Sports gynaecology

Exercise is very important for health; it plays a key role in weight, blood pressure control & bone health. It also prevents many diseases and promotes mental health. Record numbers of women are now active in sport.

Sports gynaecology

However, exercising extensively or to an elite level has several negative health implications, many of which are gynaecological. Intense exercise impacts women’s health. Conversely, the menstrual cycle can affect performance. Peak sports performance & peak health are not necessarily both achievable.

Relative energy deficiency

Balance is achieved when energy intake equals energy use, with maintenance of normal bodily functions. When more energy is used than taken in there is low energy availability. This can affect metabolism & cardiovascular health, bone health, menstrual health & fertility, immunity and psychological well being. This energy deficiency & subsequent problems is recognised as a problem in sports & exercise. Disordered eating is more common in women in sports.

Problems with periods

A part of the brain called the hypothalamus is affected in intense exercise & diet control, leading to a reduction in hormone release from a gland called the pituitary gland which affects ovarian hormone release. This can cause infrequent or absent periods. If this is sustained it should be checked out. In childhood, this reduction in hormone release also causes delayed puberty/periods (menarche) in childhood eg. by several years. If puberty is delayed, it also needs to be checked out.

Subfertility

Peak sports performance corresponds with peak fertility. The reduced hormone release noted above also causes lack of ovulation as well as fewer/no periods and hence sub fertility occurs. Fertility can be deferred as a consequence of this, or because it is not “the time” for pregnancy. Eggs can be frozen for a later time if needed, and fertility treatments can be used to cause ovulation if pregnancy is desired while exercising.

Bone health

Long-term reduced energy & reduced female hormones can cause osteoporosis (bone loss). This can be irreversible in teenagers. It’s important for younger women to protect their bone health by avoiding overtraining or under-eating. Bone scans are useful & sportswomen should have higher bone mass than average.

Bladder issues

Leakage is higher in female sportswomen. This affects performance & quality of life. Strain & pressure with decreased hormone levels & increased stress account for this problem.

Assessment

• Medical history & examination
• Food & exercise diaries
• Menstrual diary
• Hormonal profiling including HCG
• Pelvic ultrasound

Treatment

• Increase energy intake + dietician input. Involve coaches etc.
• Performance may improve when energy deficiency is addressed, which may be counter-intuitve to the sportswoman.
• Transdermal HRT is second line treatment if energy deficiency is still a problem after 12 months. A Mirena can be useful.
• Calcium
• Avoid treatments that are prohibited by regulatory bodies.
• Pelvic floor training with a physic for urinary incontinence with techniques to protect against strain.
• Fertility treatment as needed – some treatments are banned in sport.
• Care with exercise in early pregnancy.

Reference/Thanks:

Jones BP et al. Sports gynaecology. TOG 2019;21:85-94