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Meet Nancy

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Nancy’s Story

Born 1985 to Mary & Jack
Bi-racial parents: Caucasian & Indigenous
Lived in a small rural town in Northern Ontario
One older brother - Phillip
Very active child “Tomboy”
Spent a lot of time with her father, fishing and hunting
Did not have many friends
She was ‘too white’ for some kids and ‘too Indian’ for others
She got into sports to please her father
Sports provided her with a sense of accomplishment
She pushed herself hard

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Nancy’s Physical Decline

At age 15, Nancy injured her leg during a gymnastics practice
She was in considerable pain & could not weight bear
Taken to the local emergency department by her mother
X-ray & blood work were ordered
Diagnosis: stress fracture of the left tibia

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Typical Causes of Stress Fractures to the Lower Leg

Many factors can contribute to stress fractures of the shin. Some can be managed and others can not.

Repetitive movements in high-intensity activities such as:

Long-distance running, track & field, basketball, soccer, gymnastics, dance

Improper athletic technique or footwear
Increasing training or weight-bearing exercises too quickly
Not getting enough rest between workouts
Working out on a different type of surface than usual
Excessive alcohol consumption
Smoking
Being over- or underweight
Osteoporosis
Eating disorders
Low vitamin D levels
Calorie intake imbalance

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Treatment of Stress Fracture

Physician will recommend a combination of treatments & lifestyle changes:

Taking a break from high-impact activity until you’re fully healed
Elevating your leg and applying ice for 10 minutes to ease pain and swelling
Taking over-the-counter (OTC) anti-inflammatory medicine
Using crutches to keep weight off your shin while you heal
Physical therapy
Severe stress fractures may require a cast or surgery to ensure proper healing
Take 4-12 weeks (sometimes longer) to heal
Increase activity slowly
Sports medicine specialist or qualified trainer can help redesign workout routine

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BrendaCalara

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Additional Tips for Healing

Rest
Start cross-training
Invest in proper footwear
Elevate and ice
Maintain a healthy diet
Manage your weight
Work with an experienced trainer

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Nancy’s Story Continues

The emergency physician was more concerned about Nancy’s appearance & how she injured herself.

A more comprehensive history & examination followed.

Assessment findings:

Extreme fatigue (stated she always felt tired, would fall asleep if she sat still for more than 5 minutes)
Weight loss (Nancy’s BMI is 15.7)
Absence of menstrual periods for the last 6 months (stated she had only 2 very light periods in the last year)
Eating disorder – fasting, binging, self-induced vomiting (indulged in all of these practices regularly)
Extreme exercise (Nancy ran 10km each day, had morning & after school practices, games & competitions, & competed in a number of events each weekend)

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Body Mass Index

Person’s weight in kg divided by the square

of height in meters.

Can be used to screen for weight categories

that may lead to health problems.

Is not diagnostic of the body fatness

or health of an individual.

To calculate your BMI go to:

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https://www.cdc.gov/healthyweight/assessing/bmi/index.html

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Nancy’s Diagnosis….

Based on clinical findings, Nancy was diagnosed with:

Female Athlete Triad

Low energy availability
Menstrual dysfunction
Poor bone health

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Triad Screening

Early detection of athletes at risk is critical.

It is recommended that screening for the Triad be part of the Pre-Participation Physical Evaluation.

Screening Questions:

Have you ever had a menstrual period?
How old were you when you had your first menstrual period?
When was your most recent menstrual period?
How many periods have you had in the past 12 months?
Are you presently taking any female hormones (oestrogen, progesterone, birth control pills)?
Do you worry about your weight?
Are you trying to or has anyone recommended that you gain or lose weight?
Are you on a special diet or do you avoid certain types of foods or food groups?
Have you ever had an eating disorder?
Have you ever had a stress fracture?
Have you ever been told you have low bone density (osteopenia or osteoporosis)?

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Bone Mineral Density & Osteoporosis in Ages 5-19

The diagnosis of osteoporosis in children and adolescents requires the presence of both a clinically significant fracture history AND low bone mineral content or low bone mineral density

A clinically significant fracture history is one or more of the following:

Long bone fracture of the lower extremities
Vertebral compression fracture
Two or more long-bone fractures of the upper extremities

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Treatment

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Eating Disorders

Persistent eating behaviours that negatively impact your health, emotions, & your ability to function.

Focuses on weight, body shape & food, leading to dangerous eating behaviours.

Eating disorders can harm the heart, digestive system, bones, teeth & mouth, & lead to other diseases.

Most common eating disorders are:

Anorexia nervosa
Bulimia nervosa
Binge-eating disorder

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Common Symptoms of

Eating Disorders

Anorexia Nervosa

Dramatic weight loss
Dresses in layers to hide weight loss or stay warm
Preoccupation with weight, food, calories, fat grams, and dieting. Makes frequent comments about feeling “fat.’
Resists or is unable to maintain a body weight appropriate for their age, height, and build
Maintains an excessive, rigid exercise regime – despite weather, fatigue, illness, or injury

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Common Symptoms of Eating Disorders

Bulimia Nervosa

Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food
Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics
Drinks excessive amounts of water or non-caloric beverages, and/or uses excessive amounts of mouthwash, mints, and gum
Has calluses on the back of the hands and knuckles from self- induced vomiting
Dental problems, such as enamel erosion, cavities, discoloration of teeth from vomiting, and tooth sensitivity

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Common Symptoms of Eating Disorders

Binge Eating Disorder

Secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); feels lack of control over ability to stop eating
Feelings of disgust, depression, or guilt after overeating, and/or feelings of low self-esteem
Steals or hoards food in strange places
Creates lifestyle schedules or rituals to make time for binge sessions
Evidence of binge eating, including the disappearance of large amounts of food in a short time period or a lot of empty wrappers and containers indicating consumption of large amounts of food

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Complications:

Serious health problems
Depression & anxiety
Suicidal thoughts or behaviour
Problems with growth & development
Social & relationship problems
Substance use disorders
Work & school issues
Death

CNS: concentration disorders, memory disorders, syncope, brain atrophy

Blood: anemia, thrombocytopenia, electrolytes: K+, Mg₂+, Na+

Heart: bradycardia, palpitations, arrhythmia

Kidney: kidney stones, renal failure

GI tract: meteorism, obstipation

Hormones: amenorrhea, thyroid hormones decrease, cortisol increase

Skin: very vulnerable, dry, lanugo hair, acrocyanosis

Muscle Weakness & Osteoporosis

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Causes

Genetics & biology. Certain people may have genes that increase their risk of developing eating disorders. Biological factors, such as changes in brain chemicals, may play a role in eating disorders.

Psychological & emotional health. People with eating disorders may have psychological and emotional problems that contribute to the disorder. They may have low self-esteem, perfectionism, impulsive behavior and troubled relationships.

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Risk Factors

Family history. Eating disorders are significantly more likely to occur in people who have parents or siblings who've had an eating disorder.

Other mental health disorders. People with an eating disorder often have a history of an anxiety disorder, depression or obsessive-compulsive disorder.

Dieting & starvation. Dieting is a risk factor for developing an eating disorder. Starvation affects the brain and influences mood changes, rigidity in thinking, anxiety and reduction in appetite. There is strong evidence that many of the symptoms of an eating disorder are actually symptoms of starvation. Starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.

Stress. Whether it's heading off to college, moving, landing a new job, or a family or relationship issue, change can bring stress, which may increase your risk of an eating disorder.

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Nancy’s Story Continues

Nancy met with her multidisciplinary healthcare team as scheduled
Her mother watched her closely, recording her food intake, physical activity, sleep patterns, and her menstrual cycles
Her father did not see what all the fuss was about….”go back to doing what you love”
She went to her appointments to appease her mother and family doctor
She continued to binge & purge
She often skipped classes to go running
It took 3 years of hard work for her to get to a healthy weight, have a realistic view on exercise, & to having monthly menstrual periods

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Wanting to Conceive

Nancy is now in her early 30’s
She came to the point in her life where she wanted to have a baby
Paul & Nancy tried to conceive for a number of years
Nancy was unsure as ‘who’s fault’ it was (Paul had adopted children from his first marriage)
The fertility specialist suggested IVF (in vitro fertilization)
IVF is the most effective form of assisted reproductive technology
Chances of conceiving using IVF depend on many factors (e.g. age & cause of infertility)
Can be time-consuming, expensive & invasive

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In Vitro Fertilization

During IVF, eggs are removed from mature follicles within an ovary
An egg is fertilized by injecting a single sperm into the egg or

mixing the egg with sperm in a petri dish

The fertilized egg (embryo) is transferred into the uterus

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Why is it done?

Fallopian tube damage or blockage
Ovulation disorders
Endometriosis
Uterine fibroids
Previous tubal sterilization or removal
Impaired sperm production or function
Unexplained infertility
A genetic disorder
Fertility preservation for cancer or other health conditions

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Risks

Multiple births
Premature delivery & low birth weight
Ovarian hyperstimulation syndrome
Miscarriage
Egg-retrieval procedure complications
Ectopic pregnancy
Birth defects
Cancer
Stress

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Multiple births. IVF increases the risk of multiple births if more than one embryo is transferred to your uterus. A pregnancy with multiple fetuses carries a higher risk of early labor and low birth weight than pregnancy with a single fetus does.

Premature delivery and low birth weight. Research suggests that IVF slightly increases the risk that the baby will be born early or with a low birth weight.

Ovarian hyper stimulation syndrome. Use of injectable fertility drugs, such as human chorionic gonadotropin (HCG), to induce ovulation can cause ovarian hyper stimulation syndrome, in which your ovaries become swollen and painful.

Symptoms typically last a week and include mild abdominal pain, bloating, nausea, vomiting and diarrhea. If you become pregnant, however, your symptoms might last several weeks. Rarely, it's possible to develop a more severe form of ovarian hyper stimulation syndrome that can also cause rapid weight gain and shortness of breath.

Miscarriage. The rate of miscarriage for women who conceive using IVF with fresh embryos is similar to that of women who conceive naturally — about 15% to 25% — but the rate increases with maternal age.

Egg-retrieval procedure complications. Use of an aspirating needle to collect eggs could possibly cause bleeding, infection or damage to the bowel, bladder or a blood vessel. Risks are also associated with sedation and general anesthesia, if used.

Ectopic pregnancy. About 2% to 5% of women who use IVF will have an ectopic pregnancy — when the fertilized egg implants outside the uterus, usually in a fallopian tube. The fertilized egg can't survive outside the uterus, and there's no way to continue the pregnancy.

Birth defects. The age of the mother is the primary risk factor in the development of birth defects, no matter how the child is conceived. More research is needed to determine whether babies conceived using IVF might be at increased risk of certain birth defects.

Cancer. Although some early studies suggested there may be a link between certain medications used to stimulate egg growth and the development of a specific type of ovarian tumor, more-recent studies do not support these findings. There does not appear to be a significantly increased risk of breast, endometrial, cervical or ovarian cancer after IVF.

Stress. Use of IVF can be financially, physically and emotionally draining. Support from counselors, family and friends can help you and your partner through the ups and downs of infertility treatment.

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How to prepare

Ovarian reserve testing
Semen analysis
Infectious disease screening
Practice (mock) embryo transfer
Uterine exam

Important questions to discuss prior to beginning a cycle of IVF:

How many embryos will be transferred?
What will you do with any extra embryos?
How will you handle a multiple pregnancy?
Have you considered the potential complications associated with using donor eggs, sperm or embryos, or a gestational carrier?

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Ovarian reserve testing. To determine the quantity and quality of your eggs, your doctor might test the concentration of follicle-stimulating hormone (FSH), estradiol (estrogen) and anti-mullerian hormone in your blood during the first few days of your menstrual cycle. Test results, often used together with an ultrasound of your ovaries, can help predict how your ovaries will respond to fertility medication.

Semen analysis. If not done as part of your initial fertility evaluation, your doctor will conduct a semen analysis shortly before the start of an IVF treatment cycle.

Infectious disease screening. You and your partner will both be screened for infectious diseases, including HIV.

Practice (mock) embryo transfer. Your doctor might conduct a mock embryo transfer to determine the depth of your uterine cavity and the technique most likely to successfully place the embryos into your uterus.

Uterine exam. Your doctor will examine the inside lining of the uterus before you start IVF. This might involve a sonohysterography — in which fluid is injected through the cervix into your uterus — and an ultrasound to create images of your uterine cavity. Or it might include a hysteroscopy — in which a thin, flexible, lighted telescope (hysteroscope) is inserted through your vagina and cervix into your

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What you can expect

Ovulation induction

At the start of a cycle, synthetic hormones are given to stimulate the ovaries to produce multiple eggs-rather than the single egg that normally develops each month.

Multiple eggs are needed, some eggs won’t fertilize or develop normally after fertilization.

Different medications that may be needed:

Medications for ovarian stimulation
Medications for oocyte maturation
Medications to prevent premature ovulation
Medications to prepare the lining of the uterus

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Medications for ovarian stimulation. To stimulate your ovaries, you might receive an injectable medication containing a follicle-stimulating hormone (FSH), a luteinizing hormone (LH) or a combination of both. These medications stimulate more than one egg to develop at a time.

Medications for oocyte maturation. When the follicles are ready for egg retrieval — generally after eight to 14 days — you will take human chorionic gonadotropin (HCG) or other medications to help the eggs mature.

Medications to prevent premature ovulation. These medications prevent your body from releasing the developing eggs too soon.

Medications to prepare the lining of your uterus. On the day of egg retrieval or at the time of embryo transfer, your doctor might recommend that you begin taking progesterone supplements to make the lining of your uterus more receptive to implantation.

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Three days after fertilization, a normally developing embryo will contain about six to 10 cells.

By the fifth or sixth day, the fertilized egg is known as a blastocyst — a rapidly dividing ball of cells.

The inner group of cells will become the embryo.

The outer group will become the cells that nourish and protect it.

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After the procedure

After the embryo transfer, you can resume normal daily activities. However, your ovaries may still be enlarged. Consider avoiding vigorous activity, which could cause discomfort.

Typical side effects include:

Passing a small amount of clear or bloody fluid shortly after the procedure — due to the swabbing of the cervix before the embryo transfer
Breast tenderness due to high estrogen levels
Mild bloating
Mild cramping
Constipation

If you develop moderate or severe pain after the embryo transfer, contact your doctor. He or she will evaluate you for complications such as infection, twisting of an ovary (ovarian torsion) and severe ovarian hyperstimulation syndrome.

*About 12-14 days after egg retrieval, a blood test will detect whether you are pregnant

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Nancy’s Story Continues

IVF was unsuccessful
Nancy’s stress levels were rising
After extensive discussions with Paul, they decided to adopt
They did not have to wait long
The adoption agency had a 2 year old boy - Sam
At about the same time Nancy’s mother (Mary) fell and fractured her hip
She traveled north to assist her parents
She was shocked at the physical disarray her father was in (Jack)
Her stress levels continued increased with everything “on her plate”
She fell back into old eating habits
Eating was the one thing she felt she had control over

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Stress is a natural physical & mental reaction to life experiences.

The body responds to stress by releasing hormones that increase

your heart & breathing rates & ready your muscles to respond.

If your stress response doesn’t stop firing, it can take a toll on

your health & overall well-being.

Irritability
Anxiety
Depression
Headaches
Insomnia

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Central Nervous & Endocrine Systems

CNS is in charge of the “fight or flight” response
The hypothalamus triggers the adrenal glands to release the

stress hormones adrenaline & cortisol

Increasing heart rate & sending blood to the areas that need it the most

(muscles, heart, other important organs)

When the perceived fear is gone, the hypothalamus tells all systems to

go back to normal

If the stressor does not go away, the response will continue
Chronic stress is also a factor in behaviours such as overeating,

not eating enough, alcohol, drug abuse, and social withdrawal

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Respiratory & Cardiovascular Systems

Stress hormones affect the respiratory &

cardiovascular systems

Breathing increases in an effort to quickly

distribute oxygen-rich blood to the body

The heart pumps faster
Stress hormones cause the blood vessels

to constrict & divert more oxygen to muscles

May also increase blood pressure
Frequent & chronic stress will make the heart

work too hard for too long

Increase risk of stroke or heart attack

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Digestive System

The liver produces extra blood sugar (glucose) to give a boost of energy
Under chronic stress, the body may not be able to keep up with the extra

glucose surge

Chronic stress may increase the risk of developing type II diabetes
Rush of hormones, rapid breathing, increased heart rate may upset

your digestive system

Can increase the risk for ulcers or cause existing ones to act up
(ulcers are caused by a bacterium called H. pylori)
Stress may also affect the way food moves through the body,

leading to diarrhea or constipation

May experience nausea, vomiting, stomachache

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Muscular System

Muscles tense up to protect themselves from injury during stress
Once you relax they tend to release
Chronic stress may not give your muscles the chance to relax
Tight muscles cause headaches, back & shoulder pain, body aches
Over time this unhealthy cycle may affect your ability to exercise,

& pain medication for relief may be used

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Sexuality & Reproductive System

Not unusual to lose desire when under constant stress
Short-term stress may cause men to produce more testosterone, the effect doesn’t last long
Chronic stress will cause a man’s testosterone levels to drop
This can interfere with sperm production & cause erectile dysfunction or impotence
Chronic stress may increase risk of infection of male reproductive organs
For women, stress can affect the menstrual cycle
Irregular, heavier, or more painful menstrual periods
Chronic stress can also magnify the physical symptoms of menopause

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Immune System

Stimulates the immune system, which is good for immediate situations
Over time, stress hormones weaken the immune system & reduce the body’s response to foreign invaders
Chronic stress causes more susceptibility to viral illnesses & other infections
Can increase the time it takes to recover from an illness or injury

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Sandwich Generation

Nancy is now looking after a toddler & her parents
She is still working & going to school
Women often feel overextended

Strategies to help manage stress:

Identify stressors
Recognize how you deal with stress
Find healthy ways to manage stress
Take care of yourself
Ask for professional support

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Student Survey

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Instructor Survey

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