The adolescent female athlete has become a common part of the sports environment at all levels from childhood play to professional adult sports. This article considers various issues common to this athlete to help clinicians care for their patients. Basic sports physiology is reviewed and then specific conditions are considered, including iron deficiency anemia, stress urinary incontinence, breast issues (ie, pain, asymmetry, galactorrhea, injury), the female athlete triad (ie, menstrual dysfunction, abnormal eating patterns, and osteopenia or osteoporosis), and injuries. Clinical conundrums are considered including the difficulty in caring for a dedicated athlete whose intense love of her sport may lead to menstrual and bone loss complications. The knowledgeable clinician in the twenty-first century can be of considerable help to the female athlete who is at and beyond puberty.
The adolescent female athlete has become a common part of the sports environment at all levels from childhood play to professional adult sports. This article reviews basic sports physiology and then considers specific conditions, including iron deficiency anemia (IDA), stress urinary incontinence (SUI), breast issues (ie, pain, asymmetry, galactorrhea, injury), the female athlete triad (ie, menstrual dysfunction, abnormal eating patterns, and osteopenia or osteoporosis), and injuries. Various clinical conundrums are reviewed, including working with an athlete whose intense exercise patterns can lead to menstrual dysfunction and compromise of bone health.
Physiology
The Role of Gender
Children of both genders have basically the same physical condition with respect to such parameters as weight, height, injury risks, motor skills, percent body fat, endurance, strength, and hemoglobin levels. Once the activation of the hypothalamic-pituitary-gonadal axis called puberty occurs, these specific parameters are altered; changes in ability in sports competition are observable. Despite these differences, exercise training results are different for specific athletes depending on intensity of training and genetic traits rather than on gender alone. In the past, the female athlete was limited by inadequate equipment and limited training. As these factors have been corrected, the results in female athlete achievements have exponentially increased as well.
Effect of Puberty
The phenomenal process of puberty affects the female in various ways ( Table 1 ).
| Size of heart, volume of cardiac stroke and size of left ventricle are smaller |
| Lung volume and aerobic capacity are less |
| Hemoglobin levels are reduced |
| Female is smaller and has shoulders that are more narrow and reduced articular surface |
| Female has greater flexibility and increased balance |
For example, the body fat percentage is particularly affected in the female, and the final result is an average body percentage in adult females of 23% to 27% versus a range of 13% to 15% in adult males. As a result of intense and prolonged training, the elite female athlete can lower these levels to 12% to 16% (in distance runners) and 8% to 10% (in sprinters) versus 4% to 8% in highly trained male gymnasts.
The thermoregulatory capacity is similar between genders; having fewer sweat glands in the female is offset by producing less heat because of reduced body mass, reduced muscle bulk, and large body surface area. There is a higher risk for heatstroke in athletes of both genders if they are late maturing, are obese, or are exercising in hot climates. Females tend to have better balancing and flexibility abilities, which initiate in childhood and peak at 14 or 15 years of age; in contrast, males improve in flexibility from midadolescence until the end of puberty.
After puberty, females develop less strength than males, as noted in Table 2 . Although the proportion of muscle fiber type is similar, the muscle fiber size is less in the female. Females develop a small increase in muscle strength after menarche (onset of menstruation), whereas the male continues to increase muscle strength throughout the process of puberty. Trained female athletes can achieve about 70% body strength compared with males of similar training, whereas the upper body strength is 30% to 50% that of males.
| Ages birth to 10 years (before puberty): same strength |
| Ages 11–12 years: female strength is 90% of males of same age |
| Ages 13–14 years: female strength is 85% |
| Ages 15–16 years: female strength is 75% |
In the adolescent male, maximal speed peak occurs before peak height velocity (PHV) whereas power and strength peaks occur after PHV; a similar pattern is not observed in adolescent females, who typically have the most weight gain rate 12 to 14 months after maximum growth velocity in Tanner stage (sexual maturity rating [SMR]) 2 or 3. In the female, there is a small muscle mass increase in contrast to a large increase in body fat. Research notes a heightened response to training (strength and endurance) 12 to 24 months after PHV at an SMR of 4 or 5. Intense weight training in females results in only a small increase in observable muscle and perhaps some measurable strength increase; intensive exercise may lead to less adipose tissue and more muscle definition. The progression of puberty allows males to grow into their chosen sport because they get closer to their physical optimum and thus, potentially reach their optimum sports performance. However, the process of puberty in females impedes their best sports performance by lowering their physical optimum.
Normal weight and height gains from childhood to puberty allow improved performance in various sports (including basketball, volleyball and swimming), depending on genetic potential and training. Females have shorter extremities and a lower center of gravity, which may have a potential competitive advantage in sports that emphasize balancing abilities, such as gymnastics. However, research tends to note that the center of gravity is influenced by the athlete’s specific weight as well as height and not by gender itself.
A delay in puberty can be an advantage for the athletically gifted female, who may be attracted to sports that place a priority on a thin or lean physique, such as synchronized swimming, gymnastics, dance, and figure skating. Society has not encouraged the female adolescent athlete to become involved in American football; she does not face the risks for concussion, brain damage, and spinal injury now faced by males in modern football teams at all levels because of the emphasis on winning.
However, the pressure to win may result in parents and society failing to notice and prevent the sexual advances of a predatory coach or trainer, who may promise to take the female adolescent athlete to high levels of victory.
IDA
IDA ( Table 3 ) is the most common cause of anemia in adolescents and research reports a prevalence of up to 24%, with frank anemia noted in 10% of 14- to 18-year-olds. Iron deficiency (ID) and IDA are seen more commonly in females versus males and a similar prevalence is reported in female athletes versus nonathletes, except for long-distance runners, who have a higher prevalence of IDA. In contrast to males, the adolescent female has 6% reduced red blood cells, reduced (up to 19%) lower hemoglobin levels, lower iron stores, and increased iron levels. Those individuals dedicated to optimum performance in their sports are concerned about IDA, because even mild IDA may result in lowered sports performance.
| Hematocrit | <35%; 12-year-old females |
| <36%; 12–18-year-old females | |
| Hemoglobin | <11.5 g/dL; 12-year-old females |
| <12.0 g/dL; 12–18-year-old females | |
| Serum ferritin | <10 mg/L (normal, 15–200 mg/L) |
| Mean corpuscular volume (MCV) | <76 fl in 12-year-old |
| <78 fl in mid- and older adolescents | |
| Serum iron | <40 mg/dL (normal, 50–140 mg/dL) |
| Serum transferrin saturation (Fe/TIBC ratio) | <16% (normal, 35%–40%) |
| TIBC | 350–500 mg/dL (normal, 250–380 mg/dL) |
| FEP | > or = 150–200 mg/dL RBCs (normal, 54 ± 20) |
Various issues can lead to IDA, including limited oral intake of dietary iron, menstruation, iron loss in sweat and urine resulting from exercise, gastrointestinal bleeding, and intravascular hemolysis, which can be precipitated by exercise. Routine screening for IDA is not recommended for adolescent athletes unless they are at risk because of such issues as heavy menstruation, history of anemia, being a long-distance runner, or having a vegetarian diet.
There are 3 stages of developing IDA: first there is a lowering of iron stores as well as serum ferritin, followed by a lowering of serum iron along with an increase in total iron-binding capacity; the third step is development of microcytic hypochromic anemia. The IDA that occurs is typically mild and basically asymptomatic. Most research concludes that there is no overt impairment of sports performance in those with nonanemic ID (ie, those with normal hemoglobin as well as hematocrit levels and low levels of serum ferritin). However, athletes with low to normal hemoglobin and low ferritin levels may report enhanced sports performance with iron supplementation; more research is needed in this area. Athletes who develop sports anemia or pseudoanemia do not require iron supplementation because this is a normal reaction to intense and prolonged exercise. The plasma volume may expand up to 20%, although iron supplementation is not needed as long as the red blood cell mass remains normal. When the intense exercise is stopped, plasma volume returns to normal pre-exercise levels.
IDA management involves educating the young people about proper nutrition, including foods with iron (such as fortified cereals and breads), fish, meat, and eggs. If iron supplementation is required because of overt ID, elemental iron is prescribed at a dose of 3 to 6 mg/kg/d. This strategy results in an increase in hemoglobin and hematocrit levels typically in 1 to 3 weeks, whereas normal ferritin levels may not develop for several months, indicating the development of normal body iron content.
IDA
IDA ( Table 3 ) is the most common cause of anemia in adolescents and research reports a prevalence of up to 24%, with frank anemia noted in 10% of 14- to 18-year-olds. Iron deficiency (ID) and IDA are seen more commonly in females versus males and a similar prevalence is reported in female athletes versus nonathletes, except for long-distance runners, who have a higher prevalence of IDA. In contrast to males, the adolescent female has 6% reduced red blood cells, reduced (up to 19%) lower hemoglobin levels, lower iron stores, and increased iron levels. Those individuals dedicated to optimum performance in their sports are concerned about IDA, because even mild IDA may result in lowered sports performance.
| Hematocrit | <35%; 12-year-old females |
| <36%; 12–18-year-old females | |
| Hemoglobin | <11.5 g/dL; 12-year-old females |
| <12.0 g/dL; 12–18-year-old females | |
| Serum ferritin | <10 mg/L (normal, 15–200 mg/L) |
| Mean corpuscular volume (MCV) | <76 fl in 12-year-old |
| <78 fl in mid- and older adolescents | |
| Serum iron | <40 mg/dL (normal, 50–140 mg/dL) |
| Serum transferrin saturation (Fe/TIBC ratio) | <16% (normal, 35%–40%) |
| TIBC | 350–500 mg/dL (normal, 250–380 mg/dL) |
| FEP | > or = 150–200 mg/dL RBCs (normal, 54 ± 20) |
Various issues can lead to IDA, including limited oral intake of dietary iron, menstruation, iron loss in sweat and urine resulting from exercise, gastrointestinal bleeding, and intravascular hemolysis, which can be precipitated by exercise. Routine screening for IDA is not recommended for adolescent athletes unless they are at risk because of such issues as heavy menstruation, history of anemia, being a long-distance runner, or having a vegetarian diet.
There are 3 stages of developing IDA: first there is a lowering of iron stores as well as serum ferritin, followed by a lowering of serum iron along with an increase in total iron-binding capacity; the third step is development of microcytic hypochromic anemia. The IDA that occurs is typically mild and basically asymptomatic. Most research concludes that there is no overt impairment of sports performance in those with nonanemic ID (ie, those with normal hemoglobin as well as hematocrit levels and low levels of serum ferritin). However, athletes with low to normal hemoglobin and low ferritin levels may report enhanced sports performance with iron supplementation; more research is needed in this area. Athletes who develop sports anemia or pseudoanemia do not require iron supplementation because this is a normal reaction to intense and prolonged exercise. The plasma volume may expand up to 20%, although iron supplementation is not needed as long as the red blood cell mass remains normal. When the intense exercise is stopped, plasma volume returns to normal pre-exercise levels.
IDA management involves educating the young people about proper nutrition, including foods with iron (such as fortified cereals and breads), fish, meat, and eggs. If iron supplementation is required because of overt ID, elemental iron is prescribed at a dose of 3 to 6 mg/kg/d. This strategy results in an increase in hemoglobin and hematocrit levels typically in 1 to 3 weeks, whereas normal ferritin levels may not develop for several months, indicating the development of normal body iron content.
SUI
SUI, the involuntary loss of urine during exercise, is reported in approximately one-quarter of nulliparous female athletes with a mean age of 20 years. SUI is particularly noted in activities referred to as impact sports such as gymnastics, basketball, jumping, and running (ie, track and field events); less commonly implicated sports include skiing, tennis, skating, and jogging. Risk factors are noted in Table 4 and the basic cause is usually linked to an increase in intra-abdominal pressure caused by exercise that leads to urethral sphincteric unit alterations. A medical history of the female athlete may reveal the presence of SUI, with further identification of known risk factors (see Table 4 ). A general medical examination may be performed, including a pelvic examination to assess for anatomic pelvic floor integrity and dysfunction of the posterior urethrovesical angle.
| ↑ age |
| Female gender |
| Hypoestrogenic amenorrhea |
| Involvement in high-impact sports activity |
| Heavy exertion |
| Parity that is increased |
| Possibly obesity |
Because SUI is normally a self-limiting, benign condition in the adolescent female athlete, basic education about the nature of this condition is usually all that is needed. The athlete can be given information about the need to take enough fluid for the exercise event but not so much as to induce SUI; sanitary napkins placed before exercise are also helpful. If the female feels that more treatment options are needed, a variety of approaches are available, including behavior management, Kegal exercises, pharmacologic management, biofeedback counseling, vaginal cones, and electrical stimulation. Imipramine and pseudoephedrine hydrochloride have been used to prevent or reduce exercise-induced SUI. Phenylpropolamine was withdrawn from the market in the United States because of an increase in reported cerebrovascular accidents in women less than age 50 years. Use of anticholinergic medications is not recommended because they may induce abnormal sweating and overt heat disorders.
Breast issues
Effect of Exercise
Exercise does not alter the breast size by changing muscle tissue, because there is only a small amount of muscle in the areolar area and none in the rest of the breast structure. However, exercise can alter the appearance of breast size by changes in the underlying pectoralis muscle. In addition, intense exercise can reduce mammary adipose tissue, with a resultant smaller breast. The size of the breast is also affected by factors that enlarge or reduce breast size as noted with various dietary regimens. Exercise provides a protective effect with regard to breast cancer in the adult years.
Pain
Exercise-induced breast pain may be a hidden concern of the adolescent female athlete, especially in the individual with large breasts, and may prevent some of these athletes from participating in sports. Breast soreness or tenderness induced by exercise was noted in 31% of female athletes in 1 report, and 52% of the women with breast discomfort also noted exercise-induced injury to breast tissue. Research reveals that breast motion in exercise can be considerable, particularly in gymnastics, soccer, volleyball, basketball, running, and other sports. Excessive breast movement can result in overt strain of the fascial attachments of the underlying pectoralis muscle in addition to intense shoulder pain. Breast discomfort can also be increased from menstrual cycle-induced breast fluid retention, as noted by some individuals during the premenstrual phase of menses and with overt premenstrual syndrome (PMS). Excessive perspiration can cause local excoriation, abscess development, and even intrabreast-fold cellulitis. If the female adolescent presents with breast pain, various underlying causes should be considered, including those already mentioned in addition to overt breast masses, such as a fibroadenoma.
Breast discomfort and pain in female athletes may be reduced or prevented by having the individual wear a properly fitted sports brassiere that allows maximum support to the mammary tissue and minimizes exercise-induced breast movement. A sports brassiere should consist of breathable (ie, minimizing sweating) material that is nonabrasive and is manufactured to have proper cups (soft, firm), few seams, and hooks that are few in number and padded in quality. Selected women may also benefit from brassieres with shoulder straps that are properly padded. A properly fitted sports brassiere lifts and carefully separates the mammary glands in a way that reduces or minimizes overt breast motion. As noted with sports equipment in general, sports bras should be changed often (eg, every 6 months). Guidelines for sports brassieres have been published by researchers and manufacturers.
Asymmetry
Asymmetry of breasts is a common situation in growing adolescent females that resolves over time in most, although visible asymmetry remains in 1 in 4 adult women. Examination should look for other causes, including a breast mass, although asymmetry is usually a normal variant in growth. Injury to the breast may occur without proper protection, and padded brassiere and foam inserts should be used as needed; female swimmers with breast asymmetry can wear a swimming suit with breast supports. The athlete may find help at places that work with or specialize in patients who have had a mastectomy.
Galactorrhea
Females who present with nipple discharge not associated with pregnancy (galactorrhea) need a medical evaluation to look for a variety of causes, such as mental health concerns (eg, anxiety, depression), effect of medications (eg, phenothiazines, oral contraceptives), hypothyroidism, pituitary neoplasms, and hypothalamic injury (eg, infection, surgery). Most cases are idiopathic and management depends on the underlying cause. For example, hypothyroidism can be corrected, neoplasm removed, implicated medication withdrawn, and counseling provided to stop self-manipulation if appropriate.
Menstruation and sports
Menstrual Physiology
Under the influence of an activated hypothalamic-pituitary-ovarian-uterine axis, the adolescent female begins to have menstrual periods that are controlled by changes in pubertal hormones (ie, estrogen and progesterone), resulting in 3 menstrual phases: follicular, ovulatory, and luteal. Estrogen is produced by the ovaries and its increase leads to the follicular menstrual phase, in which there is endometrial growth characterized by endometrial gland growth (number and length) within a compact, proliferative stroma. When ovulation occurs, at some point after menarche, estrogen and progesterone are produced by the corpus luteum, which induces a secretory endometrium because of progesterone effects. The last part of the normal menstrual cycle is the luteal phase, with development of an endometrium with an edematous stroma containing dilated, tortuous glands. If conception does not occur, the corpus luteum becomes atretic, with a resultant precipitous decrease in the pubertal hormones and eventual menstruation.
It may take 1 to several years to proceed from menarche to menstrual periods that are regular, and this complex phenomenon is subject to a wide variety of factors, many of which can be found in the sports-minded female. An adult female (or mature adolescent female) has a menstrual cycle that occurs every 28 days (±7 days); the median blood loss per cycle is 30 mL, with an upper normal limit of 60 to 90 mL of blood.
Irregular (infrequent) menstruation that occur at intervals of more than 45 days is called oligomenorrhea. The absence of menstrual cycles (amenorrhea) can be identified as primary or secondary amenorrhea, in which primary amenorrhea refers to absence of menstrual cycles by age 14 years with no pubertal development (SMR or Tanner stage of 1) or absence of menses by age 16 years without respect to SMR rating. The absence of menses after menarche has occurred for a total of 3 previous periods or for 6 months without any periods after menarche is called secondary amenorrhea. Normal young females may have no menstrual periods for 3 to 6 months during years 1 and 2 after menarche. However, if an adolescent female presents with oligomenorrhea, primary amenorrhea, or secondary amenorrhea, the clinician should launch an investigation into potential causes ( Table 5 ).
| Primary amenorrhea | Physiologic delay |
| Pseudoamenorrhea | |
| Imperforate hymen | |
| Transverse septum | |
| Rare: agenesis of vagina, cervix, uterus | |
| Mayer-Rokitansky-Kuster-Hauser syndrome | |
| Turner syndrome | |
| Chronic illness | |
| Hypothalmic-induced | |
| Such as weight loss, eating disorders, exercise, stress, others | |
| Pituitary disorders | |
| Polycystic ovary syndrome (hyperandrogenemia syndromes) | |
| Thyroid disorders | |
| Others | |
| Secondary amenorrhea | Pregnancy |
| Hypothalamic-induced | |
| Such as weight loss, eating disorders, exercise, stress | |
| Polycystic ovary syndrome (hyperandrogenemia syndromes) | |
| Thyroid disorders | |
| Pituitary disorders (pituitary adenoma) | |
| Chronic illness | |
| Others |
Menstrual Cycles and Athletic Performance
Conflicting research results have been published regarding the effect of menstruation on female athletic performance. One investigation of 86 female soccer players noted athletes reporting more injuries when having premenstrual symptoms than at any other menstrual phase, and anecdotal reports exist of exercise leading to increased menstrual bleeding or dysmenorrheal. However, research tends to note fewer menstrual symptoms (ie, bleeding, pain, premenstrual symptoms) with exercise and no overt menstrual cycle-related differences in lactate levels, exertion efforts, or overall sports performance.
Amenorrhea
Menstrual dysfunction is well known in female athletes and includes oligomenorrhea, amenorrhea (primary or secondary), and luteal phase dysfunction; this includes 10% to 15% of female athletes and two-thirds of elite athletes. A delay of menarche can be seen at a level of 5 months for each year of intense training before the onset of puberty; if the athlete lowers her level of exercise training, menarche or return of menstrual cycles usually results. Secondary amenorrhea is commonly seen in females engaging in such sports as distance running, ballet, gymnastics, and cycling. Menstrual dysfunction is reported in 12% of swimmers as well as cyclists, up to 20% in females reporting vigorous exercise, 44% of ballet dancers, 50% of female triathletes, and 51% of endurance runners.
Multiple issues underpin athletic amenorrhea, including genetics, percent body fat, intensity of exercise, age, weight, nutritional deficits, and stress. The type of sport chosen can influence menstrual dysfunction as well. For example, dance and gymnastics support or encourage a female athlete with a thin body habitus. However, specific weight alone does not lead to absence of menstruation because those with the same weight can be amenorrheic or have a normal menstrual pattern. Specific body fat is not the sole factor and earlier research suggesting that menstruation does not occur in females with body fat less than 17% has not been verified by research. The precise role of leptin in this complex process of menstruation is not clear.
A wide variety of causes must be considered when a clinician evaluates an adolescent female with amenorrhea or other menstrual dysfunction. Often, amenorrhea in such athletes is classified as hypothalamic amenorrhea, with gonadotropin-releasing hormone and luteinizing hormone pulsivity abnormality. One theory suggests that menstrual dysfunction in athletes results from an energy drain because of the intense exercise level associated with a caloric intake that is not sufficient to maintain normal menstruation. Such an energy drain can be compounded by other issues, such as having a previous history for menstrual problems, positive family history for menstrual dysfunction, and chronic illness. Thus, any athlete with abnormal menses (ie, oligomenorrhea or amenorrhea) should receive a comprehensive evaluation. The evaluation should investigate such positive findings as congenital anomalies, short stature, galactorrhea, virilization, hypoestrogenemia, and other endocrine findings or disorders (see Table 5 ). Some suggested laboratory testing is listed in Table 6 .
| Pregnancy test |
| Thyroid hormone levels |
| Bone age |
| Antiovarian antibodies |
| Chromosome evaluation |
| Head CT/MRI |
| LH and FSH: ↓ in ovarian failure/dysgenesis; normal or ↑ in others |
| Pelvic/abdominal MRI |
| Pelvic ultrasound to define anatomy |
| Prolactin levels |
| Renal ultrasound/IVP |
| Vaginal smear to evaluate for epithelial cell estrogenization virilization/hirsutism: DHEAS, LH/FSH ratio (normal <2.5:1), testosterone (total and free) |
The specific causes of amenorrhea in an adolescent female determine precise management plans; if the menstrual dysfunction is related to her intense exercise patterns, advice should be given to decrease exercise intensity and increase nutritional intake along with providing calcium supplements (see later discussion). Improvement in the amenorrhea or oligomenorrhea will occur if this advice is followed and if there are no other underlying causes.
However, the experienced clinician quickly learns that many if not most committed athletes do not want to reduce their exercise intensity for fear of decreasing their sports performance. They often continue in this sports pattern even when informed that their menstrual problems may be related to a pattern of chronic hypoestrogenemia that may lead to reduced bone mineral density (BMD), osteopenia, and eventual osteoporosis (see later discussion). The research in this area is complex and more is needed. However, studies in recent decades note that females with chronic amenorrhea and low BMD may never acquire healthy BMD, even if the menstrual pattern eventually becomes normal. Some female dancers and other athletes who have delayed menstruation progress into a state of low BMD and have an increased risk for stress fractures that can limit their sports performance.
Experts generally recommend daily supplementation with calcium (1200–1500 mg) and vitamin D (400–800 IU) for the adolescent athlete with menstrual abnormalities or overt eating pattern dysfunction. The literature remains conflicted about the use of estrogen supplementation (ie, conjugated estrogen or oral contraceptives) for those with exercise-induced low BMD in attempts to prevent lowering of the BMD. If the athlete has low BMD, estrogen supplementation (oral contraceptive or conjugated estrogen) may help in some cases to preserve some bone loss.
One well-known approach is to avoid prescribing such hormonal treatments for amenorrheic athletes who are within 3 years of menarche, and clinicians should emphasize the need to lower the intensity of exercise workouts and the need for improved nutritional intake along with calcium supplementation. Oral contraceptives are suggested if the athlete is 3 years after menarche, is more than 16 years of age, and is amenorrheic; earlier hormonal intervention is acceptable with a history of stress fracture.
Clinical judgment is needed because there is no clear research-supported consensus on managing these young people and there is no proven benefit to providing such hormonal intervention to improve or preserve BMD with or without weight gain. Use of combined oral contraceptives (COCs) does not correct the underlying physiologic dysfunction of this abnormal menstrual pattern and the amenorrhea or oligomenorrhea typically resumes once the COC is withdrawn. Side effects of the oral contraceptive can be distressing to some females; these include breast congestion, headache, and nausea. Even with the past few decades of research and observation, it is not clear what the acute and long-term implications are for the female adolescent athlete with chronic amenorrhea and potential estrogen deficiency.
Adolescents who are thin and inactive tend to have the lowest BMD. Also complicating this picture is that intense exercise with weight bearing may neutralize the low BMD effect of having a thin body habitus because of enhanced bone accretion. Thus, athletes in some sports (ie, tennis players, ice skaters, runners, gymnasts) who are amenorrheic may still have normal or even increased bone density because of exercise-induced high mechanical forces. Some research has observed an enhanced bone density effect in some athletes if they are taking oral contraceptives; however, osteoporosis may not be prevented if the pill has less than 50 μg of ethinyl estradiol. COCs more than 50 μg are not recommended for adolescent females because of the increased risks for adverse effects. Complicating this picture is the observation that the female acquires an increased risk for osteoporosis if she never acquires normal BMD. More research is needed in this arena.
Oral Contraceptives and Athletic Performance
There is no evidence from research studies that athletic performance is reduced for females taking oral contraceptives. COCs can provide a positive influence because of their beneficial effect on improving dysfunctional uterine bleeding (DUB), anemia related to DUB, dysmenorrhea, PMS, absence of pregnancy, possibly reduced injury risk in those with dysmenorrheal or PMS, possibly reduced bone mineral loss (see earlier discussion), and possibly less risk for stress fractures.
Manipulation of COCs can be used to the athlete’s advantage by allowing few menstrual cycles when she stays on active hormone pills for longer than usual. For example, she can remain on a 21-day pack or not take the inactive pill that is part of the 28-day pack to prolong the interval between menstrual periods and thus avoid menstruation during an important sports event. Monophasic pills are less confusing to the female athlete than triphasic pills and provide more consistent hormone blood levels. However, concerns about potential adverse effects of COCs may prevent some athletes from going on or staying on these pills. Also, pharmaceutical companies have now produced continuous pills to allow reduced menses. For example, current extended cycle hormonal contraceptive pills in the US market include Seasonale, Quasense, and Seasonique, which allow a menstrual period once every 3 months. Lybrel is an extended cycle hormonal formulation that is taken every day and prevents any menstrual period.
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