MANAGING THE FEMALE RUNNERDR DANIELLE HOPE

MBBS BMedSci IOCDipSpPhys

DISCLOSURES▪ none

CONTENT

▪ RED-S/FAT

▪ Running and pregnancy

▪ Sports bras and support

▪ Pelvic floor - Stress incontinence

▪ Running and the menstrual cycle

▪ MSK issues in female runners

▪ safety

WHAT IS LOW ENERGY AVAILABILITY?

▪ Energy availability: the energy available for normal physiological function after exercise

▪ The threshold at which detrimental physiological function occurs is 30kcal/kg FFM/day

▪ 45kcal/kg FFM/day maintains physiologic function

Energy Availability (EA) = Energy Intake (EI) - Exercise Energy Expenditure (EEE)(Kcal/Kg FFM/day) (kcal/day) (kcal/day)

CAUSES OF LOW ENERGY AVAILABILITY

▪ Inadequate energy intake

▪ Dieting behaviours/intentional weight loss

▪ Dietary inadequacies: vegetarian/vegan etc

▪ Clinical eating disorder

▪ Thin build sports: ED 31% vs control population 5% (1)

▪ Endurance/ aesthetic/weight class sports: ED 25% vs control population 9% (2)

▪ Increased exercise energy expenditure (inadvertent undereating)

▪ Combination of both

▪ no strong biological imperative to match energy intake to activity induced energy expenditure (3)

1. Burne S, J Sci MedSport 20022. Sundgot-Borgen J, Clin J Sport Med 2004 3. Truswell A World Rev. Nutr, Diet 2001

HEALTH CONSEQUENCES OF RED-SMountjoy M, Sundot-Borgen J, Burke L, et al; BJSM 2014

LOW EA CAN BE PRESENT EVEN WITH STABLE BODY WEIGHT

▪ When there is a calorie deficit the brain and body try to help re-establish energy balance by decreasing RMR.

▪ So, body weight can be stable – but at a cost to health

MENSTRUAL DYSFUNCTION

▪ Menstrual dysfunction may be the first detectable problem

▪ Not having menstrual cycles is NOT NORMAL

▪ Needs evaluation

NORMAL MENSTRUAL CYCLE

Image: medscape

MENSTRUAL DYSFUNCTION

▪ Low EA →physiological and neuroendocrine responses → inhibit hypothalamic GnRH pulses

▪ LH pulsatility is disrupted within 5 days when the EA is reduced by to <30kal/kg FFM/day (1)

→ no menses

▪ Subclinical menstrual disorders

▪ Luteal phase defect

▪ Anovulatory cycles

Image: adapted from medscape

x

x x

x

1. Loucks AB, J Clin Endocrinol Metab 2003

↓leptin; insulin; GH; IGF1; T3; glucose ↑cortisol

MENSTRUAL DYSFUNCTION

▪ Eumenorroea – regular menstrual cycles 28days (SD 7d)

▪ Oligomenorrhoea – menstrual cycles at intervals >35 days

▪ Primary amenorrhoea – delay of menarche >15yo

▪ amenorrhoea – absence of menses for >3mo

▪ Luteal suppression –luteal phase <11days in length or with a low concentration of progesterone

▪ Anovulation – a menstrual cycle without ovulation

PREVALENCE OF AMENORRHEA

▪ Secondary amenorrhoea (1)

▪ 69% Dancers

▪ 65% long distance runners

▪ 2-5% General population

▪ Distance runners

▪ Prevalence of amenorrhoea increased as training distance increased (2)

▪ 3% with <13km/week

▪ 60% with >113/week

▪ Luteal deficiency or anovulation seen in 1/3 cycles in 78% of eumenorrhoeic runners (3)

1. De Souza MJ, BJSM 20142. Sanborn CF, Am J Obstet Gynecol 19823. De Souza MJ, J Clin Endocrinol Metab 1998

BONE HEALTH AND EA

▪ Low EA results in low oestrogen which results in increased bone resorption

▪ Low EA results in changes that result in decreased bone formation (1)

▪ ↓leptin; insulin; GH; IGF1; T3; glucose

▪ ↑cortisol

▪ Low EA negates the positive effect of exercise on bone

1. Ackerman K and Misra M. 2015.

BONE HEALTH CONSEQUENCES

▪ Peak bone mass is achieved between 18-25yrs

▪ After age 25yrs women lose bone mass at 0.3-0.5% annually

▪ RED-S adolescent may be losing when they should be gaining

▪ Loss of BMD may not be reversible

▪ Osteoporosis due to suboptimal peak bone mass rather than accelerated bone loss

▪ Relative risk of stress fracture is 2-4x greater in amenorrhoic atheltes (1)

Janz K Kinesiology Review 2015,4, 63-70

1. Bennell K et al. Sports Med 1999

,

BEST TYPE OF EXERCISE TO STIMULATE BONE

▪ For osteogenic potential

▪ High impact: ground reaction force

▪ Multidirectional force

▪ Irregular load

▪ Rapid peak force

▪ Changes are site specific

▪ Running is predominantly vertical and acceleration/deceleration.

▪ Soccer players >BMD than runners (1)

▪ Gymnasts have higher BMD than runners (2)

1. Fredericson, M et al. BJSM 20172. Robinson T et al. J Bone Miner Res. 1995

NUTRITION AND BONE HEALTH

CALCIUM

▪ RDI 1000-1300mg/day

▪ Dietary calcium more effective than supplements (bioavailability) (2)

▪ Young female cross country runners <800mg/day vs >1500mg/day calcium had 6x stress fracture rate (3)

VITAMIN D

▪ Recommend athletes blood levels >75nmol/L

▪ Recommend intake 600-800IU/day from food

▪ Role in regulating calcium absorption in gut and facilitates bone mineralisation

▪ Other benefits: immune function, muscle strength, CV health

▪ Longitudinal study adolescent females adequate vit D intake associated with ↓risk stress fracture (1)

1. Sonneville. Arch ped adoles Med 20122. Napoli N et al. Am J Clin Nutr 20073. Nieves JW et al PM R 2010

IRON

▪ Iron deficiency is common in female runners

▪ Combination of causes▪ Menstrual losses

▪ Heel strike, GI loss during exercise

▪ Inadequate intake

▪ Absorption issues (coeliac)

▪ NSAIDS

▪ RDI: premenopausal 18mg/day; postmenopausal 8mg/day (1)

▪ Supplement if Ferritin <30µg/L (AIS)

▪ Sources: Meat, fish, poultry, wholegrain cereals and iron-enriched cereals

▪ Absorption - Enhanced by Vit C Inhibited: Tea, Calcium

1 NRV.gov.au

PERFORMANCE CONSEQUENCES OF RED-SMountjoy M, Sundot-Borgen J, Burke L, et al; BJSM 2014

RED-S SCREENING AND DIAGNOSIS

▪ During PPE or routine reviews

▪ Following injury or consequence of RED-S (amenorrhoea, stress #, performance decline, GI …)

▪ Menstrual History

▪ Training history

▪ Nutritional assessment

▪ Recent weight loss/ attitudes to weight

▪ Injury history – stress fractures, recurrent illness and recovery

▪ medications

▪ Stressors

High Index of Suspicion

INVESTIGATIONS

▪ Labs ▪ Other causes of amenorrhoea, fatigue or other presenting issue

▪ Consequences of poor nutrition

▪ Hormones – assessment of FHA

▪ Imaging +/-▪ Of injuries as appropriate

▪ Pelvic US

▪ MRI head if abnormal prolactin

▪ DEXA scan▪ If amenorrhoeic for >6mo

▪ ED

▪ +/- History of stress fracture

▪ ECG – if anorexia, resting HR <50

There is no one diagnostic test

TREATMENT

athlete

LMO/ Sports physician/

endocrinologist

psychologist

psychiatrist

Dietitian

Family

coach

Multidisciplinary approach

TREATMENT – RED-S

▪ Treat acute orthopaedic or medical issues

▪ Education +++

▪ Counselling, therapy

▪ Restore energy deficit

▪ Maintaining energy balance

▪ OCP are no longer recommended

▪ Bisphosphonates are not advised for young women

▪ Antidepressants for bulimia, anorexia, depression and anxiety disorders

▪ For milder cases/inadvertent

▪ Continue to play whilst treatment and monitoring

▪ Eg 10% decrease in exercise load (duration or intensity)

▪ Addition of 1-2 rest days

▪ Addition of nutritional supplement and optimise spacing of nutritional intake

▪ Difficult/severe cases

▪ Cease exercise/sport

▪ Use of contract with specific goals

▪ Eg resumption of PA when reaches within 10% of ideal BW

RUNNING AND PREGNANCY

RANZCOG 2016:

1. “Women without contraindications should participate in regular aerobic and strength conditioning exercise during pregnancy

2. Women should be advised that there is no evidence that regular exercise during an uncomplicated pregnancy is detrimental to the woman or the foetus

3. Assessment of medical and obstetric risks should be undertaken to identify potential contraindications to exercise for the pregnant woman prior to commencing an exercise program

4. Exercise prescription for the pregnant woman should consider her baseline level of fitness and previous exercise experience

5. Exercise prescription for the pregnant woman should take into account the physiological adaptations to pregnancy”

NATIONAL PHYSICAL ACTIVITY GUIDELINESAGE 18-64

APPROACH TO THE UNCOMPLICATED PREGNANT RUNNER

▪ Exercise guidelines are adequate for health and well-being benefits

▪ Avoid overheating – especially in first trimester

▪ Ensure nutrition and hydration

▪ Ensure adequate warm up and cool down

▪ Add pelvic floor exercises as prevention.

▪ KNOW WHEN TO STOP

▪ Care with weight bearing exercise as weight increases

▪ Care with rapid change of direction or activities requiring balance (weight distribution)

▪ Care with rapid postural changes

▪ Avoid supine exercises after 1st trimester

▪ Avoid walking lunges as strain on pelvic connective tissues

▪ Care with jumping, bouncing and straining – weak pelvic floor

Warning signs to terminate exercise when pregnant▪ abdominal pain

▪ amniotic fluid leakage

▪ calf pain or swelling (? DVT)

▪ chest pain/tightness/palpitations

▪ decreased facial movement

▪ dizziness or presyncope

▪ dyspnoea before exertion

▪ excessive fatigue

▪ excessive shortness of breath

▪ muscle weakness

▪ pelvic pain

▪ preterm labour

▪ severe headaches

▪ uterine contractions (premature and/or painful)

▪ Vaginal bleeding

▪ Duration

▪ Health benefits within the guidelines

▪ risk of longer duration is thermoregulation and depleting nutritional supply.

▪ RANZCOG suggest beyond 60min should be light intensity

▪ No upper limit has been defined in research

▪ Intensity

▪ Talk test

▪ BORG Scale

▪ HR

▪ safe upper limit is not known.

▪ Type of exercise – running is generally ok

▪ Strength – light-moderate resistance. Avoid maximal lifts, Valsalva.

▪ Flexibility – maintain flexibility but care due to increased relaxin

Borg Scale of Perceived Exertion (1)

1. Borg GA Med Sci Sports Exerc 1982

RUNNING AND BREAST PAIN/SUPPORT

▪ Breast discomfort is common in women who run

▪ 2012 London Marathon survey (n=1285 surveys completed)

▪ 32% experience pain and most common exacerbator reported was exercise

▪ 17% reported affect on exercise behaviours

▪ 44% did not seek Rx; 15% use medications

▪ Significant relationship to cup size

▪ Greater pain during vigorous activity

Brown,N et al. BJSM 2012

RUNNING AND BREAST PAIN/SUPPORT

▪ Higher incidence of breast pain with running compared with walking (1)

▪ A well fitting bra can decrease mastalgia in about 85% patients (2)

▪ Supportive bra can decrease breast kinematics and decrease pain during treadmill running (3)

▪ Australian survey 41% wear encapsulating sports bra for sport (4)

▪ Perceptual rating of bra fit and comfort were stronger and more reliable predictors of breast pain than breast displacement (B/C cup)(5)

Dr Deirdre McGhee-choosing a sports bra: www.bra.edu.au

1. Haake S, Sports Eng 20112. Hadi MSA.Breast J 20003. White J et al. J Sports Sci. 2015

4. Bowles K BJSM 20085. Nolte K, et al. J Sports Med Phys Fitness 2016

URINARY INCONTINENCE• Risk Factors

• Pregnancy• Vaginal childbirth• Older age• Obesity• Gynaecologic surgery

• Other Factors• Threshold concept – increased abdominal pressure• Strenuous work• Coughing, sneezing• Weightlifting, running, jumping

• Common in nulliparous, highly trained college athletes (1)• 1/3 of track athletes• >1/2 of gymnasts, tennis, basketball

1. Nygaard MD et al Obsts Gynecol 1994

URINARY INCONTINENCE

▪ Management

▪ Maximize toileting habits – scheduled voiding and avoiding constipation

▪ Pelvic floor muscle training

▪ Use of protective pads

▪ Bladder retraining

▪ medications

▪ Surgical correction if indicated

EXERCISE AND THE MENSTRUAL CYCLE -1

▪ 41.7% of exercising women believe their menstrual cycle has a negative impact on exercise training and performance. 1

▪ Symptoms are difficult to quantify (bloating, fatigue, lethargy, irritability)

▪ Limited evidence – individual variation.

▪ Theoretical effects due to hormone effects on physiologic systems - cardiovascular, respiratory, thermoregulatory, metabolism.

Health

▪ No contraindication to participation at any stage

▪ May help with PMS symptoms

▪ no cases of hyperthermia attributed to elevated temperature seen during menstrual cycle

1. Bruinvels G, PLoS ONE 2016

EXERCISE AND THE MENSTRUAL CYCLE -2

Performance

▪ Winning performances documented in all phases of cycle

▪ Majority of reports show no change in cycle for

▪ VO2max (1),

▪ Lactate and ventilatory thresholds (1)

▪ flexibility (2)

▪ Metabolic changes – oestrogen and progesterone can affect CHO, fat and protein metabolism.

▪ Oestrogen predominant in LP means greater CHO availability - may make it better time for endurance)

▪ higher progesterone in FP may increase protein catabolism (?increase dietary intake) (1)

1. Oosthuyse T Sports Med 20102. Luis Da Silva Teixeira et al Rev Bras Med Esporte 2012

MSK ISSUES FOR FEMALE RUNNERS

▪ Patellofemoral pain syndrome

▪ Iliotibial band friction syndrome

▪ stress fractures

RUNNING SAFETY

▪ Run during daylight

▪ Run with a buddy or with a running group

▪ Tell someone where you are going and when to expect you back

▪ Consider a personal alarm

▪ Be aware of surroundings (music on headphones)

▪ Avoid being predictable – change the route

▪ Use reflectors if near cars

▪ Wear an ID bracelet

▪ Take mobile

REFERENCES -1

▪ Mountjoy M, Sundgot-Borgen J, Burke L, et al. Br J Sports Med 2014;48:491–497.

▪ De Souza MJ, Nattiv A, Joy E, et al 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held inIndianapolis, Indiana, May 2013 Br J Sports Med 2014;48:289.

▪ Byrne S, McLEan N. Elite athletes: effects of the pressure to be thin. J Sci med Sport 2002 Jun;5(2):80-94.

▪ Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med 2004 Jan;14(1):25-32.

▪ Truswell A. S. Energy balance, food and exercise World Rev. Nutr. Diet 90:13-25, 2001.

▪ Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sports Med 1999 Aug;28(2):91-122

▪ LOUCKS, A. B., and J. R. THUMA. Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women. J. Clin. Endocrinol. Metab. 88:297–311, 2003.

▪ Sanborn CF et al, Is athletic amenorrhea specific to runners? Am J Obstet Gynecol. 1982 Aug 15;143(8):859-61.

▪ De Souza MJ, et al, High frequency of luteal phase deficiency and anovulation in recreational women runners: blunted elevation in follicle-stimulating hormone observed during luteal-follicular transition. J Clin Endocrinol Metab. 1998 Dec;83(12):4220-32.

▪ Ackerman K and Misra M. “Neuroendocrine Abnormalities in Female Athletes” in The Female Athlete Triad- A Clinical Guide, 2015.

REFERENCES – 2

▪ Janz, Kathleen & Francis, Shelby. (2015). Childhood Physical Activity May or May Not Provide Sustained Effects to Protect Adults From Osteoporosis. Kinesiology Review. 4. 63-70. 10.1123/kr.2014-0081.

▪ Kanis, JA, on behalf of the World Health Organization Scientific Group (2007). Assessment of osteoporosis at the primary health-care level. Technical Report. World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK. 2007: Printed by the University of Sheffield. http://www.shef.ac.uk/FRAX/pdfs/WHO_Technical_Report.pdf

▪ Hui SL et al, Baseline measurement of bone mass predicts fracture in white women. Ann Intern Med. 1989 Sep 1;111(5):355-61.

▪ The International Society for Densitometry. 2013 ISCD Official Positions – Adult. Middletown, CT: The International Society for Densitometry, 2013

▪ Fredericson, Michael et al. “Regional Bone Mineral Density in Male Athletes: A Comparison of Soccer Players, Runners and Controls.” British Journal of Sports Medicine 41.10 (2007): 664–668. PMC. Web. 4 July 2018.

▪ Robinson TL, Snow-Harter C, Taaffe DR, Gillis D, Shaw J, Marcus R. J Bone Miner Res. 1995 Jan; 10(1):26-35.

▪ Sonneville KR, Gordon CM, Kocher MS, Pierce LM, Ramappa A, Field AE. Vitamin D, Calcium, and Dairy Intakes and Stress Fractures Among Female Adolescents. Archives of pediatrics & adolescent medicine. 2012;166(7):595-600.

▪ Napoli N et al. Effects of dietary calcium compared with calcium supplements on oestrogen metabolism and bone mineral density. Am J Clin Nutr. 2007 May; 85(5): 1428-33.

▪ Nieves JW et al Nutritional factors that influence change in bone density and stress fracture risk among female cross-country runners. 2010 Aug;2(8):740-50

▪ Brown N, White J, Brasher A, et al. The experience of breast pain (mastalgia) in female runners of the 2012 London Marathon and its effect on exercise behaviour Br J Sports Med 2014;48:320–325

▪ https://www.nrv.gov.au/nutrients/iron

REFERENCES – 3

▪ Haake S, Scurr J. A method to estimate strain in the breast during exercise. Sports Eng 2011;14:49–56.

▪ Hadi MSA. Sports brassiere: is it a solution for mastalgia? Breast J 2000;6:407–9.

▪ White J et al. J Sports Sci. The effect of breast support and breast pain on upper-extremity kinematics during running: implications for females with large breasts. 2015;33(19):2043-50.

▪ Bowles K and Steele R. What are the breast support choices of Australian women during physical activity? Br J Sports Med 2008;42:670–673

▪ Nolte K, et al. J Sports Med Phys Fitness. The effectiveness of a range of sports ras in reducing breast displacement during treadmill running and two step star jumping. 2016 Nov;56(11):1311-1317.

▪ Bruinvels G, Burden R, Brown N, et al. The prevalence and impact of heavy menstrual bleeding (menorrhagia) in elite and non-elite athletes. PLoS ONE 2016;11: e0149881.

▪ Oosthuyse T, Bosch AN. The effect of the menstrual cycle on exercise metabolism: implications for exercise performance in eumenorrhoeic women. Sports Med 2010;40:207–27.

▪ Luis Da Silva Teixeira et al Influence of different phases of menstrual cycle on flexibility of young women. Rev Bras Med Esporte – Vol. 18, No 6 – Nov/Dec 2012

▪ Nygaard MD et al. Urinary Incontinence in Elite Nulliparous Athletes. Obstet Gynecol 1994; 84:183-7.

▪ RANZCOG statement. Exercise in Pregnancy. Endorsed March 2016

▪ National Physical Activity Guidelines for Adults 18-64. Department of Health, Australian Government

▪ Borg, G.A., Psychophysical bases of perceived exertion. Med Sci Sports Exerc, 1982. 14(5): p. 377-81.