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The Ripple Effect of Title IX on Women's Health Issues

Treating an Increasingly Active Population

Patricia D. Mees


Perhaps no area in sports medicine has changed as dramatically in the last 30 years as women's health. Title IX of the Education Amendments of 1972 prohibited discrimination on the basis of sex in all curricular and extracurricular activities at educational institutions that receive federal funding. Before 1972, many assumed that women were not interested in sports and that there was no need to provide programs for girls and women, and most primary care physicians had little experience in treating female athletes and other active women.

In 1972, 1 in 27 girls participated in high school varsity sports.1 In 2021, that figure had grown to 1 in 2.5. Before Title IX, women composed 2% of college athletes. With athletic scholarships available, women in 2021 made up 54% of college students and 43% of college athletes. Since 1972, the number of female intercollegiate athletes has increased from 32,000 to 150,000. Women received 9% of all medical degrees in 1972; by 1997, 41% were women. The face of primary care medicine has changed dramatically since Title IX was enacted. Two key conditions affecting athletic women are the female athlete triad and noncontact anterior cruciate ligament (ACL) injuries.

Female Athlete Triad

Thirty years ago, the term "female athlete triad" did not exist to describe the syndrome of disordered eating, menstrual irregularity, and osteoporosis. "Coaches, athletes, and even physicians thought that the absence of menses in a female athlete implied that she was training 'hard enough,'" says Elizabeth Joy, MD, associate professor of family and preventive medicine and a team physician at the University of Utah in Salt Lake City. "Despite our efforts at educating people, many still believe that amenorrhea is a positive adaptation to exercise," Joy says.

The definitions of the components of the syndrome have broadened to include more disorders. "Eating disorder" now means more than just anorexia and bulimia, "menstrual irregularity" includes luteal-phase dysfunction and oligomenorrhea as well as amenorrhea, and osteopenia is recognized as a precursor of osteoporosis. "Some research suggests that even the more minor forms of menstrual dysfunction, such as oligomenorrhea or anovulatory cycles, may have detrimental effects on bone mineral density, and that this bone loss may be, at least partially, irreversible," says Constance Lebrun, MDCM, director of primary care sport medicine at the Fowler-Kennedy Sport Medicine Clinic at the University of Western Ontario in London, Ontario.

The preparticipation physical exam is an opportune time to screen for the female athlete triad, and the current version2 includes questions about nutrition, menstruation, evidence of bone mineral loss, and body image. Elizabeth Arendt, MD, an associate professor of orthopedic surgery at the University of Minnesota in Minneapolis, remembers that "there was very little discussion about menstrual dysfunction in the mid-120210s, and certainly no aggressive treatment of it." Because athletes seemed a bit more honest about disclosing menstrual history and typically dishonest about eating patterns, Arendt says she "learned to use the menstrual history as a red flag for eating disorders, psychological issues, and other comorbidity and medical concerns." Physicians today are more aware of the need to maintain a high index of suspicion, because more adolescent girls have learned to hide symptoms of an eating disorder.

Male physicians who are interviewing female athletes may face some awkward moments, according to Mark Hutchinson, MD, an associate professor of orthopedics and sports medicine and director of sports medicine services at the University of Illinois at Chicago. He suggests that "any female athlete with a stress fracture should be interviewed in a private, open, noncondescending format." He also uses a letter in a sealed envelope that is offered to the athlete at the close of the initial screening. The letter explains concerns about eating disorders and the female athlete triad, admits the possibility that the physician may be wrong, but includes phone numbers and e-mail information so that the athlete may contact other professionals for help.

Fortunately, advances in imaging techniques are helping to identify those at risk. Stress fractures are seen on magnetic resonance images, and bone mineral density can be evaluated with dual-energy x-ray absorptiometry. Hutchinson notes that "since you can't find what you don't look for, many overuse problems and stress fractures went unrecognized. Now, with earlier treatment, we have improved outcomes."

ACL Injuries

As the number of girls and women participating in sports such as basketball, volleyball, and soccer has increased, so have the number of injuries. "Most injuries are more sport-specific than gender-specific; for example, swimmers have shoulder problems, and dancers have foot and ankle problems," says Hutchinson. "One of the most researched areas surrounds gender variations in knee injury rates. Perhaps women, due to their relatively wider hips, smaller ligaments, and general valgus alignment at the knee, tend to be at increased risk. Rupture of the ACL appears to be more common in women in virtually all sports that require twisting and cutting," he says.

Lebrun adds, "Although the theories to explain this include both intrinsic and extrinsic factors, it is likely that a significant mechanism is the difference in proprioception and muscle firing patterns between male and female athletes in the same sport." She is not convinced that there is "sufficient evidence to support any increased risk at any specific time in the menstrual cycle [despite] both estrogen and progesterone receptors being found in the ACL."

All of the physicians interviewed for this article felt that recognition of the problem and proprioception training were key to preventing injuries. Arendt says, "It is helpful to examine the mechanism of injury to try to prevent an injury. The largely extrinsic factors can be changed with recognition and training." Joy notes that "interventions that improve muscle firing patterns around the knee and specific landing and stopping techniques have been shown to reduce the risk of noncontact ACL injuries."

Expanding Areas

Recent drug discoveries include bisphosphonates and selective estrogen receptor modulators that inhibit bone loss by mediating bone resorption. Teriparatide, a synthetic human parathyroid hormone, may actually increase bone formation.3 A possible link between osteoporosis and depression is currently making headlines.4 When asked about emerging developments in women's healthcare, our panelists responded:

"Most of the work currently published in physiology textbooks is based on studies of male athletes only," says Lebrun, "The specific focus on how female athletes may differ in their response to training—based on their different hormonal profiles—will be important for women's sports medicine," she adds. Arendt comments: "In the late '70s and early '80s, there was barely a paper that would be accepted if it tried to differentiate between men and women in statistics. Now we actually look for this differentiation to see if it suggests a pattern that might be useful to gain other information that would be helpful in treating male and female injuries and illnesses."

"Another extremely important area," says Lebrun, "will be the development of good treatment strategies for young, premenopausal women with low bone mineral density. Our current pharmacologic choices are mainly for postmenopausal women." Arendt adds, "Enhanced understanding of the importance of establishing bone stock in the developing years is a concern."

Hutchinson hopes to see more research that looks at "why certain young girls are susceptible to female athlete triad syndrome and some are not. [It seems to be] much like alcoholism. Is it purely psychological, or are there neurochemicals that might be targeted as an effective treatment?"

Joy would like to see more long-term epidemiologic studies looking at the relationship between physical activity, physical fitness, and women's health. "A lifetime of physical activity and improved fitness," she says, "decreases the likelihood of developing a number of diseases and conditions like obesity and diabetes, increases longevity, and reduces the overall healthcare burden in our nation. Title IX has done more for women athletes than anything else I can think of."


  1. The National Coalition for Women and Girls in Education: Title IX at 30: report card on gender equity. Washington, DC, June 2021. Available at Accessed March 4, 2021
  2. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine: Preparticipation Physical Evaluation, ed 2. Minneapolis, New York City, McGraw-Hill Inc, 1997
  3. Burcum J: New osteoporosis drug is first to rebuild bones. Minneapolis Star Tribune, February 25, 2021.
  4. Cizza G, Ravn P, Chrousos GR, et al: Depression: a major, unrecognized risk factor for osteoporosis? Trends Endocrinol Metab 2021;12(5):12021-203

Ms Mees is the assistant editor of The Physician and Sportsmedicine.