Original Research

Female Athletes: Unique Challenges Facing Women Warriors

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Since Title IX passed in 1972, women have become exponentially more involved in competitive sports, from high school to professional levels. With more women engaging in serious athletics, the specific challenges they face have come to the forefront of sports medicine. These problems include the female athlete triad, concussions, exercise safety in pregnancy, anterior cruciate ligament (ACL) injuries, and continued sex discrimination and social injustice. Orthopedists treating female athletes should be aware of these problems, each of which is discussed in this review.

1. Female athlete triad

In 1992, the term female athlete triad was coined to describe 3 problems that often coexist in high-intensity female athletes.1 Since then, the definition has evolved, but the problem has remained essentially the same. The modern definition incorporates menstrual abnormalities, low energy availability with or without disordered eating, and decreased bone mineral density (BMD).2

With intense exercise and weight loss comes a variety of menstrual disturbances.3 In affected athletes, the hypothalamus is underactivated, and changes in gonadotropin-releasing hormone and luteinizing hormone lead to decreased estrogen production. Research suggests abnormal menses result from having inadequate energy and insufficient caloric intake to support extensive exercise.1 This phenomenon can occur in athletes in any sport but is most prevalent in lean-body sports, such as swimming, gymnastics, and ballet. The incidence of abnormal menses is as high as 79% in ballet dancers but only 5% in the general population.3 Menstrual abnormalities indicate hormonal abnormalities that can interfere with growth and maturation in young athletes.

Although full-blown eating disorders are uncommon among female athletes, disordered eating patterns are often found among women in competitive sports. Disordered eating can involve a spectrum of inadequate caloric intake and purging behavior, such as vomiting or laxative abuse, and has been reported in up to 25% of collegiate female athletes.4 Physicians must recognize these conditions and initiate counseling and treatment when appropriate. Women with disordered eating are at risk for developing electrolyte imbalances, malnutrition syndromes, and osteopenia.

Although careful evaluation and counseling are important, physicians must note that, in most cases, athletics participation may also protect against disordered eating and body image difficulties. A study of 146 college-age women found better body satisfaction among athletes than among nonathletes.5 Lean-sport athletes (eg, swimmers, gymnasts) were at higher risk for disordered eating and body image problems than other athletes were. Similarly, other studies have found that a majority of athletes have healthy eating habits.4

For poorly nourished and hormonally imbalanced female athletes, decreased BMD poses substantial risk. One study found a significant difference in BMD between athletes with amenorrhea and athletes with normal menses.6 In a cohort of female Navy recruits, those with amenorrhea were at 91% higher risk for stress fractures; calcium and vitamin D supplementation reduced risk by 20%.7 Osteopenia may be a special problem for prepubescent athletes. Girls who engage in intense exercise and have delayed menarche may have a low estrogen state, predisposing them to low BMD.3 Osteopenia and osteoporosis are difficult to reverse and can put these athletes at risk for stress fractures the rest of their lives. If unrecognized, stress fractures can end an athlete’s career.

Recommendations for dual-energy X-ray absorptiometry (DXA) include testing female athletes who have a diagnosed eating disorder, body mass index under 17.5, history of delayed menarche, oligomenorrhea, 2 prior stress fractures, or prior abnormal DXA scan. Complete testing recommendations appear in the 2014 consensus statement on the female athlete triad and return to sport.2,8

Orthopedists performing physical examinations for sports participation can screen for the female athlete triad through thoughtful questioning about menstrual history, nutrition habits, and stress fracture symptoms. Best treatment for a diagnosed case of the triad is multidisciplinary care with strong social support. When abnormal menses are an issue, referral to a gynecologist or endocrinologist and consideration of estrogen replacement should be discussed. Some cases require a psychiatrist’s assistance in treating disordered eating. Athletic trainers, coaches, and parents should be involved over the treatment course.1 Orthopedists must counsel women with osteopenia and osteoporosis about decreasing exercise to a safe level, improving nutritional intake, and supplementing with calcium (1200-1500 mg/d) and vitamin D (600-800 IU/d).3,7

2. Concussions

Increasing awareness of males’ sport-related concussions, particularly of concussions that occur during National Football League practice and games, has made physicians and researchers more aware of the rate of concussion in female athletes. That rate has increased, and, according to some reports, the risk for sport-related injury is higher for female athletes.9 A study of high school athletes found that the rate of concussion in girl’s soccer was second only to that in football.10


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