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What's New in Treating Active Women

by Lisa Schnirring

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 7 - JULY 97


In Brief: A year ago, The Physician and Sportsmedicine published its first-ever issue devoted entirely to active women's health. But primary care physicians continually need to keep pace with the changing face of female athletics and treatment strategies. Here is an update on some of the topics at the forefront: anterior cruciate ligament tears, heart disease, exercise in pregnancy, nutrition concerns, osteoporosis, and breast cancer.

Physical activity can mean different things to different women, from strolling in the park to soaring through the air for a volleyball kill. Primary care physicians, therefore, need to focus on the individual benefits of sports for women of all ages and activity levels—and to be prepared to care for their ever-changing needs. This report covers pertinent hot topics, from musculoskeletal to nutritional to points in between.

ACL Injuries

The increasing number of women participating in basketball and other cutting and pivoting sports has caused a notable injury ripple: an epidemic of anterior cruciate ligament (ACL) injuries (1). In college basketball, women are nearly four times as likely as men to have an ACL injury. Suggested reasons include anatomic differences (ligament size, ligament laxity, intercondylar notch dimensions, and limb alignment) and incidental differences (skill level, experience level, proprioception, style of play, muscle strength, and coordination).

Experts on ACL injuries say the high ACL injury rates call for further studies, but some, such as Mary Lloyd Ireland, MD, caution that "you don't want anybody to get the message that women shouldn't be playing (2)." Ireland is an assistant professor in the departments of surgery (orthopaedics) and family medicine at the University of Kentucky in Lexington, a consultant for sports teams at two universities, and director of the Kentucky Sports Medicine Clinic in Lexington.

There seems to be some agreement that women, like men, might prevent ACL injuries by employing sport-specific conditioning (quadriceps and hamstring strengthening), learning proper technique, and playing with competitors of comparable skill level. In a panel discussion in April at the annual meeting of the American Medical Society for Sports Medicine in Colorado Springs, Ireland said she believes that the ACL injury epidemic among women might derive in part from the fact that too few women have been encouraged to play sports as young girls.

University of Iowa athletic trainer Alex Kane told Sports Illustrated, "You combine [a] lack of early training with the sudden expectation that women will perform at the level of Division I athletics today, and you have a major problem. Something's got to give (2)." Simone Edwards, a former center for Iowa who tore her ACL during practice her senior year, did not begin playing basketball until she was in high school.

Reports of ACL injuries in women should not influence how women compete or choose their sports, writes Elizabeth A. Arendt, MD (3). She is medical director of men's and women's varsity athletics at the University of Minnesota in Minneapolis, where she is also an associate professor and director of the Sports Medicine Institute in the Department of Orthopaedic Surgery. Arendt writes that more research is needed to explore the variables that contribute to the difference, in hopes of making sports safer for all participants.

Preventing Heart Disease

Though breast cancer seems to grab most of the women's health headlines, heart disease is the No. 1 killer of American women each year. Nearly 500,000 women in this country die of heart disease annually—more than twice as many as die of all types of cancer combined.

Before age 50 or so, women are less likely than men to develop heart disease, although women with risk factors (diabetes, obesity, high cholesterol, or smoking, for example) have a higher risk than other women. Once women reach menopause, however, the risk for coronary artery disease increases dramatically as the protective effects of estrogen wane. By the time the average woman is in her 70s, her risk is equal to a man's of the same age.

Ethnic-group comparisons show that black women have the greatest risk of coronary artery disease among women. Black women between the ages of 35 and 74 are twice as likely to die of a heart attack as white women are. Also, heart disease strikes black women at an earlier age than white women.

Researchers aren't sure why heart disease is more common in women of African heritage. But they do know that black women tend to score high on certain heart disease risk factors. For example, the American Heart Association (AHA) estimates that about half of black women have high total serum cholesterol levels (over 200 mg/dL). Also, hypertension is a problem for many black women. Access to medical care may also contribute to the higher risk of heart disease.

In 1992 the AHA upgraded lack of physical activity to the status of a risk factor for heart disease. Most studies of physical activity and cardiovascular disease have dealt with men. Among those that have focused on women is a study (4) presented in November 1996 at the AHA annual meeting in New Orleans. Researchers found that women who walked at least 3 hours per week had a 40% lower risk of heart attack and stroke than sedentary women.

The exercise prescription for women who want to reduce their cardiac risk should include a regular program of aerobic exercise like walking, running, swimming, biking, or rowing for 20 to 30 minutes, three to five times per week. For people who are unable to exercise more vigorously or are sedentary, the AHA recommends low-intensity activities such as walking for pleasure, gardening, yard work, house work, and prescribed home exercise.

Pregnancy and Exercise

Many women who play sports or exercise want to maintain their active lifestyles during pregnancy, and physicians should be prepared to field their questions and offer advice. A recent survey (5) of 9,953 women who gave birth found that 42% exercised during pregnancy, half for longer than 6 months.

And there are plenty of good reasons for women to be active, within reason, during pregnancy. Though exercise doesn't guarantee a problem-free pregnancy or labor, the benefits include less weight gain and prevention or control of gestational diabetes. In the delivery room, exercise provides greater strength, flexibility, endurance, and stamina and portends less need for augmentation of labor and fewer signs of fetal distress.

The benefits of exercise during pregnancy are so convincing that a recent review (6) suggests, "A more liberal and rational approach to exercise prescription in general and to the training regimens of female athletes in particular is not only safe but probably indicated during pregnancy."

The American College of Obstetrics and Gynecology exercise guidelines (7) may be too conservative for some active patients, and some physicians do modify the recommendations for individual patients. Consensus exists, though, about the absolute contraindications to exercise during pregnancy: congestive heart failure, valvular heart disease associated with an increased risk of heart failure because of volume overload, severe hypertension, uterine bleeding, premature rupture of membranes, and an incompetent cervix. However, the majority of women can exercise with few limitations.

Given the many benefits, a few women may overdo exercise during pregnancy. For example, a recent report (8) details the case of a woman who fractured her femoral neck after running 1 hour daily throughout pregnancy. The author suggests that physicians monitor pregnant patients' exercise habits and negotiate exercise terms with patients who appear exercise dependent.

Women can generally exercise safely during pregnancy if they limit cardiovascular workouts to 30 minutes of moderate-intensity exercise, avoiding an increase in core temperature and extreme exhaustion and dehydration. Activities such as scuba diving, mountain climbing, and contact sports that carry a risk of pelvic or abdominal trauma to the mother and fetus should be restricted. It's especially important to replace lost fluid and carbohydrates after exercise. (See "Expecting Questions About Exercise and Pregnancy?" April 1997.)

Heart rates cannot reliably be used to assess fitness or monitor exercise intensity during pregnancy because cardiovascular dynamics such as blood pressure, stroke volume, and resting heart rate change significantly, Raul Artal, MD, told an audience at the April AMSSM annual meeting. Artal is professor and chairman of the Department of Obstetrics and Gynecology at the State University of New York Health Science Center in Syracuse and is an editorial board member of The Physician and Sportsmedicine. He advised physicians to urge patients to use the rating of perceived exertion instead. "For most patients, the 'talk test' is appropriate. If the patient can't talk normally while exercising, she is working out too hard," he said.

Nutrition and Eating Disorders

Concerns about the effects of the female athlete triad in young women are having a global impact. The female athlete triad of disordered eating, amenorrhea, and osteoporosis affects many active women and girls, especially those in sports emphasizing appearance or leanness. In elite sports, women's professional tennis and international gymnastics organizations addressed the female athlete triad and other women's health issues by raising the age of eligibility for competition (9,10). A task force from WomenSport International (WSI) and the International Olympic Committee's Medical Commission is working on prevention tactics that include educating athletes, parents, coaches, health professionals, and athletic administrators about the triad.

Meanwhile, healthcare professionals at the local level are working to devise creative, multidisciplinary management strategies that involve primary care physicians, nutritionists, radiologists, psychiatrists, counselors, and athletic trainers (see "Team Management of the Female Athlete Triad, Part 1: What to Look for, What to Ask," March 1997, and "Team Management of the Female Athlete Triad, Part 2: Optimal Treatment and Prevention Tactics," April 1997). A group of experts on the female athlete triad recently put forward a position statement on the subject on behalf of the American College of Sports Medicine (ACSM) (11). The ACSM recently launched an educational program on the triad that includes a video, brochures, and a slide series. Contact the ACSM at (317) 637-9200 to obtain the materials.

One of the problems in treating women who have the female athlete triad is the lack of diagnosis and treatment guidelines, says Carol L. Otis, MD, who is a staff physician at the University of California at Los Angeles Student Health Service and chair of the ACSM Women's Initiative. That leaves physicians on their own in determining if and when a woman needs a medical workup for the triad. "If a woman has had 3 months of amenorrhea, she needs a medical evaluation," Otis says. "That's like a smoke alarm going off. The patient needs to realize that amenorrhea is not a normal change."

When taking the patient history, Otis says, she asks about age at menarche, menstrual history, amount of training, weight history, nutrition history, and thyroid and pituitary disease. During the physical exam she evaluates the patient for thyroid irregularities, breast discharge, and signs of androgen excess, and she performs a pelvic exam. Otis says diagnostic tests can include a pregnancy test (if indicated), a thyroid screening test, prolactin level, and perhaps a luteinizing hormone and/or follicle-stimulating hormone level. The decision to check bone density is based on individual risk factors and the duration of menstrual changes.

Otis says initial treatment is aimed at reversing the patient's energy imbalance. The patient should decrease training, increase dietary intake, and take 1,500 mg of calcium per day. "Try that for 2 to 3 months to see if menstruation resumes. If she has low bone density or doesn't want to correct the underlying problems, an oral contraceptive can be prescribed," Otis says.

It's important for physicians to consider the female athlete triad in women who have amenorrhea or other triad symptoms, even if they are not elite athletes, Otis says. "The female athlete triad was first identified in elite athletes, but it can appear in women at all levels of physical activity," she says.

Osteoporosis and Bone Health

When younger women engage in weight-bearing activities, they build bone mass that will help them have high bone density at menopause (12,13). Mature women who begin exercise during menopause can also slow their bone loss. But osteoporosis is still a problem for postmenopausal women and young women who have menstrual irregularities.

Though women are getting the message that exercise can help them maintain their bone strength, it can't fully offset the effects of low estrogen levels after menopause. So medication is often needed to supplement activity benefits. Estrogen is still the mainstay of treatment for osteoporosis, but there are some new options for women who can't tolerate it:

  • A synthetic form of salmon calcitonin, previously available only in injection form, is now available in a nasal spray. When compared with calcium alone, calcitonin appears to increase bone density (14), but its ability to reduce the risk of fractures is uncertain. It is indicated for use as a second-line therapy.
  • Alendronate, a bisphosphonate, has been shown to increase bone density and reduce fracture risk for people who have a clinical fracture or are two standard deviations from the standard DEXA bone scan (15,16).

Other treatments under investigation include other bisphosphonates, sodium fluoride, vitamin D metabolites, and selective estrogen receptor modulators, according to the Osteoporosis and Related Bone Diseases National Resource Center in Washington, DC.

Breast Cancer and Exercise

It's likely that more women are asking their doctors how exercise can reduce their risk of breast cancer. A recent large prospective study (17) that appeared in The New England Journal of Medicine made headlines in the lay press when it confirmed several smaller studies that suggested that physical activity reduces the risk of breast cancer. The possible mechanisms include reduced exposure to estrogen and progesterone and alterations in energy balance.

Though exercise is a wise prevention tactic for many other diseases, it may be too early to recommend it for breast cancer prevention, says Anne McTiernan, MD, PhD, in an editorial (18) that accompanied The New England Journal of Medicine study. McTiernan is an associate member at the Fred Hutchinson Cancer Research Center in Seattle. Further exploration is needed to define the biologic mechanisms, and clinical trials are needed to confirm the findings, she says. "It will be particularly important to define the types, intensity, and duration of exercise required to protect against breast cancer, as well as the critical age at which a fitness program should be initiated," writes McTiernan.

Looking Ahead

As the body of knowledge about healthcare for active women grows, it's natural to wonder what new challanges are in store for physicians. "We're trying to focus on getting more women physically active and to get the message out about the health benefits of exercise," says Otis. Of special concern are adolescent women, who seem to resist regular exercise, despite increasing sports opportunities, she says. "We've got to make the messages in the surgeon general's report on physical activity more targeted to women," says Otis. "And we have to look at ways to reduce barriers and increase motivation."

References

  1. Arendt E, Dick R: Knee injury patterns among men and women in collegiate basketball and soccer: data and review of literature. Am J Sports Med 1995;23(6):694-701
  2. McCallum J: Out of joint. Sports Illus 1995;82(6):44-53
  3. Arendt EA: Common musculoskeletal injuries in women. Phys Sportsmed 1996;24(7):39-48
  4. Manson J, Rich-Edwards WJ, Colditz GA, et al: The role of walking and the prevention of cardiovascular disease in women, abstracted. Circulation 1996;94(8):I339
  5. Zhang J, Savitz DA: Exercise during pregnancy among US women. Ann Epidemiol 1996;6(1):53-59
  6. Clapp JF: The effect of continuing regular endurance exercise on the physiologic adaptations to pregnancy and pregnancy outcome. Am J Sports Med 1996;24(6):S28-S29
  7. Exercise during pregnancy and the postpartum period. ACOG Technical Bulletin Number 189—February 1994. Int J Gynaecol Obstet 1994;45(1):65-70
  8. Spieker MR: Exercise dependence in a pregnant runner. J Am Board Fam Pract 1996;9(2):118-121
  9. Howard RR: Rule changes in women's tennis target medical issues. Phys Sportsmed 1995;23(6):25
  10. Anderson V: Female gymnasts: older—and healthier? Phys Sportsmed 1997;25(3):25-26
  11. Otis CL, Drinkwater B, Johnson M, et al: ACSM position stand: the female athlete triad. Med Sci Sports Exerc 1997;29(5):i-ix
  12. Lane NE, Bloch DA, Jones HH, et al: Long-distance running, bone density, osteoarthritis. JAMA 1986;255(9):1147-1151
  13. Michel BA, Bloch DA, Fires JF: Weight-bearing exercise, overexercise, and lumbar bone density over age 50 years. Arch Intern Med 1989;149(10):2325-2329
  14. Overgaard K, Hansen MA, Jensen SB, et al: Effect of salcatonin given intranasally on bone mass and fracture rates in established osteoporosis: a dose response study. BMJ 1992;305(6853):554-561
  15. Chesnut CH III, McClung MR, Ensrud KE, et al: Alendronate treatment of the postmenopausal osteoporotic woman: effect of multiple dosages on bone mass and bone remodeling. Am J Med 1995;99(2):144-152
  16. Liberman UA, Weiss SR, Bröll J, et al: Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. N Engl J Med 1995;333(22):1437-1443
  17. Thune I, Brenn T, Lund E, et al: Physical activity and the risk of breast cancer. N Engl J Med 1997;336(18):1269-1275
  18. McTiernan A: Exercise and breast cancer: time to get moving? editorial. N Engl J Med 1997;336(18):1311-1312

Lisa Schnirring is a senior associate editor of The Physician and Sportsmedicine.


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