The Female Athlete- Activity across the lifespan: The Female Athlete - Activity across the lifespan Dr Julia Newton Nuffield Orthopaedic Centre 5th December 2007


Overview: Overview Why are women special? Adult athlete and menstrual irregularities The female athlete triad Pregnant athlete Adolescent athlete Older athlete


Why are women special?: Why are women special? Prior to puberty little difference Morphology ‘pear’ Women have greater stability and balance Body fat 26% vs. 14% ↓blood vol, ↓Hb VO2 max 20% ↓ Menstrual cycle


Menstrual irregularities in adult female athletes: Menstrual irregularities in adult female athletes Luteal phase defects/Anovulation Oligomenorrhoea Functional Hypothalamic Amenorrhoea Eumenorrhoea


Energy imbalance: Energy imbalance Energy availability Energy intake – exercise energy expenditure Critical level ~30kcal/kgFFM/day Energy cost running ~90kcal mile Low energy availability may occur inadvertently


Consequences of energy imbalance: Consequences of energy imbalance Menstrual irregularities Uncoupling of bone formation and resorption Subfertility/Infertility Low BMD Reduced energy availability


Exercise induce menstrual irregularities and fertility: Exercise induce menstrual irregularities and fertility Exercise intensity correlates with luteal phase defects (LPD) Infertility with apparent eumenorrhoea


Exercise induced menstrual irregularities and bone: Exercise induced menstrual irregularities and bone Amenorrhoea 4% bone loss/yr in 1st 2-3yrs Recurrent LPD 2-4% bone loss/yr Short term: stress fractures, recurrent STI Long term: osteoporosis On recovery of menses bone mass ↑ for 2yrs then ↓ Most important factor for PMO prevention is achieving peak bone mass Impact exercise does not compensate Less response to OE therapy


The Female Athlete Triad: The Female Athlete Triad Historically: anorexia nervosa, osteoporosis, amenorrhoea In practice: disordered eating, osteopenia, menstrual irregularities No generic critical body fat % or training volume Energy imbalance


Management: Management Target early Explanation ‘Energy Balance’ Normalise nutritional intake Calcium/vit D supplements 1200mg/800iu Fe supplements Recovery days Efficient training – ‘cut out the rubbish miles’ Trial for 6 months before using OCP Become: dietician, psychologist, coach! Consider referral


Practical tips: Practical tips Reduced fertility due to energy imbalance may be present despite an apparently normal cycle Target menstrual irregularities early as bone loss maximal in first 2 years Exercise does not compensate for a normal cycle for bone health Less response to OE therapy


The Pregnant Athlete: The Pregnant Athlete Exercise in pregnancy is good! Healthier weight gain 50% less gestational diabetes 40% less pre-eclampsia More likely to exercise after pregnancy Adverse pregnancy or neonatal outcomes are not increased for exercising women PARMed-X


Guiding intensity of exercise: Guiding intensity of exercise Maximal heart rate Age Heart rate range <20 140-155 20-29 135-150 30-39 130-145 Rate of perceived exertion 6 7 Very, very light 8 9 Somewhat light 10 11 Fairly light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Very, very hard 20 Talk test You should be able to carry on a verbal conversation


Previously inactive pregnant woman: Previously inactive pregnant woman Second trimester Regular not intermittent Intensity 60% maximal heart rate Talk test – talk throughout RPE – somewhat hard 15 mins continual exercise 3 x week Increase by 5-10% week Aim for 4-7 x 30mins sessions a week Include warm up and cool down Low impact: swimming, cycling


Previously active pregnant woman: Previously active pregnant woman Continue regular exercise Modify intensity do not exercise to exhaustion 70-80% pre pregnancy intensity – monitor heart rate 60-90% maximal heart rate Cross training to include lower impact low risk activities


Competitive pregnant athlete: Competitive pregnant athlete Do not conceal the pregnancy Inform National Governing Body Specialist obstetric care Expect a decline in overall activity and performance as pregnancy progresses


Considerations of the changes of pregnancy on exercise: Considerations of the changes of pregnancy on exercise Body position Change supine position to side lying or standing after 4 months Hypotension Avoid isometric contractions/Valsalva Joint/ligament laxity Avoid rapid changes of direction and plyometrics Stretch with caution Abdominal muscles If diastasis recti do not do abdominal exercises


General points: General points Avoid exercise in the supine position after first trimester Avoid prolonged periods of motionless Adequate nutrition Maintain hydration Avoid isometric exercise (Valsalva manoeuvre) Avoid exercise in hot humid environments Balance issues in third trimester Avoid contact sports/sports with risk blunt trauma after first trimester/16-20 weeks Track foetal activity and uterine contractions Use a well fitted supportive bra!


Contraindications: Contraindications Medical problems pre pregnancy Pre-eclampsia Cervical weakness Previous recurrent miscarriages/PROM Eating disorders Multiple pregnancy IUGR/abnormal doppler flow Hb<10 Placenta praevia


Stop exercise if:: Stop exercise if: Excessive fatigue Chest pain Palpitations Dizziness or fainting Abdominal pain Painful uterine contractions Leakage of amniotic fluid Vaginal bleeding Reduced foetal movement


Practical tips: Practical tips PARMed-X for Pregnancy as an initial guide Adjust exercise intensity using max HR guide and RPE Women should be encouraged to participate in aerobic and strength-conditioning exercise


The Older Female: The Older Female Increasing numbers of older women are exercising Veteran age groups for most competitive sports Considerable physiological and psychological benefits Post menopausal osteoporosis Needs to be commenced perimenopausally; most bone loss within first 2-3 years Resistance training and high impact training Strength and balance to reduce falls Combine with adequate calcium/vit D intake


General guidelines: General guidelines Aerobic training 60% max HR (220-age) 5% increase only per week Strength training - upper and lower body reps with 70-80% max weight


Practical tips: Practical tips To minimise bone loss increased physical activity levels should be introduced at/or before the onset of the menopause Exercise prescription should include aerobic, strength conditioning and balance work


Thank you: Thank you


References: References Royal College of Obstetricians and Gynaecologists Statement No.4 January 2006 American College of Sports Medicine. The Female Athlete Triad. Position Stand MSSE 2007 1867-1882 Olympic Medical Institute Position Statement on the Pregnant Athlete American College of Sports Medicine. Physical Activity and Bone Health. Position Stand MSSE 2004 1985-1996 PARMed-X for Pregnancy. Canadian Society for Exercise Physiology