[Special Feature: Youth and Sports] Education and Support for Female Athletes from Puberty

2020/03/05

Female athletes face unique issues related to menstruation starting from puberty. It is crucial for both athletes and coaches to understand and address these issues for athletic performance, student life, and future well-being. In recent years, support systems for female athletes have been strengthening in Japan. The number of female members in the Keio University Athletic Association is increasing every year. At the Sports Medicine Research Center, with the cooperation of many clubs, we have conducted fatigue fracture surveys in collaboration with the School of Medicine Department of Orthopedic Surgery, basic lectures for female members, and the "Athletic Association Female Member Health and Lifestyle Survey." Since many members potentially face issues unique to women, there was a need for a consultation desk within the university where they could feel comfortable seeking advice. Consequently, the Female Athlete Support Desk was established in the summer of 2018. Although small in scale, female staff from the Sports Medicine Research Center, including physicians and public health nurses, provide consultations. When necessary, they collaborate with highly specialized doctors in gynecology, orthopedics, and neuropsychiatry, as well as registered dietitians and athletic trainers to help resolve issues.

There is a concept known as the Female Athlete Triad. When first announced at the American College of Sports Medicine in 1993, the triad consisted of eating disorders, amenorrhea, and osteoporosis. However, it was later discovered that the risks of amenorrhea and osteoporosis increase even without a clinical eating disorder. In 2007, it was redefined as three components: Low Energy Availability, Hypothalamic Amenorrhea, and Osteoporosis. The root cause is Low Energy Availability—a situation where energy intake does not match energy expenditure. As shown in Figure 1, in a healthy state, energy intake and expenditure are balanced, menstruation is normal, and optimal bone mass is maintained. If Low Energy Availability persists, it leads to menstrual irregularities and low bone mass, and further exacerbates hypothalamic amenorrhea and osteoporosis.

The key point in preventing amenorrhea is how well energy availability can be improved at the stage of menstrual irregularity. Prolonged amenorrhea can affect future fertility (ease of pregnancy). Furthermore, bone density is strongly influenced by estrogen. Typically, bone density increases rapidly between the ages of 12 and 14, when estrogen secretion rises sharply. Bone mass reaches its peak at age 20 and then drops sharply around age 50 with the onset of menopause. In the era of the 100-year life, securing sufficient bone mass in one's teens is extremely important for preventing osteoporosis later in life.

Female-specific issues that affect conditioning include dysmenorrhea (menstrual pain that interferes with daily life), Premenstrual Syndrome (PMS; mental and physical symptoms that persist during the luteal phase 3 to 10 days before menstruation and subside or disappear with the onset of menstruation), and hypermenorrhea (heavy bleeding). It is necessary to manage periodic changes in physical condition associated with menstruation effectively. Sometimes, the help of a gynecologist, including the appropriate use of low-dose birth control pills, is required.

In fiscal year 2018, we worked on the "Athletic Association Female Member Health and Lifestyle Survey" with Mayaka Tani, who was then a master's student at the Graduate School of Health Management and an alumna of the Athletic Association. The purpose was to understand the actual status of lifestyle conditions such as exercise volume and diet, menstrual abnormalities, symptoms associated with menstruation, PMS, and health status such as history of injuries, and to utilize this for future support. Thanks to Ms. Tani's strong motivation, we were able to conduct the survey with the cooperation of 421 female athletes from 33 clubs out of the 495 members in 36 clubs belonging to the Athletic Association. I would like to express my gratitude to everyone involved. Part of the results is shown in Figure 2.

For example, while over 60% of respondents reported that menstrual pain interferes with their lives, including club activities, only one-quarter had ever visited a gynecologist, and less than 10% had experience with menstrual cycle adjustment. Regarding lifestyle, it was found that overall food intake was low, particularly a lack of staple foods at breakfast and a tendency to lack fish and beans (for details, please refer to the Sports Medicine Research Center website: "Athletic Association Female Member Health and Lifestyle Survey" Result Report - News | Keio University Sports Medicine Research Center). It is necessary to disseminate accurate information in a form that athletes and coaches can utilize.

During puberty, when the body matures, accepting and managing the changes in one's own body and establishing the foundations of lifestyle habits are important for success as an athlete and for future life. Looking ahead to life after graduation, we face the reality that exercise habits among women in their 20s to 40s are extremely low. To enable women to achieve their own work-life balance, including work and childcare, it is necessary to consider female athlete education and support from puberty, and to change social and competitive norms. Furthermore, where to set goal settings in school sports will also be an important issue.

De Souza MJ, Nattiv A, Joy E, et al. 2014 Female Athlete

Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference held in San Francisco, California, May 2012 and 2nd International Conference held in Indianapolis, Indiana, May 2013.Br J Sports Med. 2014;48 (4): 289-289.

Sayaka Nose et al. "Health Management for Female Athletes ver.3 — Menstruation Management Handbook for Female Athletes — 2018" (Accessed February 1, 2020)

Mikako Sunaga "Textbook for Female Athletes" Shufunotomo Co., Ltd., 2018; Ministry of Health, Labour and Welfare "Results of the 2018 National Health and Nutrition Survey" (Accessed February 1, 2020)