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• W56969460 abstract "The idea of women exercising to the elite level is relatively new, although from today’s perspective this may seem quaint. Some kinds of athletic activity were for many years deemed inappropriate for women, and exercise during pregnancy was frowned upon. Even distance running was considered inappropriate until comparatively recently; a 1500 metre race for women was not included in the Olympic Games until 1972, and the women’s marathon was not included until 1984. Imagine that. This emancipation of athletic activity for women was paralleled by an interesting observation: in 1964, 90% of women athletes participating in the Tokyo Olympic Games had a regular menstrual cycle, but by the time of the Montreal Olympic Games in 1976 only 43% had a regular cycle.1.Dusek T. Influence of high intensity training on menstrual cycle disorders in athletes.Croat Med J. 2001; 42: 79-82PubMed Google Scholar There are many reasons why women develop oligoovulation, and there may have been many reasons for this change. But the increasing participation of women in more, and more physically demanding, sports was likely a major factor. Although there are few milestones that mark the point at which women in general became significantly more athletic, a marker in the United States was the introduction of Title IX of the Education Amendments of 1972, which required schools and colleges receiving federal grants to provide the same opportunities for girls as for boys.2.United States Department of LaborTitle IX, Education Amendments of 1972.http://www.dol.gov/oasam/regs/statutes/titleix.htmDate: 2013Google Scholar The effect of this federal strategy was remarkable. By 1978, only six years after introduction of the amendment, the proportion of girls participating in team sports had increased from 4% to 25%.3.Parker-Pope T. As girls become women, sports pay dividends.http://well.blogs.nytimes.com/2010/02/15/as-girls-become-women-sports-pay-dividendsDate: 2013Google Scholar It is likely that an increase of similar magnitude took place in participation in nonteam sports as well. There were beneficial consequences for women’s overall health; a follow-up more than 20 years later showed that women who had greater opportunity to participate in athletics while young had lower BMI, lower rates of obesity, and reported being more physically active than women who were not afforded these opportunities.4.Kaestner R. Xu X. Title IX, girls’ sports participation, and adult female physical activity and weight.Eval Rev. 2010; 34: 52-78Crossref PubMed Scopus (38) Google Scholar But the increase in women’s physical activity had—of course—some negative consequences as well. Depending on their chosen athletic activity, dedicated participation frequently required either caloric restriction (for example, in elite gymnastics) or sustained caloric expenditure (long-distance running), driven by the need to develop a particular phenotype. Juggling caloric intakes and expenditures, combined in some with the psychological and social pressures of wanting to win, not uncommonly led to menstrual disturbances including amenorrhea. The menstrual disturbances have been causally linked to an energy deficiency (caloric intake insufficient for the expenditure required for exercise) that omits growth and reproductive needs in favour of immediate (survival) needs, and they can be reversed by increasing energy availability.5.Kopp-Woodroffe S.A. Manore M.M. Dueck C.A. Skinner J.S. Matt K.S. Energy and nutrient status of amenorrheic athletes participating in a diet and exercise training intervention program.Int J Sport Nutr. 1999; 9: 70-88Crossref PubMed Scopus (114) Google Scholar The varying frequency and severity of the menstrual disturbance may have a genetic background: women with functional hypothalamic amenorrhea that results from exercise conditioning have been shown (in some cases) to have mutations in genes regulating GnRH ontogeny and action.6.Caronia L.M. Martin C. Welt C.K. Sykiotis G.P. Quinton R. Thambundit A. et al.A genetic basis for functional hypothalamic amenorrhea.N Engl J Med. 2011; 364: 215-225Crossref PubMed Scopus (177) Google Scholar Gut peptides such as ghrelin and adipocytokines such as leptin, both of which regulate food intake, may also be involved in these menstrual disturbances.7.Scheid L. De Souza M.J. Menstrual irregularities and energy deficiency in physically active women: the role of ghrelin, PPY and adipocytokines.Med Sport Sci. 2010; 55: 82-102Crossref PubMed Scopus (36) Google Scholar The potential for harm through the combination of athletic activity and caloric restriction was acknowledged 20 years ago with the first description of the female athlete triad: disordered eating, amenorrhea, and osteoporosis.8.Yeager K.K. Agostini R. Nattiv A. Drinkwater B. The female athlete triad: disordered eating, amenorrhea, osteoporosis.Med Sci Sports Exerc. 1993; 25: 775-777Crossref PubMed Scopus (290) Google Scholar The significance of this combination led the American College of Sports Medicine to publish a “Position Stand” on the topic in 1997 and again in 2007,9.Nattiv A. Loucks A.B. Manore M.M. Sanborn C.F. Sundgot-Borgen J. Warren M.P. American College of Sports Medicine position stand. The female athlete triad.Med Sci Sports Exerc. 2007; 39: 1867-1882Crossref PubMed Scopus (971) Google Scholar urging physicians to screen for the triad and to arrange for appropriate management. As this College has stressed, it is vital for healthy female athletes to adjust their caloric intake to compensate for exercise expenditure. When an athlete becomes pregnant, should she stop exercising? Unless she has one of the contraindications described in the 2003 SOGC Clinical Practice Guideline “Exercise in Pregnancy and the Postpartum Period,”10.Davies G.A.L. Wolfe L.A. Mottola M.F. MacKinnon C; SOGC Clinical Practice Obstetrics Committee. Exercise in pregnancy and the postpartum period. SOGC Clinical Practice Guideline No. 129, June 2003.J Obstet Gynaecol. 2003; 25: 516-529Google Scholar the answer is definitely “no.” In fact, even if a pregnant woman is not used to regular exercise she should be encouraged to begin aerobic and strength-conditioning exercises, which improve both maternal and neonatal outcomes.10.Davies G.A.L. Wolfe L.A. Mottola M.F. MacKinnon C; SOGC Clinical Practice Obstetrics Committee. Exercise in pregnancy and the postpartum period. SOGC Clinical Practice Guideline No. 129, June 2003.J Obstet Gynaecol. 2003; 25: 516-529Google Scholar Although no evidence from a prospective study in women has shown that exercise during pregnancy can prevent preeclampsia, there is evidence from other sources to support such a preventive role.11.Genest D.S. Falcao S. Gutkowska J. Lavoie J.L. Impact of exercise training on preeclampsia: potential preventive mechanisms.Hypertension. 2012; 60: 1104-1109Crossref PubMed Scopus (66) Google Scholar But—and here’s my real point—from other reproductive standpoints, cranking up the exercise can be beneficial beyond expectation. A woman whose BMI is well above the ideal range will see enormous health benefits from reducing her weight before she becomes pregnant. As Darine El-Chaar and colleagues described in the March issue of JOGC, increasing obesity pre-pregnancy led to increasing risks of preeclampsia, gestational hypertension, gestational diabetes, induction of labour and Caesarean section.12.El-Chaar D. Finkelstein S.A. Tu X. Fell D.B. Gaudet L. Sylvain J. et al.The impact of increasing obesity class on obstetrical outcomes.J Obstet Gynaecol Can. 2013; 35: 224-233Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar In this issue of the Journal, Joan Crane and colleagues point out that women with extreme obesity (with a BMI≥50 kg/m2) before pregnancy are at particular risk.13.Crane J.M.G. Murphy P. Burrage L. Hutchens D. Maternal and perinatal outcomes of extreme obesity in pregnancy.J Obstet Gynaecol Can. 2013; 35: 606-611Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar For these women, weight loss before pregnancy will significantly improve outcomes, and exercise is an essential (but often unwelcome) component of a weight loss program. For women who are anovulatory and overweight or obese, losing weight can restore ovulation. If ovulation is not restored, exercise may improve the response to clomiphene citrate; in a recent RCT, as little as six weeks of structured exercise and a hypocaloric diet significantly increased the probability of ovulating in overweight and obese women with polycystic ovary syndrome who were previously clomiphene-resistant.14.Palomba S. Falbo A. Giallauria F. Russo T. Rocca M. Tolino A. et al.Six weeks of structured exercise training and hypocaloric diet increases the probability of ovulation after clomiphene citrate in overweight and obese patients with polycystic ovary syndrome: a randomized controlled trial.Hum Reprod. 2010; 25: 2783-2791Crossref PubMed Scopus (73) Google Scholar But one of the most impressive demonstrations of the benefits of exercise and diet control in managing anovulatory infertility was in a study performed in South Australia.15.Clark A.M. Ledger W. Galletly C. Tomlinson L. Blaney F. Wang X. et al.Weight loss results in significant improvement in pregnancy and ovulation rates in anovulatory obese women.Hum Reprod. 1995; 10: 2705-2712Crossref PubMed Scopus (31) Google Scholar Eighteen obese (mean BMI 38.5 kg/m2), anovulatory women participated in a six-month program of lifestyle modification (without medication) that focused on structured exercise, healthy eating, and positive behavioural change. Five women dropped out after one to three months; but the 13 women who continued lost a mean 6.3 kg, 12 of them resumed ovulation, and 11 conceived within 12 months. None of the women who dropped out ovulated or conceived. When the program was expanded to include other forms of infertility, the mean weight loss increased to 10.2 kg over six months, and similar rates of ovulation and conception resulted.16.Clark A.M. Thornley B. Tomlinson L. Galletly C. Norman R.J. Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment.Hum Reprod. 1998; 13: 1502-1505Crossref PubMed Scopus (567) Google Scholar But more impressive than these figures were the related cost savings. Before the program was introduced, 67 women had had IVF treatments costing (in total) A$550 000, resulting in two live births—a cost of A$275 000 per baby. After the program, the same women had treatment costing A$220 000, resulting in 45 babies—a cost of A$4600 per baby. These figures speak for themselves. In counselling women about reproduction and reproductive concerns, we often overlook the importance of regular, structured exercise in favour of discussing diet and medication. We shouldn’t, because facilitating structured exercise can be our strongest therapeutic tool. Whether a woman is pregnant, wanting to be pregnant, or simply wanting to be healthy, exercise must be part of the discussion. No sweat." @default.
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