Medical Issues in Female Athletes

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In the Name of GOD
Medical Issues in Female Athletes
Dr. Laleh Hakemi Internist Vice-President of
Sports Medicine Federation of Iran
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Physical benefits ? Reduced risk of illnesses
such as heart disease, hypertension, diabetes,
and endometrial and breast ca. ? Improved
muscle-to-fat ratio-body composition ? Stronger
immune system with moderate physical activity ?
Less menstrual discomfort ? Stronger bones and
reduced risk of developing osteoporosis later in
life
Micheli, Smith, Biosca, Sangenis
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Psychosocial benefits ? Improved self-esteem,
self-confidence, and perception of competence
better performance in academic settings ?
Decreased risk of unwanted pregnancy ? Decreased
risk of drug and alcohol abuse
Micheli, Smith, Biosca, Sangenis
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Performance differences
Pre Post pubertal differences

• Running performance is related to max aerobic
  power
• the slower running speed due to lower VO2 max
• difference in VO2 max related to body
  composition (fat F? 20-25/ M? 10-14) Hb
  lower blood volume (relative to lean body mass),
  lower stroke volume (relative to lean body mass)
• if these corrected, no difference

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Strength

• Age 20 30-50 difference in muscle CSA between
  men and women
• strength difference upper gt lower extremities
• Upper F 40-75 M / Lower F60-80 M
• Similar differences in bones

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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 (interval continuous) produce
  similar improvements in M F

Nattiv, Ireland 1998
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Musculoskeletal differences

• Muscle size
• bone mass
• wider pelvis
• knee valgus (QASIS (patella/patella-tibial
  tubercle)lt 12o)
• ligamentous laxity

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? Are girls/women at greater risk of certain
types of injuries?

• 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
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? Do girls/women get injured more often?

• not at greater risk of acute injuries one
  exception is ACL injuries.
• Overuse injuries

Micheli, Smith, Biosca, Sangenis
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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 lt .0001).  
• Timothy E. Hewett, PhD, , , Kevin R. Ford, MS
  and Gregory D. Myer, MS, CSCS ,2003

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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 (plt.05)
• 2.5 times greater knee abduction moment (plt .001)

• 20 higher ground reaction force (plt.05)
• Stance time 16 shorter
• 73 specificity and 78 sensitivity of knee
  abduction moment for predicting ACL injury

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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
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• 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
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Association Between the Menstrual Cycle and
Anterior Cruciate Ligament Injuries in Female
AthletesEdward 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.

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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
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Menstrual cycle performance

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

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• 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 1332 (7544)749-55
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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 (plt0.001)
• 2-lower age at beginning exercise (p0.019)
• 3-lesser number of sisters (p0.007)
• 4-lesser number of brothers (p0.003)
• 5-higher percent body fat (p0.037)
• 6-higher body mass index (p0.002)7-residing
  mountain side regions (p0.001)

Hakemi L, Torkan F, Kabir A, 2002
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Female Athlete Triad

• Disordered eating
• Menstrual dysfunction
• Bone mineral density

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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 ? irregular and
  then ceased after she began to exercise,
  especially if lost weight at the same time.
• 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.

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CONSIDER DIFFERENTAIL DIAGNOSES

• THE MOST IMPORTANT
• PCOS
• Drug use

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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
121496
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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
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Asia Pac J Clin Nutr. 200918(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.
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Sports Med Arthrosc Rehabil Ther Technol. 2009
Jul 301(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/oligomenor
rhea 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.
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Int J Sport Nutr Exerc Metab. 2002
Sep12(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 lt.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.
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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 )
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Med Sci Sports Exerc. 2005 Feb37(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 lt 0.01). A higher
percentage of controls than athletes reported use
of pathogenic weight-control methods and had high
BD subscale scores (Plt0.001). However, more
athletes reported menstrual dysfunction and
stress fractures compared with controls (P lt
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 lt 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 lt 0.001).
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BONE HEALTH IN WOMEN
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• 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)
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About 50 of men and 70 of women with age 50 or
older suffer from osteoporosis or osteopenia in
Iran.
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• 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 EXERCISEDr.
Laleh Hakemi, Dr. Farzaneh Torkan, 2003
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• 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 of
  osteoporotic fractures in the year 2001 in
  Iranian women was 417 fractures in spine, 4337
  fractures in femur, and 1806 fractures in the
  forearm.

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menopause
Calcium supplements protect against bone loss
post menopause
Reid, IR, Ames, RW, Evans, MC, et al, N Engl J
Med 1993 328460.
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pregnancy

• Benefits
• Enhances maternal fitness
• enhance physiologic reserve
• no difference in premature labor

• 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

Precautions multiple fetuses, bleeding, IUGR,
premature cervix change, previous miscarriages
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1st trimester Cramp Bleeding Avoid abdominal
trauma Avoid hyperthermia After 1st
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
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Breast protection

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

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ANEMIA
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Percent of anemia according to different
hemoglobin thresholds, national level Iranian
female athletes
percent Hemoglobin (g/dl)
6.9 lt11.5
17.3 lt12
57.7 lt13
Torkan, Kabir, Hakemi, 2001
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Kordi
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Thank You For Your Kind Attention