In the Name of GOD

Medical Issues in Female Athletes

Dr. Laleh Hakemi Internist Vice-President of Sports Medicine Federation of Iran

Physical benefits

• hypertension, diabetes, and endometrial and breast ca.

• • • Stronger bones and reduced risk of developing osteoporosis later in life Micheli, Smith, Biosca, Sangenis

Psychosocial benefits

• perception of competence; better performance in academic settings • Decreased risk of drug and alcohol abuse Micheli, Smith, Biosca, Sangenis

Performance differences

Pre & Post pubertal differences    Running performance is related to max aerobic power

the slower running speed due to lower VO

2

max difference in VO

(fat F  20-25%/ M  2

max related to: body composition

10-14%)

& Hb & lower blood volume

(relative to lean body mass),

lower stroke volume

(relative to lean body mass) 

if these corrected, no difference

Strength

  Age 20: 30%-50% difference in muscle CSA between men and women  strength difference: upper > lower extremities

Upper: F= 40-75% M / Lower: F=60-80% M

Similar differences in bones

Endurance

  6-15% lower in F Larger muscle fibers in men (both fast and slow twitch) 

the actual muscle fiber composition is similar in M & F



Athletic training F

(interval & continuous)

produce similar improvements in M &

Nattiv, Ireland 1998

Musculoskeletal differences:

     Muscle size bone mass wider pelvis knee valgus

(

Q ASIS (patella/patella-tibial tubercle) <

12

o

)

ligamentous laxity

 Gender-specific injuries are rare  The female reproductive organs are better protected  Breast injuries are among the rarest of all sports injuries Micheli, Smith, Biosca, Sangenis

  not at greater risk of “acute” injuries one exception is ACL injuries.

Overuse injuries Micheli, Smith, Biosca, Sangenis

Anterior Cruciate Ligament in Female Athletes



A Meta-analysis of Neuromuscular Interventions Aimed at Injury Prevention

Female athletes have a 4 to 6 times higher incidence of anterior cruciate ligament injury than do male athletes participating in the same landing and pivoting sports.

 A meta-analysis of 6 studies demonstrates a significant effect of neuromuscular training programs on anterior cruciate ligament injury incidence in female athletes (test for overall effect, Z = 4.31, P < .0001).



Timothy E. Hewett, PhD *, , , Kevin R. Ford, MS and Gregory D. Myer, MS, CSCS , 2003



Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes A Prospective Study, Hewett et al

A cohort study  205 female athletes (soccer, basketball, volleyball)  Results: In the 9 athletes with ACL rupture  different knee posture & loading - 8 degrees greater knee abduction angle at landing (p<.05) 2.5 times greater knee abduction moment (p< .001) 20% higher ground reaction force (p<.05) Stance time 16% shorter 73% specificity and 78% sensitivity of knee abduction moment for predicting ACL injury

Some measures to reduce ACL injuries:

1) strengthening muscles stabilizing the knee, especially hamstrings; 2) improving aerobic conditioning to prevent fatigue related missteps; 3) modifying the usual “cutting,” or “side-stepping,” maneuver from a two-step to a three-step motion so the knee is never fully extended; 4) performing running and pivoting with the weight forward on the balls of the feet, emphasizing soft jump landings; 5) educating coaches about the increased risk of ACL injuries in female athletes and enhancing the ability of coaches to evaluate female athletes’ skills, conditioning, and readiness to participate.

Micheli, Smith, Biosca, Sangenis

 In a case control study among female alpine skiers, the risk of suffering an

ACL

was significantly

greater during the pre-ovulatory

phase of the menstrual cycle

compared with the postovulatory

phase – therefore, phase of menstrual cycle may be a risk factor for knee ligament injury in female athletes Am J Sports Med 2006; 34(5): 757-764



Association Between the Menstrual Cycle and Anterior Cruciate Ligament Injuries in Female Athletes

Edward M. Wojtys , MD et all

40 female athletes with less than 3 month ACL injury  significant statistical association was found between the stage of the menstrual cycle and the likelihood for an anterior cruciate ligament injury (P = 0.03). In particular, there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase.

Overuse injuries

     Common overuse injuries include stress fractures, tendonitis, and bursitis. Female athletes are more susceptible Two apparent reasons for this: a lack of long-term preparation for vigorous sports and not beginning sports training until growth spurt (typically 11-13), a time when musculoskeletal injury incidence is greater Micheli, Smith, Biosca, Sangenis

Menstrual cycle & performance

   No change in aerobic capacity No change in anaerobic capacity No change in performance  no reason to restrict activity

 In a systematic review of risk factors for chronic pelvic pain in women,

exercise

was associated with a

decreased

risk of

dysmenorrhoea

BMJ 2006; Apr 1;332 (7544):749-55

EVALUATION OF MENARCHE AGE AND RELEVANT FACTORS IN IRANIAN FEMALE ATHLETES          In 454 cases that were passed menarche age mean of age at menarche: 158.2+/- 0.7 m. (13.18 yr)

Earlier menarche was reported in :

1-lower height (p<0.001) 2-lower age at beginning exercise (p=0.019) 3-lesser number of sisters (p=0.007) 4-lesser number of brothers (p=0.003) 5-higher percent body fat (p=0.037) 6-higher body mass index (p=0.002) 7-residing mountain side regions (p=0.001)

Hakemi L, Torkan F, Kabir A, 2002

Female Athlete Triad

   Disordered eating Menstrual dysfunction Bone mineral density

Amenorrhea

EVALUATION

 Most women with exercise-induced amenorrhea have hypothalamic amenorrhea: suppression of pulsatile GnRH from hypothalamus  decreased FSH & LH  loss of ovarian cyclicity and estrogen deficiency.  are at risk for all complications of estrogen deficiency.

   Exercise-induced amenorrhea is a Dx of exclusion. The characteristic history is that of a woman with previously normal cycles same time.  irregular and then ceased after she began to exercise, especially if lost weight at the If PMHX of exercise-induced amenorrhea, which remitted after stopping exercise  likely to recur if she resumes exercising.

     hCG serum prolactin serum FSH premature ovarian failure Serum LH for PCOS or ovarian failure Androgen hormones  primary amenorrhea should be evaluated for anatomic abnormalities of the uterus and uterine outflow tract.

CONSIDER DIFFERENTAIL DIAGNOSES:

• THE MOST IMPORTANT: • PCOS • Drug use

Mean serum concentrations of testosterone (pg/mL), androstenedione (pg/mL), and DHEA-sulfate (ug/mL) in 10 normal women between day two to four of their menstrual cycle and 19 women with polycystic ovary syndrome (PCOS). The mean serum concentration of each androgen was high in the women with PCOS, but there was substantial overlap between the two groups and many women with PCOS had normal values for one or more androgens.

Data from DeVane, GW, Czekala, NM, Judd, HL, Yen, SS, Am J Obstet Gynecol 1975; 121:496

Med Sci Sports Exerc 2009; 41(6: 1241-1248)

Hyperandrogenism may explain reproductive dysfunction in Olympic athletes Hagmar M, Berglund B, Brismar K, Hirschberg AL In female Olympic athletes from different sport disciplines, menstrual disturbances were common (mainly endurance athletes) but these were more frequently associated with polycystic ovarian syndrome (PCOS) rather than chronic energy deficiency or hypothalamic inhibition

Asia Pac J Clin Nutr. 2009;18(2):200-8.

The female athlete triad among elite Malaysian athletes: prevalence and associated factors .

Quah YV , Poh BK , Ng LO , Noor MI .

67 elite female athletes aged between 13-30 years Prevalence of all 3 components was low (1.9%), but the prevalence for individual triad component was high, especially in the leanness group.

The prevalence of subjects who were at risk of menstrual irregularity, poor bone quality and eating disorders were 47.6%, 13.3% and 89.2%, respectively, in the leanness group; and 14.3%, 8.3% and 89.2%, respectively, in the non-leanness group.

Sports Med Arthrosc Rehabil Ther Technol. 2009 Jul 30;1(1):16.

The relation between athletic sports and prevalence of amenorrhea and oligomenorrhea in Iranian female athletes.

Dadgostar H , Razi M , Aleyasin A , Alenabi T , Dahaghin S .

female athletes in national teams and medalists of Tehran N= 788 (95% response rate) Post menarche (age range: 13- 37) There was also a positive association between amenorrhea/oligomenorrhea and the following: age under 20, weight class sports, endurance sports , late onset of menarche, and use of oral contraceptive pills.

Intensity of training sport or BMI were not risk factors.

Int J Sport Nutr Exerc Metab. 2002 Sep;12(3):281-93.

Disorders of the female athlete triad among collegiate athletes.

Beals KA , Manore MM .

425 female collegiate athletes from 7 universities across the United States.

The percentage of athletes reporting a clinical diagnosis of anorexia and bulimia nervosa was 3.3% and 2.3%, respectively. Menstrual irregularity was reported by 31% of the athletes not using oral contraceptives, and there were no group differences in the prevalence of self-reported menstrual irregularity.

Muscle and bone injuries sustained during the collegiate career were reported by 65.9% and 34.3% of athletes, respectively, and more athletes in aesthetic versus endurance and team/anaerobic sports reported muscle (p =.005) and/or bone injuries (p <.001). Athletes "at risk" for eating disorders more frequently reported menstrual irregularity (p =.004) and sustained more bone injuries (p =.003) during their collegiate career.

Eating disorders

.

 The athlete with an eating disorder may also frequently abuse laxatives and diuretics, and is at increased risk for dehydration and electrolyte disturbances. The mortality rate in treated anorectic females reaches 18%.

(

The Female Athlete

Holschen, Jolie C. MD )

Med Sci Sports Exerc. 2005 Feb;37(2):184-93.

The female athlete triad: are elite athletes at increased risk?

Torstveit MK , Sundgot-Borgen J .

Female elite athletes in Norway ; national teams; 13-39 yr of age (N = 938) and non athlete controls in the same age group (N = 900). After exclusion, a total of 669 athletes (88%) and 607 controls (70%) A higher percentage of controls (69.2%) than athletes (60.4%) was classified as being at risk of the Triad (P < 0.01). A higher percentage of controls than athletes reported use of pathogenic weight-control methods and had high BD subscale scores (P<0.001).

However, more athletes reported menstrual dysfunction and stress fractures compared with controls (P < 0.05). A higher percentage of both athletes competing in leanness sports (70.1%) and the non-athlete control group (69.2%) was classified as being at risk of the Triad compared with athletes competing in non-leanness sports (55.3%) (P < 0.001). Furthermore, a higher percentage of athletes competing in aesthetic sports (66.4%) than ball game sports (52.6%) was classified as being at risk of the Triad (P < 0.001).

BONE HEALTH IN WOMEN

• Risk of hip fracture in older females can be reduced by nearly 20% if adolescent and teenage girls engage in regular physical activity

(healthlink 2004)

About 50% of men and 70% of women with age 50 or older suffer from osteoporosis or osteopenia in Iran.

    Osteoporosis at L2-L4: 16.7% in M and 56.3% in F Osteopenia at L2-L4: 38.9% in M and 25% in F.

PBM at L2-L4  at the age 29.3 years in women.

Means of PBM (20-45 years) (gr/cm2): ◦ for females 1.20+/-0.013 (lumbar spine) and 0.994+/-0.13 (hip) ◦ for males 1.18+/-0.14 (lumbar spine) and 1.05+/-0.16 (hip).

Peak bone mass in Iranian population seems to be 3.9% higher than Japanese and 5.6% lower than American population

OSTEOPOROSIS IN IRAN & EFFECTS OF EXERCISE Dr. Laleh Hakemi, Dr. Farzaneh Torkan, 2003

Prevalence of vitamin D deficiency is significant in Iran, and one study showed that 80% of the population has at least mild vitamin deficiency.

Hip fracture is the most serious consequence of osteoporosis.

The estimated incidence in femur, and 1806 fractures in the forearm.

of osteoporotic fractures in the year 2001 in Iranian women was 417 fractures in spine, 4337 fractures

menopause

Calcium supplements protect against bone loss post menopause Reid, IR, Ames, RW, Evans, MC, et al, N Engl J Med 1993; 328:460.

pregnancy

    Benefits: Enhances maternal fitness enhance physiologic reserve no difference in premature labor Precautions:              Safety: good nutrition hydration rest exercise after 3 hr post meal snack after exercise avoid extreme hot & humid avoid extreme intensity exercise avoid hyperthermia exercise should not cause discomfort avoid abdominal trauma avoid exercise in high altitude avoid exercise in deep water multiple fetuses, bleeding, IUGR, premature cervix change, previous miscarriages

1 st trimester: Cramp Bleeding Avoid abdominal trauma Avoid hyperthermia After 1 st trimester: Exercise performance is decreased: Physiologic Psychologic Avoid supine position Avoid prolonged standing Avoid upside down Avoid sudden movements Avoid Valsalva maneuver Avoid unsteady conditions

Breast protection

   Bra especially for large breasts breast padding for contact sports petroleum jelly abrasion likely

ANEMIA

Percent of anemia according to different hemoglobin thresholds, national level Iranian female athletes

Hemoglobin (g/dl) <=11.5

<12 <13 percent 6.9

17.3

57.7

Torkan, Kabir, Hakemi, 2001

mean of Hb in different levels of physical activity 14 12 10 8 6 4 2 0 14 12 13.5

11.5

13 11 pop ulati on amate ur eli te M F

Kordi

Thank You For Your Kind Attention