Managing the Special Health Concerns of Women Athletes

For the past three decades, girls and women have been competing in athletics like never before. The executive summary on the US Secretary of Education's Commission on Opportunity in Athletics contains this fact: "In 1971, 294,015 girls participated in high school athletics. Today over 2.7 million participate in high school athletics. This represents an 847% increase." At the 2000 Summer Olympics, women accounted for more than half the US team.

This surge in competitive female sports has rewarded women with significant health benefits, says Anne Zeni Hoch, DO, Associate Professor of Orthopaedic Surgery at the Medical College of Wisconsin and Director of the Women's Sports Medicine Program - one of only three such programs in the United States.

"Research has shown that women under 45 years of age who exercise aerobically at least four hours a week have a 37% reduction in breast cancer risk," she says. "Exercise has been shown to increase bone mineral density, which may help prevent osteoporosis and fractures." She also cites studies that show that high school girls involved in sports are less inclined to be involved in high-risk behaviors.

But women's involvement in competitive sports does carry special health concerns. Women athletes are four to six times more likely to injure the anterior cruciate ligament (ACL) of the knee than men, especially women who play soccer and basketball. Stress fractures of the pelvis, hip, leg and foot are more common among women. Women athletes can also experience more leg and knee pain, stress incontinence and iron deficiency than men, Dr. Hoch says.

Female Athlete Triad Poses Serious Health Risks
Of greater concern is the number of competitive female athletes who experience the Female Athlete Triad - an interrelated condition of disordered eating, amenorrhea (absence of menstrual periods) and osteoporosis (decreased bone density).

The American College of Sports Medicine (ACSM) first published a Position Stand on the Triad in 1997, the same year Dr. Hoch joined the Medical College faculty. Two years later, she began the Women's Sports Medicine Program as part of the Department of Orthopedic Surgery. Since then, her practice and research have focused on acute sports injuries with an emphasis on the female athlete.

At the 2003 ACSM Annual Meeting in San Francisco, Dr. Hoch - recognized as one of the nation's foremost researchers on the Triad - presented study results that found female athletes who do not consume enough nutrients to fuel their active bodies show signs of early heart disease, in addition to amenorrhea and brittle bones. Their arteries do not dilate as they should for normal circulation.

For her study, Dr. Hoch examined 18 varsity athletes from Marquette University and the University of Wisconsin-Milwaukee, whose age averaged 23, and who ran a minimum of 20 miles per week. Nine of the women had had no menstrual periods for 2½ years, on average; the other nine had no menstrual or bone problems, and were used as a control group.

"The Female Athlete Triad should actually be called the Female Athlete Tetrad," she says, to reflect that it's actually a collection of four health conditions, now that early heart disease has been found in young women who combine poor nutrition and extreme exercise.

Dr. Hoch, an athlete herself, runs four or five times a week. She also serves as the team physician for Mount Mary College, Divine Savior Holy Angels High School in Milwaukee, and the US Junior National Speed Skating Team, which trains at the Pettit National Ice Center in Milwaukee. She is a consulting physician for the Milwaukee Ballet.

Creating Awareness of Health Risks
Dr. Hoch considers it part of her mission to educate young women, their parents and coaches - as well as her fellow physicians - about the risks facing young women athletes who don't fuel their bodies enough to support their physical activity.

"Parents, coaches and trainers should be suspicious if they notice a significant weight loss, because it could indicate an eating disorder," Dr. Hoch says. Adolescent girls and young women often believe thinness and a low body weight are desirable. Those who participate in sports may believe leanness helps them excel. Sometimes, this obsession with body image can lead to excessive physical activity and serious eating disorders like anorexia nervosa or bulimia.

Because eating disorders are so prevalent among girls and young women and dangerous to their health, Dr. Hoch says that whenever an active young woman is seen by her primary care physician, the doctor should ask the patient whether she is happy with her weight and whether her menstrual periods are normal.

Holistic Approach to Health
At the Women's Sports Medicine Program, women of all ages and girls 8 years and older comprise about 80% of her practice. Many of her male patients are family members of those female patients. And not all of her patients are young. "If they have an orthopedic problem, I see them, regardless of age."

"Here we take a holistic approach to make sure women get the total care they need," Dr. Hoch says. "Not only do I examine them, they also meet with the nurse educator. Every girl and woman who comes into the clinic receives a folder filled with information about the issues that are unique to the female athlete." They also have access to physical therapy, metabolic testing, a sports dietitian and a sports psychologist.

Treating Triad Patients
For patients with amenorrhea, reduced bone density and signs of early heart disease, Dr. Hoch may prescribe dietary intervention to help them return to health.

"Heart problems can be reversed with a sound diet, but bone loss can't," Dr. Hoch says. In addition, her research found that when these patients were back to a healthy weight, their sports performance also improved. Those competing in 5K races shortened their times by an average of 45 seconds. "Our whole philosophy is that exercise and participation in sports are good for girls if they fuel their bodies appropriately."

In addition to the health benefits of sports, Dr. Hoch often cites research showing that women who play sports have higher self-esteem and less depression than non-athletes. Sports participation also gives girls and young women values that carry over into the competitive workplace.

Dr. Hoch and others who are advocates of women's sports credit the passage by Congress in 1972 of Title IX of the Education Amendments Act with promoting the great upsurge in women's athletics. (Title IX prohibits sex discrimination in educational institutions that receive federal financial assistance.)

Since early 2005, however, she and others have been alarmed by efforts to weaken the criteria used to determine compliance with the rule that all schools receiving public funds provide equal sports opportunities for men and women. Dr. Hoch and women athletes across the country are cautiously watching what will become of Title IX - and the future of women's sports.

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.