrictive eating
Vegetarianism
Belief that thinness = social success
Belief weight or fat performance
Perfectionism or obsessive-compulsive traits
Competitive Nature
Judging sports, revealing uniforms, weight classification
Onset sport training early age
Coaching emphasizing weight and body type
Anorexia Nervosa
DSM IV Criteria
Refusal to maintain minimally normal body weight
Body weight < 85% expected
Primary amenorrhea by age 16
Secondary amenorrhea (absent 3 consecutive cycles)
Restrictive Type
Not regularly engaged in binge-eating or purging
Binge-Eating/Purging type
During Episode person regularly binge-eating/purging
Anorexia Nervosa Complications
Cardiovascular- mortality 10%
Hypotension and bradycardia
Arrhythmias (Look for prolonged QT)
Cardiomyopathy (from refeeding or ipecac)
Endocrine
Amenorrhea with FSH and LH despite estrogen
Electrolyte imbalance: K,Na,Ph,Mg
Euthyroid sick syndrome: T3/T4, reverse T3
Osteopenia/Osteoporosis
Hypothermia, Hypoglycemia, Diabetes Insipidus
Anorexia Nervosa Complications
GI: Constipation, decreased intestinal motility
Heme: Anemia, leucopenia, thrombocytopenia
Integument: Dry skin, lanugo,fragile nails
Neuro: Cerebral atrophy, ventricular enlargement
Reproductive: Infertility, low birth weight infant
Bulemia Nervosa
DSM IV Criteria
Recurrent Binge Eating
> food than most people would eat in a discrete period
Sense of lack of control of eating
Recurrent inappropriate compensatory behavior
Binging and Compensation occur twice a week for 3 mo
Self eval unduly influenced by body shape/weight
Not exclusively during Anorexia Nervosa Episode
Purging Type: vomiting, laxatives, diuretics, enemas
Nonpurging Type: fasting, excessive exercise
Bulemia Nervosa Complications
Cardiovascular: Arrythmia, hypertension (diet pills)
Endocrine:
Menstrual irregularities
Pseudo-Bartter Syndrome- normotensive hypokalemic
alkalosis
Hyperchloremic metabolic alkalosis with laxatives
GI: Enlarged salivary glands, esophageal dysmotility,
postbinge pancreatitis
Skin: Russell’s Sign- scarring/callous dorsal index/middle
fingers
Neuro: Cerebral hemorrhage (diet pills)
Pulm: Pneumomediastinum
Eating Disorder Not Otherwise
Specified
Meets some or most criteria for Anorexia or Bulemia but
does not meet full criteria for specific disorder
Anorexia with normal menses
Anorexia but despite weight loss normal weight range
Bulimia but < twice a week or 3 months
Purging after small amounts of food
Chewing and spitting out food
Menstrual Disorders
Delayed Menarche or Primary Amenorrhea
Age 15 with secondary sex characteristics
Secondary Amenorrhea
NOT A NORMAL RESPONSE TO TRAINING
Luteal phase deficiency
Prolonged follicular phase but luteal phase < 10 days
Decreased progesterone and anovulatory cycle
One study incidence 78% incidence in regularly
menstruating recreational runner vs 9% sedentary
Functional Hypothalamic
Amenorrhea
Insufficient calories/carbs to brain disrupts GnRH
Energy conservation reproductive function
suppression and hypoestrogenism
Likely to occur if < 30kcal/kg lean body mass per day
LH pulse disrupted if < 30kcal/kg for 5 days
Must exclude other causes of amenorrhea
Amenorrhea Evaluation
History: menstrual, training, diet, drugs, stress, family
Exam: Turner’s, Cushing’s, hirsutism, fundi, thyroid,
tanner staging, breast exam, pelvic exam
Labs: HcG, TSH, prolactin, FSH, LH, testosterone,
DHEAS
Progestin Challenge test
Estrogen/progesterone challenge test
Positive = hypothalamic-pituitary axis dysfunction or ovarian
failure
Amenorrhea Treatment
Increase caloric intake: 25-30 kcal/kg of fat free mass
Decrease training if needed
AAP recommends OCP’s if 16 yo or 3 years post
menarche
Low dose OCP (20 to 35 ug) no associated weight gain
Bone Mineral Density
Bone Mineral Density used to evaluate bone health
Should be assessed if
6 months amenorrhea, oligomenorrhea
6 months disordered eating
After stress or low-impact fracture
BMD loss can be irreversible
Athletes in weight bearing sports BMD 12-15%
Hypoestrogenic state accelerated bone resorption
Estrogen has a suppressive effect on osteoclasts
Bone Mineral Density Classification
T-scores
Average peak adult BMD
Used in postmenopausal women
Fracture risk doubles every SD below the mean
Normal > -1, Osteopenia -1 to -2.5, Osteoporosis < -2.5
Z-scores
Mean for chronologic age
Used in premenopausal women,adolescents, children
ACSM accounts for 5-15% in athletes
Low if secondary clinical risk factors and -2 < Z < -1
Osteoporosis if secondary clinical risk factor and Z < -2
Low BMD Treatment
Initiate within first year of amenorrhea
Correct energy deficits
OCP
Evidence good in perimenopausal
Evidence fair in hypothalamic oligomenorrheic
premenopausal
Evidence Limited in anorexic and healthy
premenopausal
Consider if over 16 and BMD despite nutrition
DO NOT USE < 16 yo : premature growth plate closure
Low BMD Treatment
Nasal Calcitonin
Calcium 1500 and Vitamin D 400-1000 IU daily
Weight bearing exercise and resistance training
Smoking cessation
Reduce excessive alcohol intake
Synthetic human parathyroid hormone
DO NOT USE Bisphosphonates in premenopausal
women
Summary
Men and Women are different, but not so different
Woman have a higher incidence of ACL Injury, PFPS,
and stress fractures
Menstrual Cycle is an important metabolic factor
Female Athlete Triad of energy availability, menstrual
function, and BMD interrelationship is important to
consider, prevent, and treat
Questions