Over the course of the 20th century, the adolescent female athletes became an important participant in the sports environment around the world.1 Women were banned from the first Modern Olympics in 1896, but now make up a significant part of the Olympic games and not infrequently outshine the men. Beyond athletic competition and sporting events, the proven benefits of physical exercise on somatic and mental health are numerous; thus, adolescent females should be encouraged to participate in sport activities. This chapter reviews selected aspects of the adolescent female athletes that include stress urinary incontinence, breast injuries, pregnancy and exercise, menstrual dysfunction, and the female athlete triad Box 9-1. Iron deficiency anemia is increased in female athletes versus males and is discussed in the hematology chapter. An overview of the physiology of the female athletes is considered at this time.

Both male and female children are basically equal in physical condition and have equal parameters as noted in Table 9-1. Male and female children have the same strength before puberty but these changes with the event of puberty. After puberty, females aged 11 to 12 years are 90% as strong as their male counterparts versus 85% as strong at ages 13 to 14 years and 75% at ages 15 to 16 years.1 The specific responses to exercise training do vary from person to person based on willingness to train and genetic factors; however, being a female child or a male child does not influence these responses. There are, of course, individuals in general society who predict that female children are “poor” athletes in contrast to the males, resulting in a cultural attitude that can limit or even exclude the female athlete from training, often compounded by providing her with inferior sports equipment.

The consequences of puberty include an increase in body fat percentages, particularly in females, with an eventual average body fat percentage of 23% to 27% in adult females versus 13% to 15% in adult males.1 Intensive training in adolescent athletes can reduce these body fat percentages to 8% to 10% in female sprinters or 12% to 16% for distance female runners in contrast to 4% to 8% in highly trained male gymnasts. Table 9-2 notes other puberty-induced differences in females and males, as a result of changes induced by puberty.1–3 There are fewer sweat glands in the female; however, her thermoregulatory capacity is similar to the male because she has less muscle bulk that produces less heat, less overall body mass, and a relatively larger surface area. However, there is an increased heatstroke risk in both genders, if they are obese, late in pubertal maturation, and exercise in hot environments.

The muscle fiber type proportion is similar in adolescent females and males; however, the muscle fiber size is reduced in females.3 Females show a small increase in muscle strength once menstruation begins (menarche), while males show muscle strength gains throughout puberty (especially the 6–12 months following their growth spurt).3 Females can never reach the muscle capacity of males, because of their lower testosterone levels. Testosterone like doping agents have been used in order to improve the athletic performance of females (see Chapter 6). Appropriate training can result in the adolescent female having upper body strength that is 30% to 50% that of male counterparts while the lower body strength an approximate 70% of males.4,5 Females can benefit from age-appropriate weightlifting programs, maximizing muscle strength, and endurance. Such programs may help these athletes improve their performance and limit sport-induced injuries.

In the adolescent male athlete, his maximal speed peak occurs before his peak height velocity (PHV) while peaks in strength and power occur after PHV; this same pattern is not noted in the female. The adolescent female typically has her most rapid rate of weight gain in 12 to 14 months after her maximum growth velocity (sexually maturity rating [SMR] of 2 or 3). Also, she has a relatively small increase in muscle mass in contrast to a larger increase in body fat. There is an increased result in endurance and strength training in the female that is seen 12 to 24 months after her PHV (SMR of 4–5). Weight training produces only a small increase in muscle mass that can be seen, though some strength increase can be noted. There can be loss of subcutaneous adipose tissue and more muscle definition with extensive training.

Puberty allows males to grow into their sport because they are brought closer to their physical optimum that maximizes their sports performance. In contrast, adolescent females tend to grow out of their sport as these maturing athletes move away from their physical optimum for reduced sports performance.1,6 Early adolescent females have better flexibility and balancing skills than early adolescent males, an advantage that begins in childhood and peaks at 14 or 15 years of age; males typically improve in flexibility from midadolescence until final puberty. The height and growth changes from childhood to adolescence allows the female to become competitive in various sports (i.e., basketball, volleyball, swimming, and others) as determined by her genetic potential and quality of sports training. The adolescent female has some advantage over the male in gymnastics and other sports that require excellent balancing proclivities because of her shorter extremities and lower center of gravity. Some research concludes that the center of gravity is not influenced by gender per se but more by the actual height and weight of the athlete.1,6 The late maturing female may be more interested than her peers in sports that require a thin or lean body type, such as synchronized swimming, gymnastics, dance, and figure skating; these late maturing athletes may excel at these sports. Some female athletes deliberately attempt to delay their puberty and maintain a girlish figure by significantly reducing food consumption. Such abnormal eating patterns can lead to overt eating disorders and the female athlete triad, as reviewed later in this chapter.

Definitions and Epidemiology

The involuntary loss of urine during exercise or during sneezing or coughing is called SUI and it is described in 28% of nulliparous female sports participants with a mean age of 20 years.7 SUI has prevalence rates that range from 10% to 55% in 15- to 64-year-old females.8

Pathogenesis

SUI is particularly noted in “high impact” sports that involve running and jumping found in track and field, gymnastics, and basketball; it is described much less often in females participating in sports such as skiing, jogging, skating, and tennis.3,7–10 SUI risk factors are listed in Table 9-3 and the etiology is linked to an increase in intra-abdominal pressures because of exercise, resulting in urethral sphincteric unit changes.

Clinical Presentation

The athlete may be embarrassed by the incontinence and not voluntarily mention this event unless directly asked by the clinician. The history should point out if this occurs only during sports activity or is part of a picture of enuresis (daytime and/or nighttime) that has continued since childhood. The history can also note if risk factors are present, as indicated in Table 9-3. SUI describes a pattern of frequent or infrequent urinary incontinence that is only exercise-related. A general physical examination is done that may include a pelvic examination assessing pelvic floor anatomic integrity and abnormality of the posterior urethrovesical angle.1,3 If the SUI is part of a larger incontinent pattern, laboratory testing can include a urinalysis, urine cultures, renal sonogram, voiding cystourethrogram, and others.11,12

Management

In most situations, the athlete can be educated that SUI is typically a benign, self-limited phenomenon that simply requires basic understanding of this condition along with such measures as prevention of pre-exercise excessive fluid intake and possibly the use of sanitary napkins placed prior to the exercise. The athlete, however, needs to avoid dehydration as well. Table 9-4 lists additional management options that are available in selected situations. The use of anticholinergic medications is not recommended, since these drugs can induce sweating dysfunction and heat disorders. Phenylpropolamine was removed from the US market because of reports of increased cerebrovascular accidents in females younger than 50 years of age. However, imipramine and pseudoephedrine hydrochloride are used by some clinicians to reduce the incidence of exercise-induced SUI.1

Introduction

Breasts are modified, milk-producing apocrine glands anatomically situated within superficial thoracic fascial layers that are suspended from the anterior chest wall by fibrous septae called Cooper’s ligaments and extend from the second to the sixth intercostal space (Figure 9-1).13,14 The breast contains 15 to 20 lobes and excretory ducts opening into the nipple while the lobes contain alveoli (10–100). The breast contour is formed by connective tissue that is dense and fatty while Cooper’s ligaments provide some support to the breasts as they reach from the skin to the pectoralis muscle that is underneath the breasts (Figure 9-2). The areola is a darkened structure in the breast center that contains the nipple and also sebaceous glands called Montgomery tubercules.

Thelarche (breast bud stage or SMR 2) is the first clinical sign of puberty and normally occurs between 8 and 14 years of age, with a mean age of 9 to 11 years of age. Thelarche begins the process of clinical puberty with further breast development over the next few years and menarche (onset of menstruation) 2 to 5 years later.13,14 An SMR 1 or Tanner stage 1 is defined by no breast development, 2 is the breast bud stage, 3 is further breast development, 4 is a doubled-contoured appearance with the areola and nipple separated from the breast in a secondary mound, and 5 is further breast enlargement with a single contour appearance (nipple separated from the rest of breast). A number of normal females never actually reach SMR breast stage 5 and stop their breast development at stage 4.

Effect of Exercise and Breast Size

There is only a small amount of muscle in breast tissue in the areola and thus, exercise does not affect breast size by impact on muscle tissue. There may be an appearance of exercise-increase in breast size, if the underlying pectoralis muscle is increased by intense physical activity.15 Intense exercise can reduce the adipose tissue in the mammary gland leading to a smaller breast. Dieting can also change the breast size by increasing or decreasing breast adipose tissue. Also, exercise, even when very strenuous does not increase the athlete’s risk for breast cancer.16

Nipple Injuries

Pathogenesis

The nipple is the most prominent part of the breast and thus can be injured in the course of sports activity. Jogging or other physical activity can injure nipple tissue by frequent nipple rubbing caused by friction between the nipple and cloth that covers the breast and nipple. This is called “jogger’s nipple” or “bicyclist’s nipple” and can be an acute or chronic injury worsened by a tight-fitting shirt, bra, or other irritating material rubbing against a nipple.5,6,15,17 Direct stimulation and exercise in cold weather that leads to nipple prominence by areolar muscle effects can lead to nipple irritation and trauma as well. It is more common in males than females and one classic reports notes a 20:1 male to female ratio of jogger’s nipple in marathon runners.18

Clinical Presentation

Athletes can present with a painful, raw, and sometimes bleeding nipple or nipples that can be acute or chronic. If there is an accompanying unilateral pain mass under the areola often in association with a sanguineous or dark-brown nipple discharge, the differential diagnosis includes nonexercise-related disorders as an intraductal papilloma (papillomatosis), nipple adenoma, cystosarcoma phyllodes, papillary carcinoma, mammary duct ectasia, ductal hyperplasia, or infiltrating ductal adenocarcinoma.19 If a mass is present, breast ultrasonography and fine needle aspiration are needed to study this condition further. However, most will present with a raw, bleeding nipple in association with exercise and no other findings on breast examination.

Management

Table 9-5 lists methods to prevent nipple trauma caused by exercise that includes a well-fitting sports bra. Management of overt nipple damage include using a proper sports bra, good hygiene, avoidance of ongoing nipple trauma, and antibiotic treatment of any secondary nipple infection.

Breast Injuries

Pathogenesis

Besides injury to the nipple, sports activity may cause trauma to the breast tissue, in which direct trauma can cause breast contusions, abrasions, hematomas, or lacerations.5,6,19 The injury may be from falls, seat belt injuries, sports equipment, elbows, kicks, or other trauma to the breast tissue. The sports bra itself may contribute to injury from bra clips, straps, hooks, or underwire metal. A breast contusion represents superficial rupture of capillaries, while a hematoma results from hemorrhage of deep blood vessel (s). Although a history of direct breast trauma is not always present, Mondor’s disease may present as thrombophlebitis of superficial breast veins. If a female athlete has had silicone-implanted breasts, trauma may lead to rupture of an implant in rare situations.

Clinical Presentation

A breast contusion is typically mild with variable breast pain, edema, and ecchymoses over the injury. An abrasion presents as an excoriation or removal of superficial skin because of trauma; there may be secondary infection increasing pain over this abraded wound. A breast hematoma may be deep within mammary tissue and not easily appreciated as a localized collection of blood in the breast tissue because of a known or unknown breast trauma. A breast laceration is a variable sized cut in the breast skin. Mondor’s disease presents as tenderness, redness, and swelling over superficial breast veins. Trauma-induced rupture of a silicone-implant leads to breast pain with bleeding and breast deformity.

Management

Table 9-6 reviews management of breast tissue injuries. Breast contusions are typically mild and resolved over 15 to 21 days. A hematoma usually resolves by itself with no need for aspiration; however, this resolution may take months to years and result in the development of fat necrosis and secondary induration, scarring, and calcification that may be mistaken for breast carcinoma.1,15,19 Surgical closure of a breast laceration should occur with careful observation for the potential development of a painful breast abscess. Spontaneous resolution of Mondor’s disease occurs usually over 1 to 2 weeks. An athlete with silicone implant rupture should be referred for removal of the implant.

Breast Pain

Pathogenesis

Breast discomfort or overt pain is not an uncommon event in female athletes involved in exercise and sports play. It is a concern often not mentioned by the adolescents unless directly asked by the clinician. It can prevent many females from taking part in sports activities. Breast soreness or tenderness caused by physical activity was reported in 31% of female athletes and 52% of this group also noted breast injury while involved in sports participation.20 Considerable breast movement can occur in exercise such as noted with volleyball, basketball, running, gymnastics, and others. This pain or discomfort can be intensified with increase fluid retention in the breasts, noted during the premenstrual phase and other parts of the menstrual cycle as well as those with premenstrual syndrome. Excessive breast motion can lead to pectoralis muscle strain of fascial attachments and shoulder discomfort, especially in female athletes with large breasts. Breast pain can also be caused by various breast masses, as noted in Table 9-7.

Management

A well-fitted sports brassiere will prevent much of the pain and discomfort experienced by the female athlete by providing maximum breast support and reducing painful breast movement.21,22 The sports bra should minimize breast motion by being well-fitted and able to lift as well as separate the breasts. It is important that the bra be made of material that is nonabrasive and “breathable” (in order to reduce sweating). It should not be old or worn-out and usually needs to be replaced on a regular basis, after every 6 months. The bra should have soft, firm cups, very few seams, and limited hooks that are padded. Some athletes will also benefit from padding of the bra and shoulder straps. Guidelines for sport bras have been published.1,15,21,22 Excessive sweating may cause excoriation, development of abscesses, and cellulitis in the breast folds.

Breast Asymmetry

Pathogenesis

Breast asymmetry is a common event in adolescent females as they mature. By the time puberty is completed, one in four adult females still have visible breast asymmetry.1,15 It is usually a normal variant, but a careful evaluation is needed for any female athlete who presents with breast asymmetry, especially looking for a mass in the larger breast (Table 9-7).