Women's Health and Sports

by Stephen M. Pribut, DPM and Amelia Perri-Pribut M.B.A., R.N.


Women are constantly on the go both at work and home. Active in Sports at all levels, women now look at exercise as a vital part of life. Through the years many people feel that women's health needs have not been met by the male dominated medical profession. Recently, the medical profession has become less male dominated with more research being undertaken on women's health issues. Articles on a variety of Women's Health issues and Women and Sports Medicine are being published with increasing frequency. Self help books and guides to women's health are readily available. There are many good sources of information on women's health on the Internet.

Musculoskeletal Injuries In Women

While many injuries occur in both women and men, some are more common in one sex or the other. Many of those that occur in both are discussed in detail in other sections of this home page. One of the most readily discerned differences between women and men is a wider pelvis in women. This results in a higher incidence of "knock knees" which may increase the Q (Quadriceps Angle). This can result in patellofemoral pain syndromes.

Hormonal differences are thought to be one of the factors that influence both a possible tendency towards more ligamentous laxity in women and certain injuries. This has not yet been accurately and precisely documented by research. It is clear however that the changes that occur during pregnancy certainly result in many changes in a woman's body, both temporary and longer lasting. Ligamentous laxity certainly increases during pregnancy as the time to parturition comes closer. Feet and ankles swell, more weight is carried in an unusual location and a variety of mechanical structures may be affected. The back is one of those frequently affected parts. Back pain is a commonly occurring problem during pregnancy. A woman with pre-existing scoliosis, will usually have an increase in the curvature occur with each pregnancy.

The shape of a particular woman's foot may not meet the manufacturers concept of the average woman. This may necessitate a switch to a man's shoe for the individual with a wide forefoot. If this results in the heel being too wide, a thicker sock or one with more heel padding might prevent some of the heel instability that can occur. Shoes can also aggravate pre-existing foot problems and create additional problems for those with the tendency for certain problems to occur. High heeled shoes can speed up the process of bunion and hammer toe formation. The abnormal tight shape of the forefoot can also squeeze your toes and cause corns to form and aggravate ingrowing nails. One of the best ways to see how your shoe fits your foot is to draw an outline of your foot on paper and than place your dress shoe over it. You might be surprised to see that there is no room for your last two toes! To get an idea of which way your toes might move over the years you can place short pencils (or link sausages) in the inner and outer border of the shoe. If they point towards each other significantly, your toes may one day do that also.

“...The shape of a particular woman's foot may not meet the manufacturers concept of the average woman. ..”

Stress Incontinence

Urinary stress incontinence occurs frequently in elderly patients. It is also found in younger, active women. Some studies (Nygaard et. al. Obstetrics & Gynecology 1990: 75(5):848-851) have reported up to 47% of active women may experience this problem at some time. Stress incontinence is the leakage of urine during physically stressful activities. These activities may include coughing, lifting, running and even laughing or sneezing.

If you have this a problem it should be mentioned to your internist or gynecologist who can thoroughly evaluate the pelvic muscles, check for bladder infection, check the sacral nerves and evaluate if low estrogen in a peri-menopausal woman is contributing to the symptoms. The primary care physician may also evaluate a variety of other possible causes and, if necessary, refer you to a urogynecologist. Besides muscle weakness and the causes just mentioned other possible contributing factors include pregnancy, vaginal births, neurological dysfunction, obesity and gynecological surgery.

Abnormal functioning of the pelvic support muscles are a frequent cause of this condition. Important structures in this area include the urethral sphincter, pubocervical fascia, and a variety of ligaments and muscles.

For a woman without other significant causative factors "Kegel Exercises" can be helpful. These exercises tone the pubococcygeal muscle and improve the tone of the external urethral musculature. The best way to experience what this exercise should feel like is to stop the flow of urine while urinating. That will contract the muscles that you should be exercising. The muscles around your vagina and anus should be contracted with the feeling that they are being lifted up and in. However, it is recommended that you perform this exercise at other times rather than when voiding to avoid changing your voiding patterns. Patty Kulpa, M.D., writing in the July 1996 Physician and Sports Illustrated, recommends starting with 1 set of 10 contractions performed 3 times a day. Hold each contraction for 5 seconds and then gradually work your way up to holding the contractions for 10 seconds. She recommends increasing the number of sets per day to 20 sets of 10 per day. It is possible that you may find a significant improvement occurring at a level of 5 sets of 10 per day.

Female Athlete Triad

The female athlete triad is a combination of eating disorder with weight loss, amennorrhea and osteoporosis. This triad may result in irreversible bone loss, decreased serum estrogen levels, psychological abnormalities and death. The eating disorder may include moderate restriction of food intake, occasional bingeing and purging (bulimea) to severe food restriction (anorexia nervosa) and regular binging and purging (bulimea nervosa). It has been estimated that female athletes may have an incidence of eating disorders ranging somewhere between 15% and 62%. (Physician and Sports Medicine, Vol24:7, 1996, p. 67-86). Anorexics have a body weight less than 85% of normal. The definition of anorexia nervosa also includes the absence of three or more consecutive menses and a distorted body image. Bulimea nervosa behavior disorder includes bingeing and purging regularly at least twice a week for 3 months or more. Bulemic purging may involve either vomiting or the use of laxatives.

Amennorrhea is the absence of menses. Primary amennorrhea is defined as occurring if a female who has reached the age of 16 has not had the development of menses or a female has not developed menses for two years after the development of secondary sex characteristics. This is often associated with low serum estrogen levels. The low estrogen leads to decreased bone mass and possible increased heart risk. This occurs because of the important role that estrogen plays in maintaining bone mass and in lowering risk of heart disease. Infertility may also be more likely to occur among female athletes with this type of reproductive system dysfunction.

One should always remember that the absence of a period, while implying infertility, does not assure it. When ovulation resumes, it will occur before the first period.

The female athlete may attempt to hide the symptoms of this disorder. Some of the signs include preoccupation with food and weight, worry about becoming overweight, frequent eating alone, trips to the bathroom immediately after and during meals, and feet pointing towards the toilet in a bathroom stall (while silently vomiting). Some of the other signs and symptoms include:

  • Fatigue
  • Anemia
  • Stress Fractures
  • Depression
  • Decreased concentration
  • Constipation
  • Dry Skin
  • Enlargement of Parotid glands
  • Hypothermia or Cold intolerance

Pregnancy and Exercise

Post Menopausal Osteoporosis

Osteoporosis is a problem that usually occurs in postmenopausal women and older individuals in general. It is a primary cause of fractures in the elderly. The mass of the bone decreases, which makes the bones more fragile. Activities which in a normal person would not cause an injury could result in a broken bone in an individual with osteoporosis. Tripping and falling or getting bumped which would not hurt a person without this condition could easily result in injury to a person with severe osteoporosis.

Exercise is often thought to be an aid in the delay of osteoporosis. In some cases however, in the highly motivated elite athlete, over training combined with weight loss may be counter productive and may result in contributing to osteoporosis. In the post menopausal patient with osteoporosis the proper use of medications, such as calcium, vitamin D, estrogens, fluorides, and other new drugs such as alendronate which inhibits bone resorption have led to major research efforts, few answers and much controversy. An article on Alendronate appeared recently in the New England Journal of Medicine. ("Effect of Oral Alendronate on Bone Mineral Density and the Incidence of Fractures in Post Menopausal Women". Liberman et al., New England Journal of Medicine Nov. 30, 1995, Vol 333 #22 p. 1437)

Cortical bone mass appears to peak at about 35 years of age according to the National Institutes of Health Consensus Development Conference Statement of April 2-4, 1984. NIH Statement online .

Peak bone mass occurs earlier for trabecular bone. A variety of factors affect the timing and quality of this peak mass. Sex, race, nutritional status, exercise, and overall health all affect peak mass. Bone mass is about 30 percent higher in men than in women. The bone mass is approximately 10 percent higher in blacks than in whites. Following the attainment of peak bone mass, the mass subsequently declines throughout life. Immediately following menopause the bone mass decreases rapidly for 3 to 7 years.

Bone is a dynamic substance. It is not static as many lay persons think. It changes continuously. Use, disuse, and overuse each affect bone density and mineralization. Osteoclasts are cells that bone. After a fracture or other bone injury they are the cells that are active first. Osteoblasts are the cells that create new bone. In normal bone, there is a close relationship and balance between bone resorption and formation. Mechanical forces, hormones, and other factors that influence local regulatory systems have an impact on bone remodeling.

The NRC reports that studies indicate a daily requirement of about 1,000 mg of calcium for premenopausal and estrogen-treated women. Postmenopausal women who are not treated with estrogen may require about 1,500 mg daily for calcium balance. Therefore, the RDA for calcium has been thought to be too low. The conclusion they reached was that "It seems likely that an increase in calcium intake to 1,000 to 1,500 mg a day beginning well before the menopause will reduce the incidence of osteoporosis in postmenopausal women. Increased calcium intake may prevent age-related bone loss in men as well."

A readily available source of calcium in the U.S. are milk and dairy products. An 8 ounce glass (240 ml) of milk contains 275-300 mg calcium. Skim or low fat milk contains as much calcium as whole milk and would be a superior source since it contains less fat. Calcium supplementation is recommended for those unable to take 1,000 to 1,500 mg calcium by diet.

Vitamin D is vital to permit normal calcium absorption. Sunlight is important to allow natural production of Vitamin D. Supplementation is possible, but Vitamin D is toxic in large amounts.

According to the American College of Sports Medicine Position Statement On Osteoporosis and Exercise (Med. Sci. Sports Exerc, Vol 27:4, pp. i-vii, 1995) there is no evidence that exercise alone or exercise with calcium supplementation can prevent the rapid decrease in bone mass in the immediate post menopausal years. Exercise was still recommended for women in this age group because of the overall benefit of physical activity.

Additional (older material) - by Dr. Pribut

April 1998 Looking For Women's Health Resources On The Net

February 1998 Women's Internet Resources: Osteoporosis

External Links

Links To Cancer Sites

Pregnancy & Babies

(dr.pribut at gmail.com)


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Copyright 2003 - 2011 Stephen M. Pribut