Talk about gynaecological issues faced by female sports women.

1. Gynaecological issues in female sports
person
Dr Antima Rathore
(Obs & Gynae)
Nottingham University Hospitals
NHS Trust, UK 1

2. “The worst form of inequality
is to try
to make
unequal things equal”
2

3. Childhood
Until puberty no significant difference
• most measurements
• composition
• physiological responses to exercise
Boy = Girl
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4. Womanhood
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5. Topics
1. Adolescent girls
a) Delayed puberty
b) Periods related symptoms
2. Adult woman
a) Menstrual Problems
b) Female athlete triad
c) Syndrome of RED-S
d) Pregnant athlete
e) Return to work after baby birth
3. Older woman
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6. Adolescent
• Delayed Puberty/menarche
• Altered pubertal progression
• Menstrual irregularities
• Psychological stress due to
pubertal changes
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7. Hormones
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8. Effects of Oestrogen
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9. Effects of Oestrogen
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10. Low BMD
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11. BMD
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12. Managing delayed puberty
1) Decrease the intensity of their exercise
2) Improve their nutritional intake
3) Hormonal therapy
• If menarche has not occurred by the age of 16 years and bone age matches
the chronological age
• Rationale - an increase in bone mass
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13. Periods Related Symptoms
• Highly prevalent and highly individualised
• May impacted negatively on sporting performance.
• Athletes generally choosing to adapt to or accept symptoms.
• Perceiving a gender barrier in discussing menstrual cycle concerns/issues
with male staff members
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14. Solution
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Educate
Support at the point of contact
Regular monitoring
Menstrual cycle profiles

15. Adults
• Menstrual irregularities
• Prevalence
• General adult population - 1.8
to 5%
• In athletes - as high as 79%
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16. Menstrual irregularities
• Age
• Athletic disciplines
• Ballet dancers - high
• Cyclists and swimmers - lower
• Level of activity and
performance
• Training prior to menarche
• Genetic factors
• Reproductive maturity
• Environmental factors
• Mental stress
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17. Energy and nutrient balance
Strict diets and intense training
Negative caloric balance
↓
Energy deficiency
↓
↓ Energy availability for
reproductive system function
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18. Effect of body composition
• Frisch's theory
There is a critical percentage of body fat for the initiation of puberty (17%) and for
the maintenance of regular cycles (22%)
• Most female athletes have less than 22% body fat
• Individualized threshold
• A change of as little as 1-2 kg will make the difference
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19. Complications
• Osteoporosis
• Infertility - usually reversible
• Lipid metabolism and risk of coronary heart disease
• Endometrial cancer
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20. Management
• A 10% decrease in exercise (either duration or intensity) or gain of 1-2
kg will often reverse the problem
• Many athletes are unwilling to change their life-style
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21. Issues in Sports Women
• Female athlete triad
Originally described in 1992
First recognized as three separate but unrelated entities
Now recognized by the American College of Sports Medicine (ACSM) as a
spectrum of symptoms and conditions between health and disease
• RED-S (Relative Energy Deficiency in Sport)
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22. Female Athlete Triad
Low energy
With/without eating disorder
Amenorrhoea Osteoporosis
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23. Female Athlete Triad
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24. Additional Consequences of the Triad
Risk to heart disease
Osteoporosis
Infertility
Metabolic issues
Excessive fatigue
Increased recovery time
Decreased response to training
Impaired Performance
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25. Screening
• Low Energy Availability
• High dietary restraint
• High drive for thinness
• Excessive or compulsive exercise
• Restriction of specific food
groups
• Repeated dieting
• Eating disorder
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26. Screening
• Menstrual dysfunction
• How many periods has the
athlete had within the past 12
months?
• Has she missed >3 periods in
a row?
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27. Screening
BMD
DEXA scan
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28. Management
Educate
Nutritionist
Calcium 1200-1500mg/day
Vit. D 400-800IU/day
Psychological counselling
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29. Management
Hormonal treatment – 2nd line
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30. Cumulative risk assessment
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31. The Syndrome of RED-S
Definition
“impaired physiological functioning caused by relative energy deficiency,
and includes but is not limited to impairments of metabolic rate,
menstrual function, bone health, immunity, protein synthesis, and
cardiovascular health.”
Etiological factor - low energy availability (LEA)
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32. Health Consequence of RED-S
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33. Potential Performance Effects RED-S
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34. Low Energy Availability (LEA)
• Mismatch between energy intake and the energy expended in exercise
• Inadequate energy to support the body’s functions
• Energy availability (EA)
½Energy intake (EI) (kcal) − Exercise Energy Expenditure (EEE) (kcal) /Fat-free mass
(FFM) (kg)
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35. Low Energy Availability (LEA)
• EA of 30 kcal/kg/FFM roughly equates to the average resting metabolic
rate (RMR)
• Optimal EA for healthy physiological function
- 45 kcal/kg FFM/day (188 kJ/kg FFM/day)
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36. The IOC consensus statement: 2014
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37. The IOC consensus statement: 2014
The Relative Energy Deficiency in Sport Return-to-Play Model
High risk: red light Moderate risk: yellow light Low risk: green light
• Full sport participation
• May compete once
medically cleared under
supervision
• May train as long as is
following the treatment plan
• No competition
• Supervised training
allowed when medically
cleared for adapted
training
• Use of written contract
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38. The IOC consensus statement: 2014
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39. Recommendations for
prevention
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40. Athlete Entourage Recommendations
1) Educational programmes on RED-S, healthy eating, nutrition, EA,
the risks of dieting and how these affect health and performance
2) Reduction of emphasis on weight, emphasising nutrition and health
as a means to enhance performance
3) Development of realistic and health-promoting goals related to weight
and body composition
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41. Athlete Entourage Recommendations
4) Avoidance of critical comments about an athlete’s body shape/weight.
5) Use of reputable sources of information.
6) Promotion of awareness that good performance does not always mean the
athlete is healthy.
7) Encouragement and support of appropriate, timely and effective treatment
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42. Healthcare Professional Recommendations
1) Identification of a multidisciplinary athlete health support team
including sports physician, nutritionist, psychologist, physiotherapist
and physiologist.
2) Education of the medical team in the detection and treatment of the
RED-S
3) Implementation of the RED-S Risk Assessment Model
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43. Sport Organisation Recommendations
1) Preventative educational programmes
2) Rule modifications/changes to address weight-sensitive issues in sport
3) Policies for coaches on the healthy practice of managing athlete
eating behaviour, weight and body composition
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44. Pregnancy and Sports Woman
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45. Pregnancy Related Changes
Physiological changes during pregnancy are similar to the
adaptations of the body to exercise
• Cardiac output
• Maternal blood volume
• Oxygen consumption increase
• Minute ventilation
• Metabolic rate
• Body temperature
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46. Anticipated risks
Mother
• ↓ blood pressure and dizziness
• ↑ risk of injuries
- Effect of weight gain on coordination and
center of gravity
- Increased ligamentous relaxation
Baby
• ↓ blood flow
• ↓ oxygen delivery
• ↓ glucose availability
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47. Complaints/Complications
during pregnancy or after birth
• Same as general population
• Insufficient data (miscarriage, preterm birth, caesarean section, etc)
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48. Exercise During Pregnancy
Regular exercise is beneficial
• Reduces back pain
• Eases constipation
• May decrease your risk of gestational
diabetes, preeclampsia, and cesarean
delivery
• Promotes healthy weight gain during
pregnancy
• Improves your overall general fitness
and strengthens your heart and blood
vessels
• Helps you to lose the baby weight
after your baby is born
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49. Exercise in pregnancy
• Stay active, stay fit
• Do not exhaust yourself.
• Should be able to hold a conversation during exercise
• If become breathless as talk - then probably exercising too
strenuously
• Always warm up before exercising, and cool down afterwards
• Avoid any strenuous exercise in hot weather
• Drink plenty of water and other fluids
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50. Exercises to avoid in pregnancy
• Do not lie flat on your back for long period
- specially after 16 weeks
• Avoid contact sports (kickboxing, judo or squash)
- higher risk of being hit
• Avoid SCUBA diving - the baby has no protection against
decompression sickness and gas embolism
• Do not exercise at heights over 2,500m above sea level –mother and
baby are at risk of altitude sickness
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51. 53

52. Target Heart Rate
140-150 bpm
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53. ACSM’s Guidelines for Exercise Testing & Prescription:
Relative Contraindications for Exercising during Pregnancy
Severe anemia
• Unevaluated maternal cardiac dysrythmia
• Chronic bronchitis
• Poorly controlled Type 1 diabetes mellitus
• Extreme morbid obesity
• Extreme underweight
• History of extremely sedentary lifestyle
• Intrauterine growth restriction in current pregnancy
• Poorly controlled hypertension
• Orthopedic limitations
• Poorly controlled seizure disorder
• Poorly controlled hyperthyroidism
• Heavy smoker
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54. ACSM’s Guidelines for Exercise Testing & Prescription:
Absolute Contraindications for Exercising during Pregnancy
• Hemodynamically significant heart disease
• Restrictive lung disease
• Incompetent cervix/cerclage
• Multiple gestation at risk for premature labor
• Persistent second or third trimester bleeding
• Placenta previa after 26 week of gestation
• Premature labor during the current pregnancy
• Ruptured membranes
• Preeclampsia/pregnancy-induced hypertension
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55. International Olympic Committee (IOC)
• May require some adjustments in intensity and activity
• If exercising at a moderate level throughout the pregnancy, they can
expect their maximal aerobic capacity (VO2max) after childbirth to be
similar to their prepregnancy levels
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56. International Olympic Committee (IOC)
• High-intensity endurance training
• use perception of exertion or fatigue to gauge their training
intensity
• Refrain from training at intensities >90% of their VO2max
(Maximum aerobic capacity)
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57. International Olympic Committee (IOC)
• Strenuous strength training should be adjusted to avoid the Valsalva
manoeuvre and excessive pressure towards the pelvic floor
• Pelvic floor muscles should be contracted before and during heavy
lifting to counteract the impact on the pelvic floor from increased intra-
abdominal pressure
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58. International Olympic Committee (IOC)
• Strength training of the pelvic floor muscles
• Prevent and treat urinary incontinence
• Reduce the duration of labour
• Near maximal pelvic floor contractions, in sets of 8–12, performed three
times per day on most days
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59. Physical Activity Readiness Medical Examination
(ParMed-X)
A guideline for health screening prior to participation in a prenatal
fitness class or other exercise
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60. Return to sports after child-birth
• Return to participation:
Rehabilitation, training
• Return to sport:
Return to her defined sport, but not performing at her previous level
• Return to performance:
Gradually returned to her defined sport and is performing at or above
her pre-pregnancy level
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61. Return to sports after child-birth
• Strength training in the postpartum period should start gradually
• Main focus
• Pelvic Floor Muscle - first
• Abdominal and back muscles
• Breast feeding
• Safe
• Consider special nutritional requirement
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62. The Older Athlete
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63. The Older Athlete
Concerns
• Dehydration, electrolyte
imbalance and heat-related
illness
• Musculoskeletal injury
• An ischaemic cardiac event
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64. The Older Athlete
Benefits - ↓ risk
• Dementia
• Diabetes
• Depression
• Anxiety
• Fatigue
• Heart Problems
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65. The Older Athlete
Post-menopausal women
• Lower bone density – increase
risks of fractures
• Calcium supplement
• Regular exercise beneficial
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66. Thank You
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