The Female Athlete

1. The Female Athlete Antoin Alexander Maj USAF MC Adapted from Dr. Terry Adirim

2. Overview • General Differences • Injury Patterns • Menstrual Cycle • Female Athlete Triad

3. General Differences

4. General Differences

5. Injury Patterns • Common injuries in women/girls include: • Anterior cruciate ligament (ACL) injuries • Patellofemoral pain syndrome • Stress fractures

6. Women have an increased predisposition to ACL injury Many theories, but no one proven definitive cause ACL Injuries

7. Intrinsic factors: Joint laxity Hormones Limb alignment Ligament size Intercondylarnotch size Extrinsic factors: Conditioning Experience Skill Strength Muscle recruitment patterns Landing techniques ACL Injury

8. 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

9. ACL Injury • What to do? • Teach preventative skills • Learn how to fall, jump and to cut • Plyometrictraining • Reduce landing forces and improve strength ratios • Increase hamstring activation

10. Patellofemoral Pain Syndrome • Probably more than one etiology • Chondromalacia • Malalignment of patella

11. Patellofemoral Pain Syndrome • Causes of PFPS • Anatomical • Larger “Q” angle • Leads to abnormal tracking of the patella

12. Patellofemoral Pain Syndrome • Other causes • Muscle imbalances • Foot type (either pesplanus or pescavus) • Shoes • Overuse

13. Stress Fractures • Chronic, overuse injury • Most common in weight bearing bones • Feet, tibia, femoral neck • Seen commonly in Female Athlete Triad

14. 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

15. Menstrual Cycle 6 3 9 5 1 8 7 4 2

16. 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

17. 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%

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Bulemia Nervosa Complications • Cardiovascular: Arrythmia, hypertension (diet pills) • Endocrine: • Menstrual irregularities • Pseudo-Bartter Syndrome- normotensivehypokalemic 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Questions • ?