PART 1

ENDOCRINE/MENSTRUAL FACTORSThe female athlete responds to a programme of regular exercise in a similar
fashion to the male. Women show improvements in aerobic capacity, strength,and “speed” to the same qualitative degree as men. However, due to differences
associated with in-utero hormonal effects on myocyte stem cell number, as well as
those induced by estrogen vs. androgen, women have a smaller skeleton, less muscle
mass, lower hemoglobin levels, and a higher proportion of body fat. Thus, women’sworld records are 7–10% lower than those of men. Female athletes generally show
training-induced structural changes of lower body fat and a higher percent of muscle
than untrained women.
A. Endocrine Function

The changes in body composition and energy metabolism associated withintense exercise may be responsible for a number of changes in endocrine function,
particularly those related to the reproductive cycle.
1. Menarche
A number of studies have suggested that an exercise programme begun early inlife may delay the onset of menarche. This has not been conﬁrmed, but women who
have not begun menarche by age 16 in the northern hemisphere (and perhaps earlier
in other populations) should have an endocrine evaluation.
2. Exercise-Related Changes in the Menstrual Cycle
Exercise and its energy demands, if not compensated by adequate nutrition, may
affect several cerebral neuro-transmitters and, subsequently, the hormones of the
hypothalamic-pituitary-ovarian axis. These hormonal changes may be reﬂected invarious ways: luteal phase deﬁciency, anovulatory cycles, and exercise-associatedamenorrhea (EAA). About 2–5% of the untrained female population has one ofthese abnormalities; among distance runners and some athletes in other events theincidence ranges from 5–65%.
a. Luteal Phase Deﬁciency
In this condition, the menstrual cycle length is unchanged, but the luteal
phase is shortened. Progesterone secretion is deﬁcient, probably associatedwith a defective mid-cycle LH surge. The subject usually does not notice anychanges, and therefore does not seek evaluation unless complications occur.
These include infertility, endometrial hyperplasia, and a reduced bone mass
(with stress fractures). Studies show an absence of the basal body temperature(BBT) rise (due to the lack of the LH surge), low plasma progesterone,
and an abnormal endometrial biopsy. This may represent a precursor to thedevelopment of anovulation or amenorrhea. Although menstrual cycles may
be within normal limits, it is uncertain whether estrogen therapy may benecessary to prevent bone mineral loss.

CHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETES

b. Anovulation
Anovulatory cycles may be short (less than 21 days between menses) orvery long (35 to 150 days). Affected women may produce adequate estrogen,but do not have an LH pulse, and have low progesterone levels. The unopposed
estrogen causes proliferative endometrial growth and may lead to irregular,
heavy bleeding. This can cause iron deﬁciency and anemia. Management may
include monthly progestin therapy during days 14–25, or oral contraceptives
for sexually active women. Clomiphene may be used to induce ovulation if
pregnancy is desired. However, in these cases there may not be adequate
estrogen to protect bone mineral competence, and estrogen replacement or
an oral contraceptive should be considered. Athletes and physicians should
always be aware that clomiphene is included in the list of prohibited substances.
c. Exercise-Associated Amenorrhea (EAA)
This is the commonest type of menstrual change noted in athletes, andoccurs in one of two forms:
i. Primary amenorrhea. Primary amenorrhea is the absence of menses
by age 16. This is probably due to multiple factors, including intense
training from an early age, plus dietary inadequacy leading to an energy
drain. Risks include a low bone density, scoliosis, and stress fractures.
Amenorrhea beyond age 16 should be fully evaluated.
ii. Secondary amenorrhea. This is deﬁned as the absence of 3 to 12
consecutive menses. The lack of a uniform deﬁnition makes theincidence difﬁcult to determine. About 2% to 5% of “normal” womenare amenorrheic at some time. The incidence in athletes ranges from
5% to 65%, depending upon the sport and event. This condition ismost common among distance runners.
The causes of amenorrhea are not well-deﬁned, but are probably multi-factorial.
Intensive training demands in the face of inadequate caloric and nutritional replacement leads to an “energy drain” that affects cerebral neuro-transmitters and the
hypothalamic-pituitary-ovarian hormone system.
EAA is a type of hypothalamic amenorrhea. The gonadotrophin-releasing
hormone (GnRH) pulse generator is suppressed. Many hormones that affect the
GnRH pulse generator are altered by exercise. These include the endorphins,
prostaglandins, catecholestrogens, serotonin, catecholamines, dopamine, cortisol,etc. These hormones in turn affect the release of LH and FSH, and thus estrogen andprogesterone. A combination of the above factors, which results in an energy drain,
is likely responsible for this reversible suppression of the GnRH pulse generator.
The long-term consequences include infertility, a reduced bone density, stressfractures, and increased injuries.
3. Medical Assessment
Changes in the menstrual cycle associated with exercise are probably caused
by a variety of complex, interrelated factors that are still under study. Menstrual

CHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETESTable 13-1. Differential diagnosis of secondary amenorrhea.
SourceAbnormal Findings

UterinePregnancy
Asherman’s Syndrome

Positive pregnancy test
Uterine scarring

Pituitary
Prolactin-secreting adenoma
Tumours
Pituitary failure

Elevated prolactin
Abnormal sella X-ray/CT
Low FSH, LH, TSH

Ovary
Ovarian failure
Ovarian tumours
Polycystic ovary syndrome (PCO)
Hypothalamus
Anorexia nervosa
TumourExercise-induced amenorrhea
AdrenalCushing’s disease/syndrome
Congenital adrenal hyperplasia
Other Endocrine
Hyperthyroid
Hypothyroid

Elevated LH, FSH
Palpable mass
LH/FSH = 3/1,
elevated testosterone, DHEA-S
Distorted body image
Abnormal sella X-ray/CT
History
Elevated cortisol
Elevated androgens,
17-OH progesterone
Suppressed TSH
Elevated TSH

Medications
Oral contraceptives
Anabolic steroids/testosteronechanges should not automatically be attributed to the exercise programme, and othercauses must be considered (Table 13-1).
EAA should be considered part of the Female Athlete Triad of disorderedeating, amenorrhea, and a low estrogen state leading to decreased bone mineralcontent and eventually osteoporosis. Evaluation requires a physical examinationand careful medical history, including the timing of menarche and changes in
the menstrual cycle in relation to the initiation and intensity of training. Weightﬂuctuations and nutrition habits should also be correlated with menstrual changes.
Concerns about body image, ideal weight, and methods of weight control must be
noted. Many distance runners have adopted the “be thin to win” myth and develop
a distorted perception of their body image. They acquire disordered eating patterns,
including bulimia and anorexia. These behaviors may be difﬁcult to elicit initially,so the examiner must be persistent. Athletes at risk of disordered eating should be
evaluated and appropriate referrals made (Figure 13-1).

CHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETES

Symptomatic or at-risk athlete
is evaluated by physician
Referred for dietaryassessment and meal plan
Athlete follows meal plan
without difﬁculty

Athlete has difﬁculty or does
not follow plan

Periodic reassessment of
diet, menstrual status,bone density

Referred to eating disorders(ED) specialist for assessment
Recommends nofurther action

Treatment isrecommended
Athlete agrees to ED
treatment
Progress in treatment,
cleared medically andpsychologically, andwants to train/compete

Does not progress or is
not cleared medicallyand psychologically

Athlete is permitted totrain/compete as longas meeting healthmaintenance criteria

Athlete is not considered fortraining or competition until
progressing and cleared

Successful completion of
ED treatment

Unsuccessful completion of
ED treatment

Athlete returns
to sport

Athlete does not
return to sport

Athlete refuses to attend
ED treatment
Athlete is withheld fromtraining until treatmentcompliantFigure 13-1. Disordered eating decision tree.

Team physicians should also be alert to other gynecologic disorders, sexual
activity, sexually transmitted diseases, contraceptive practices, thyroid disorders,and other medical illnesses. Symptoms and signs of androgen excess, such as malepattern hair growth and acne (endogenous or exogenous androgens), visual changes(pituitary mass), and galactorrhea (prolactin-secreting adenoma) should also be
evaluated.

CHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETES

4. Testing
A step-wise protocol should begin with a pregnancy test, thyroid stimulating
hormone (TSH) and a prolactin level (see Figure 13-2). Androgens (testosterone,
DHEA-S and androstenedione) can be measured if virilisation or hirsutism arenoted. If the pregnancy test is negative, a progesterone challenge test may be started.
Progesterone can be administered orally in doses of 5–10 mg daily for 7–10 days, orin a single intramuscular dose of 100–200 mg of progesterone in oil. Progesterone
converts an estrogen-stimulated proliferative endometrium into a secretory one,which is shed when the progestin is stopped. Bleeding suggests anovulation
rather than hypothalamic amenorrhea. The pregnancy test should precede theprogesterone challenge because this hormone is teratogenic.
If the progesterone test is positive, search for causes of unopposed estrogen,including androgen excess syndromes. If there is no response, causes of
inadequate estrogen must be sought, including pituitary or ovarian failure.
Measure LH and FSH, which are elevated in primary ovarian failure and low inhypothalamic-pituitary disorders such as anorexia nervosa and EAA.
5. Risks of Altered Menstrual Function
Abnormal menstruation or amenorrhea are often regarded by athletes asfavorable, because they believe that performance is affected by the menstrual cycle
and that amenorrhea is indicative of “leanness” and ﬁtness. Recent studies haveshown, however, that serious consequences result from prolonged amenorrhea, oreven a short luteal phase. This hypoestrogenic state results in an uncoupling of boneformation and resorbtion, with increased resorbtion resulting in an approximate
4% loss of trabecular bone for each year of amenorrhea. This results in a higher
incidence of stress fractures, and also eventual osteoporosis. Mineralisation is
only partially restored with estrogen therapy and cannot be restored with calcium
administration alone. Therefore, intervention should take place within 3 to 6 monthsof the onset of amenorrhea.
Further, the low estrogen state also affects the vascular endothelium and may
be a factor in the development of premature atherosclerosis. Also, athletes must be
cautioned that EAA should not be considered a form of contraception, as ovulation
may occur before menses resume.
6. Management
EAA should be regarded as a form of “energy drain,” symptomatic of several
possible stresses upon the athlete. Adequate nutrition must be emphasised, withstress placed upon a balanced, high-carbohydrate diet (see Chapter 6, Nutrition,section C.3). There should be a calcium intake of 1500–2000 mg daily, to provide
a substrate for bone mineralisation. Physical and psychological stresses should be
minimised. It will be difﬁcult if not impossible for the athlete to accept a reduced
training load unless there is clear evidence of overtraining. A bone mineral density
examination (DEXA scan) may be needed to demonstrate to the athlete the presenceof osteopenia and the need for nutritional changes and further therapy.

CHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETES

Amenorrhea
History and PhysicalExamination
Initial Screening
Androgen excess signs
LH/FSH ratio
Testosterone
DHEA-S

1. Pregnancy Test
2. Thyroid stimulating
hormone (TSH)
3. Prolactin

Progesterone
Challenge Test
Bleeding = Positive test
( = estrogen production)

No bleeding = Negative test
(inadequate estrogen production)

Anovulatory cycles
orAndrogen excess syndrome

LH/FSHHighLow• Ovarian failure• Hypothalamic EAA• Anorexia• Pituitary failure
Assess for
pituitary mass

Figure 13-2. Flow chart for assessing amenorrhea.

Estrogen replacement is essential if other measures do not alleviate the condition
within a few months. Estrogen therapy is best accomplished by the use of low-dose
oral contraceptive pills. Although athletes may be concerned about adverse effects
on performance, this is a minor problem with modern formulations and can bealleviated by trying different preparations. Recent studies show estrogen therapy
has no effect on aerobic capacity, reaction time, speed, or strength. Unless there is achange in lifestyle, medications should be continued. Discontinuance may be tried,but hormonal therapy should be resumed if there is no menses in 3 to 6 months.
B. Dysmenorrhea

Pre-menstrual symptoms of bloating, weight gain, depression, and abdominal
cramping affect the athlete’s sense of well being and ability to perform. Exercise
is helpful in reducing some of these effects, but it does not totally alleviate theCHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETES

problems. Simple analgesics may be sufﬁcient in mild cases, but non-steroidal
anti-inﬂammatory drugs are more effective as prostaglandin inhibitors, especially if
begun just prior to the anticipated onset of symptoms.
More complete control can be obtained by suppressing ovulation with hormones,
such as oral contraceptives. These can be used to regulate the timing of the menstrual
cycle to avoid major competitions as well as to control symptoms. Use of theseagents has been shown to produce minimal if any weight gain and no changes in
performance-related factors.
References

1.

Brown, C. H., and J. Wilmore. The effects of maximal resistance training on
the strength and body composition of women athletes. Med.Sci. in Sports 6(3):174-177, 1974.
2. Brown, C. H., and J. Wilmore. Physical and physiological characteristics ofchampion women long distance runners. Med. Sci. in Sports 6:178-181, 1974.
3. International Olympic Committee. Position stand on the female athlete triad.
IOC: Medical Commission Working Group Women in Sport, 2005. Available
at http://www.olympic.org/uk/organisation/commissions/medical/full_story_
uk.asp?id=1540
4. Loucks, A. B. Effects of exercise training on the menstrual cycle: existence
and mechanisms. Med. Sci. in Sports Exerc. 22:275, 1990.
5. Loucks, A. B. Energy availability, not body fatness, regulates reproductivefunction in women. Exerc. Sport Sci. Rev. 31(3): 144-148, 2003.
6. Otis, C. L., B. Drinkwater, M. Johnson, A. Loucks, and J. Wilmore. American
College of Sports Medicine Position Stand. The Female Athlete Triad. Med.
Sci. Sports Exerc. 29:i-ix, 1997.
7. Pettersson, U., B. Stalnacke, G. Ahlenius, K. Henriksson-Larsen, R. Lorentzon.
Low bone mass density at multiple skeletal sites, including the appendicularskeleton in amenorrheic runners. Calcif. Tissue Int. 64:117-125, 1999.
8. Puhl, J. L., and C. H. Brown (eds.). The Menstrual Cycle and Physical Activity.
Champaign, IL: Human Kinetics, 1986.
9. Rickenlund A., K. Carlstrom, B. Ekblom, T. B. Brismar, and A. vonSchoutzschberg. Hyperandrogenicity is an alternative mechanism underlying
oligomenorrhea or amenorrhea in female athletes and may improve physicalperformance. Fertil. Steril. 84:394-401, 2003.
10. Roberts, W. O. Primary amenorrhea and stress fracture. Phys. Sportsmed.
23(9):33-42, 1995.
11. Shangold, M., et al. Evaluation and management of menstrual dysfunction inathletes. JAMA 263:1665, 1990.
12. Stager, J. M., J. K. Wigglesworth, and L. K. Hatler. Interpreting the relationship between age of menarche and prepubertal training. Med. Sci. Sports Exerc.
22:54-58, 1990.

CHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETES

13. Wilmore, J., C. H. Brown, and J. A. Davis. Body physique and compositionof the female distance runner. Annals of the New York Academy of Sciences
301:764-776, 31 Oct. 1977.

PART 2GENDER VERIFICATION AND
SEX REASSIGNMENT POLICY
A. History

Gender veriﬁcation has been required of all female athletes since the early
1960s, when allegations surfaced that men and perhaps “hermaphrodites” wereparticipating in women’s sports events. Although there was no strong evidence
to support these claims, the IOC and other international sports governing bodies
initiated gender veriﬁcation procedures.
At ﬁrst, athletes were physically examined by a panel of female physicians.
Because this caused considerable embarrassment, athletes and ofﬁcials quickly
embraced the buccal smear (Barr body) method, which can separate XX (genetic
female) from XY (genetic male) individuals. However, geneticists have shownthat a number of genetic defects in hormone synthesis or recognition can render an
XY individual anatomically and physiologically female. Labeling these women as“male” has caused irreparable harm.
In 1991, the IAAF abandoned the X-chromatin (buccal smear) test and adopted
the recommendation that female and male athletes undergo a general physicalexamination by their team physician as part of a general “health check” prior
to international competition. Thus, questions concerning sexual identity could
be resolved in the athlete’s own country. This procedure, however, was nearly
impossible to standardise or verify at the international level.
B. Current IAAF Policy

In 1992, the Medical Committee recommended and the Council adopted thecurrent policy on gender veriﬁcation, which states:
1. The general “health check” is strongly recommended, but no longer
required.
2. Visual examination of the genitalia during the delivery of a urine
specimen in the women’s doping control station is a sufﬁcient methodof determining whether the athlete is male or female. The risk of a malebeing discovered during the doping control procedure is sufﬁcient
deterrent to prevent males from attempting to compete as females.
3. The Medical Delegate at international competitions has the authority toinitiate additional examinations if there is a question or ambiguity
concerning an athlete’s gender.
There is currently concern among some athletes and ofﬁcials that genitalia are
not being examined adequately in doping control stations, due to lack of trainingof station personnel, and perhaps due to cultural constraints as well. Hence, further
clariﬁcation or changes may be forthcoming. (See also Appendix 13, Process for theManagement of Gender-Related Issues.)

CHAPTER 13, SPECIAL ISSUES OF WOMEN ATHLETES

C. Sex Reassignment—IOC Consensus Statement

The IAAF Medical /Anti-Doping Commission has adopted the IOC Medical
Commission’s statement on sports participation for athletes who have undergone sex
reassignment.
1. Before Puberty“Individuals undergoing sex reassignment of male to female before puberty
should be regarded as girls and women.” Similarly, this also applies to female tomale reassignment, and they should be regarded as boys or men.
2. After Puberty
Individuals undergoing sex reassignment from male to female, or the reverse,
after puberty are eligible to participate in their reassigned gender under the following conditions:a. Surgical anatomic changes have been completed, including external
genitalia changes and gonadectomy.
b. Legal recognition of their assigned sex has been conferred by theappropriate ofﬁcial authorities.
c. Hormonal therapy appropriate for the assigned sex has been administeredin a veriﬁable manner and for sufﬁcient length of time to minimise
gender-related advantages in sport competitions.
Further guidelines:
a. Eligibility should begin no sooner than two years after gonadectomy.
b. A conﬁdential case-by-case evaluation will occur.
c. In the event that the gender of a competing athlete is questioned, themedical delegate (or equivalent) of the relevant sporting body shallhave the authority to take all appropriate measures for the determinationof the gender of a competitor.
Reference

1.

International Olympic Committee. IOC Medical Commission. Statement of
the Stockholm consensus on sex reassignment in sports. 28 October, 2003.