The Female Athlete Antoin Alexander

Maj USAF MC

Adapted from Dr. Terry Adirim

OverviewGeneral Differences

Injury Patterns

Menstrual Cycle

Female Athlete Triad

General DifferencesFemales Males

Prepubertal Capabilities

Equal Equal

Growth Spurt 11 13Maximum 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 DifferencesFemales 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) injuriesPatellofemoral pain syndromeStress fractures

ACL InjuriesWomen have an increased predisposition

to ACL injuryMany theories, but no one proven

definitive cause

ACL InjuryIntrinsic

factors:Joint laxityHormonesLimb alignmentLigament sizeIntercondylar

notch size

Extrinsic factors:ConditioningExperienceSkillStrengthMuscle

recruitment patterns

Landing techniques

ACL InjuryIntercondylar 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 InjuryWhat 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 etiologyChondromalaciaMalalignment of patella

Patellofemoral Pain SyndromeCauses of PFPS

Anatomical Larger “Q” angle Leads to abnormal tracking

of the patella

Patellofemoral Pain SyndromeOther causes

Muscle imbalances

Foot type (either pes planus or pes cavus)

Shoes

Overuse

Stress FracturesChronic, overuse injury

Most common in weight bearing bonesFeet, tibia, femoral neck

Seen commonly in Female Athlete Triad

Menstrual CycleAverage Age Menarche : 12.8 yearsAverage Cycle Length : 28 days (20-45)Well-Defined Pattern of hormonal changesFollicular or Proliferative phase

Menses through OvulationFSH causes overies to make estrogenFollicle Forms and lining proliferatesFollicle ruptures and Ovum formed

Luteal or secretory phaseOvulation through menstruation – 14 days Estrogen LH Surge Ovulation Estrogen/ProgesteroneIf no fertilization Estrogen/Progesterone Menstruation

Menstrual Cycle

1

2

3

4

5

6

78

9

MenstruationStudies fail to show decreased performance Luteal Phase 7 beats per minute ≠ Δ in

performance? Asthmatics Vulnerable during

perimenstrual phasePeak 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 TriadDefinition

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 AvailabilityAvailability = Dietary intake – exercise

expenditure

Key dysfunction underlying triad is disordered eating manifesting as low energy availabilityMay be inadvertent

DSM-IV eating disordersAnorexia nervosaBulimia NervosaEating Disorders not otherwise specified

Energy AvailabilityAffects 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 AvailabilityRisk Factors

Dieting or restrictive eatingVegetarianismBelief that thinness = social successBelief weight or fat performancePerfectionism or obsessive-compulsive traitsCompetitive NatureJudging sports, revealing uniforms, weight

classificationOnset sport training early ageCoaching emphasizing weight and body type

Anorexia NervosaDSM IV Criteria

Refusal to maintain minimally normal body weight Body weight < 85% expectedPrimary amenorrhea by age 16Secondary amenorrhea (absent 3 consecutive cycles)

Restrictive TypeNot regularly engaged in binge-eating or purging

Binge-Eating/Purging typeDuring Episode person regularly

binge-eating/purging

Anorexia Nervosa ComplicationsCardiovascular- mortality 10%

Hypotension and bradycardiaArrhythmias (Look for prolonged QT)Cardiomyopathy (from refeeding or ipecac)

EndocrineAmenorrhea with FSH and LH despite estrogen

Electrolyte imbalance: K,Na,Ph,MgEuthyroid sick syndrome: T3/T4, reverse T3Osteopenia/OsteoporosisHypothermia, Hypoglycemia, Diabetes Insipidus

Anorexia Nervosa ComplicationsGI: 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 NervosaDSM 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 behaviorBinging and Compensation occur twice a week for 3

moSelf eval unduly influenced by body shape/weightNot exclusively during Anorexia Nervosa Episode

Purging Type: vomiting, laxatives, diuretics, enemas

Nonpurging Type: fasting, excessive exercise

Bulemia Nervosa ComplicationsCardiovascular: Arrythmia, hypertension (diet pills)Endocrine:

Menstrual irregularitiesPseudo-Bartter Syndrome- normotensive hypokalemic

alkalosisHyperchloremic 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 SpecifiedMeets 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 DisordersDelayed Menarche or Primary Amenorrhea

Age 15 with secondary sex characteristicsSecondary Amenorrhea

NOT A NORMAL RESPONSE TO TRAININGLuteal phase deficiency

Prolonged follicular phase but luteal phase < 10 days

Decreased progesterone and anovulatory cycleOne study incidence 78% incidence in regularly

menstruating recreational runner vs 9% sedentary

Functional Hypothalamic AmenorrheaInsufficient calories/carbs to brain disrupts

GnRH

Energy conservation reproductive function suppression and hypoestrogenism

Likely to occur if < 30kcal/kg lean body mass per dayLH pulse disrupted if < 30kcal/kg for 5 days

Must exclude other causes of amenorrhea

Amenorrhea EvaluationHistory: 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, DHEASProgestin Challenge testEstrogen/progesterone challenge test

Positive = hypothalamic-pituitary axis dysfunction or ovarian failure

Amenorrhea TreatmentIncrease 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 DensityBone Mineral Density used to evaluate bone

healthShould be assessed if

6 months amenorrhea, oligomenorrhea6 months disordered eatingAfter stress or low-impact fracture

BMD loss can be irreversibleAthletes in weight bearing sports BMD 12-15% Hypoestrogenic state accelerated bone

resorptionEstrogen has a suppressive effect on osteoclasts

Bone Mineral Density ClassificationT-scores

Average peak adult BMDUsed in postmenopausal womenFracture risk doubles every SD below the meanNormal > -1, Osteopenia -1 to -2.5, Osteoporosis < -

2.5Z-scores

Mean for chronologic ageUsed in premenopausal women,adolescents, childrenACSM 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 TreatmentInitiate within first year of amenorrhea Correct energy deficitsOCP

Evidence good in perimenopausalEvidence fair in hypothalamic oligomenorrheic

premenopausalEvidence Limited in anorexic and healthy premenopausalConsider if over 16 and BMD despite nutritionDO NOT USE < 16 yo : premature growth plate closure

Low BMD TreatmentNasal CalcitoninCalcium 1500 and Vitamin D 400-1000 IU

dailyWeight bearing exercise and resistance

trainingSmoking cessationReduce excessive alcohol intakeSynthetic human parathyroid hormoneDO NOT USE Bisphosphonates in

premenopausal women

SummaryMen 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

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