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Women in Sports: �Balance Needed

Sarah Callister Sellers, CRNA

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Mom to 4
Husband practices with dad
CRNA
Runner

Sitting in the OR last fall twiddling my thumbs as we do in the anesthesia world. JK wasn’t twiddling thumbs, I was playing tetris.
Text last fall to speak on Women’s Sports: Balance Needed

Immediately laughed and thought “I’m the last person that should be talking about balance in sports”
I’ve had a variety of injuries / illnesses / performance declines due to lack of balance between sports and life

Felt like learning about safe driving by watching car crashes

However, realized there are some broader lessons within these “car crash” experiences that could be helpful to discuss with healthcare providers supporting women in sports

2^nd meaning:

Not just balance in sports from an individual perspective, but from a community and organizational perspective

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Women in Sport: Benefits

All-cause mortality (ACM)

Women derive proportionally greater mortality reduction than men from equivalent doses of physical activity
300 min/week of mod to vigorous activity = 24% reduction in ACM in women vs 18% reduction in men

Depression

Exercise is comparable in effectiveness to antidepressants
ACOG: physical activity is “an essential factor in the prevention of depressive disorders in the postpartum period”

Breast cancer

10-22% reduction in breast cancer risk

Bone health

Proportion of US adults > 50 with osteoporosis: 19.6% of women vs. 4.4% of men
Resistance training + high-impact aerobic training = most effective to preserve BMD

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Resistance Training Benefits

Women derive proportionally greater mortality reduction from RT than men

3 sessions / week: 28% reduction in ACM in women vs. 14% in men
Only 24% of US women engage in RT ≥ 2 days / week
~ 60 min / week: maximum mortality reduction

Resistance training addresses conditions that disproportionately affect women:

Osteoporosis
Sarcopenia
Perinatal depression
Menopausal symptoms

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Running Background

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College running

Set a goal to become an All-American

Requires qualifying for NCAA Nationals and placing high at at nationals
Made a bet with a teammate that I wouldn’t eat ice cream until I achieved All-American
2 years in a row, I missed qualifying for nationals by one spot
I qualified for nationals in XC but ended up sick at nationals

Junior indoor season

Finally healthy and running great
End of the season, flew to University of Washington for a “last chance” meet to qualify for nationals.
To qualify for nationals, I needed to run the 5k in 15 minutes 50 seconds.
Halfway through the race, I felt what had been a nagging pain in my left foot split into an excruciating pain. Each lap, my pace slowed as my foot became unbearable. I finished the race well off of my goal time, feeling completely crushed.
One of my most vivid memories from collegiate running is from after that race - sitting in a folding chair in the corner of the stadium, head in my hands, feeling like I had failed everyone. Failed my team, my coach, myself.

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REDs

Relative Energy Deficiency in Sport

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Female Athlete Triad, REDs

1997: ACSM defined the Female Athlete Triad as:

Disordered eating
Amenorrhea
Osteoporosis

2014: Relative Energy Deficiency in Sport (REDs)

International Olympic Committee (IOC) expanded the triad to include males and describe outcomes on many body systems

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REDs: 2023 IOC Consensus Statement

REDs:

A syndrome of deleterious health and performance outcomes experienced by athletes exposed to low energy availability

Energy Availability (EA):

EA = Energy Intake – Exercise energy expenditure

Fat Free Mass

The dietary energy left over and available for optimum function of body systems after accounting for the energy expended from exercise

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Low Energy Availability (LEA)

LEA:

Any mismatch between dietary energy intake and energy expended in exercise that leaves the body’s total energy needs unmet

Adaptable LEA

Short-term, minimal impact on long-term health, well-being, performance
Physiologic plasticity: benign adaptations to energy fluctuations

Problematic LEA

A maladaptive response to prolonged or severe LEA

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LEA: Females vs. Males

Most males can sustain a lower EA before physiological and psychological disturbances manifest

Parameter	Females	Males
Optimal EA	~ 45 kcal / kg FFM / day	~ 45 kcal / kg FFM / day
Threshold for clinical consequences	~ 30 kcal / kg FFM / day	~ 15-20 kcal / kg FFM / day Overt at 10 kcal / kg FFM / day
Reproductive marker	LH pulsatility, amenorrhea	Testosterone suppression
Resilience	Lower = earlier onset of dysfunction	Higher = requires more severe deficit
Recovery speed	Slower (months to > 1 yr)	Faster (days to weeks)
Examples	55kg FFM: REDs threshold ~ 1650 kcal / day	70 kg FFM: REDs threshold ~ 1050-1400 kcal / day

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Health Effects Performance Effects

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REDs: Impaired bone health

Peak bone mineral density:

Women: age 18-20
Men: 1-3 years later

REDs = uncoupling of bone turnover due to:

LEA: suppresses bone formation
Estrogen deficiency: from FHA promotes bone resorption
When energy status is adequate, bone formation appears unperturbed regardless of estrogen status, underscoring that LEA is the primary driver of skeletal compromise

Osteoporosis

Failure to achieve optimal peak bone mass is considered one of the most important risk factors for the development of osteoporosis

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REDs: Reduced Immunity

2016 Study of Australian Olympic Athletes

LEA was the leading variable associated with illness

Driven by coordinated neuroendocrine response to LEA:

LEA increases systemic cortisol by approx. 22% = immunosuppression
Leptin suppression, T3 and IGF-1 reduction also contribute to immunosuprression

Post-exercise “open window”

Transient immunosuppression: typically 15-70% decrements in innate and adaptive immunity lasting hours
Prolonged and deepened by LEA

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REDs: Low Carbohydrate Availability (LCA)�

Energy-independent impact

Even with adequate calories, LCA can contribute to �endocrine disruption overlapping with REDs
LCA may be exacerbated by current emphasis �on protein intake

Shift toward fat utilization = intensity-dependent impact

Moderate intensity is not significantly limited
High intensity, anaerobic performance, and muscle hypertrophy are all negatively impacted

ACSM recommends “high carbohydrate availability”

Matching glycogen and blood glucose to event fuel demands as the standard for performance optimization

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Marathon Training

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Progress in Women’s Sports

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Challenges in Women’s Sports

1967:

Katherine Switzer pushed off Boston marathon course

Today:

Equal prize money in men’s and women’s professional marathon fields

Women’s peak fertility coincides with their peak athletic performance

Choosing to pursue both motherhood and competitive sports presents unique challenges
Alysia Montano: NYT op-ed

“Nike told me to dream crazy, until I wanted a baby”

Phoebe Wright:

“Getting pregnant is the kiss of death for a female athlete”

1967 to today

Huge progress since Katherine Switzer was pushed off the Boston marathon course
Today there is equal prize money in men’s and women’s professional marathon fields

Kara Goucher, Alysia Montano and Allyson Felix had contracts suspended or deeply cut (70%) during pregnancy

Personal experiences

(1) Rejected from Boston

After the birth of my first child, I had a prolonged recovery due to trying to jump into training quickly
1 year postpartum, I was in the best shape I’d ever been in, and knew I was ready for a fast marathon
I contacted the Boston marathon elite athlete coordinator, but was told it had been too long since my last competitive marathon (due to pregnancy and postpartum) and I wouldn’t be able to compete in the elite women’s field

(2) Professional contract withdrawn

After running the 15^th fastest marathon by an American woman, I signed a professional contract with a shoe company
Before receiving my first paycheck, I found out I was expecting our second child and told the shoe company
The contract was withdrawn with no offer to restart after the pregnancy

(3) Breastfeeding at the 2024 Olympic trials

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“Does maternity during sports career jeopardize future athletic success in elite marathon runners?”

2022 EJSS: Investigated the impact of maternity among elite marathoners on their overall performance progression
37 of the top 150 female marathoners had at least 1 child during her career. 14 had 2 children

11 runners (29%) made their PR before maternity
26 runners (70%) made their PR after maternity
Age-performance relationship model explains 92% of the performance variability

Conclusion

Mid-career maternity does not have a significant impact on overall progression in high level runners who return to official races

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2024 Olympic Trials

Seeded 14^th of 165 women entered
Top 3 qualified for the Olympics. Had an outside shot
Arrived with my coach and family including my 3 year old and exclusively breastfeeding 9 month old

Pre-race plan

Planned to breastfeed my daughter at the athlete hotel before starting my warmup to the start line less than 1 mile away
The night before the race, race officials announced that due to security concerns, athletes would no longer be allowed to arrive at the start of the race via any other method than the official athlete busses, which departed 3.5 hours prior to the race
I contacted officials, requesting an exception due to my exclusively breastfed infant
The solution from the officials:

Check-in to the bus, sneak away without actually boarding the bus, and hope the security personnel let me into the secure, fenced off starting area when I jogged over from the hotel and told them who I was

Morning of the race

Pretended to check-in to the bus, breastfed my baby at the appropriate time, and thankfully was let through into the starting area by each of the surprised security personnel I ran into

Personal experiences

(1) Rejected from Boston

After the birth of my first child, I had a prolonged recovery due to trying to jump into training quickly
1 year postpartum, I was in the best shape I’d ever been in, and knew I was ready for a fast marathon
I contacted the Boston marathon elite athlete coordinator, but was told it had been too long since my last competitive marathon (due to pregnancy and postpartum) and I wouldn’t be able to compete in the elite women’s field

(2) Professional contract withdrawn

After running the 15^th fastest marathon by an American woman, I signed a professional contract with a shoe company
Before receiving my first paycheck, I found out I was expecting our second child and told the shoe company
The contract was withdrawn with no offer to restart after the pregnancy

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Pregnancy and Postpartum

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Exercise during pregnancy

2025 meta-analysis of 16 RCT’s:

High intensity exercise during pregnancy does not adversely affect pregnancy outcomes in healthy women and significantly reduces GDM while improving 5-minute Apgar scores

ACOG:

Avoid hyperthermia
Maintain hydration
Adequate calories, avoid hypoglycemia
May need to decrease load on resistance training

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Postpartum exercise

ACOG:

Exercise may be resumed gradually after pregnancy as soon as medically safe
“Some women are capable of resuming physical activities within days of delivery”

2024 International Delphi consensus statements:

Minimum 3-week rest and recovery period
Return to run:
Begin with a walk-run protocol, gradually increasing ratio
Avoid sudden jumps in increases in duration and intensity
Strength training: glutes, core, pelvic floor
Modify training based on symptoms, sleep, mental health, lactation demands, energy availability concerns

Support:

Dietician, PT, structured strength training program

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Overtraining Syndrome (OTS)

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OTS

Definition

“A sports-specific decrease in performance together with disturbances in mood state.
Underperformance persists despite a period of recovery lasting weeks or months”

Long-term imbalance between training and recovery

Reflects a chronic accumulation of training and non-training stressors that can take months to years to fully recover from

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Continuum: Overreaching to OTS

Term	Definition	Timeline	Outcome
Functional Overreaching	Increased training leading to a temporary performance decrement and with improved performance after rest	Days to weeks	Positive (super compensation)
Nonfunctional Overreaching	Intense training leading to a longer performance decrement but with full recovery after rest; accompanied by increased psychological and/or neuroendocrine symptoms	Weeks to months	Negative due to symptoms and loss of training volume
Overtraining Syndrome	Extreme nonfunctional overreaching but with (1) longer performance decrement (> 2 months), (2) more severe symptomology and maladaptive physiology and (3) an additional stressor not explained by other disease	Months to years	Negative due to symptoms and possible end to athletic career

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OTS Symptoms

Persistent performance decline – weeks to months
Muscle pain / soreness and stiffness
Severe, persistent fatigue
Delayed recovery from exertion
Decreased VO2 max
Sleep disturbances
Overuse injuries

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OTS: Diagnosis of exclusion

Diagnosis rests on:

Document sport-specific decrease in performance that persists despite adequate rest (weeks to months)
Exclude organic disease: endocrine disorders, iron deficiency anemia, infectious diseases, eating disorders, REDs
Identify potential triggers: training errors, excessive competition, psychological stressors, sleep disturbance

No single biomarker is sufficiently sensitive or specific

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OTS Symptoms and Diagnosis in Athletes: Where Is the Research? A Systematic Review

Objective:

Establish and detail the objectively demonstrated physiological and psychological changes that occur as a result of OTS in athletes

Retrieved 768 studies on OTS

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OTS Symptoms and Diagnosis in Athletes: Where Is the Research? A Systematic Review

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OTS: Intramuscular pathways of maladaptation

Propose that OTS represents a state of exercise-induced chronic inflammation, in which systemic immune activation, endocrine disturbances, and metabolic stress converge to impair skeletal muscle adaptation
Integrates emerging molecular evidence to highlight skeletal muscle as the central target of maladaptation in OTS
Parallels between OTS and chronic inflammatory or catabolic diseases

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Training Optimization Protocol (TOP) Test

Two maximal incremental exercise bouts separated by 4 hours of rest

Key measurements: performance, hormonal variables, psychological variables

Diagnosis:

NFOR athletes:

Exaggerated ACTH and prolactin response to the second exercise bout
Reflects a hypersensitive but still functional HPA axis

OTS athletes:

Blunted ACTH and prolactin response to the second bout
Reflects HPA exhaustion / maladaptation

TOP test achieves 98% sensitivity in classifying NFOR vs OTS

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OTS Management: �2013 ECSS and ACSM Joint Statement

Prevention

“The overwhelming impression… is that the emphasis needs to be on prevention of NFOR and OTS (mostly by appropriate periodization of the training program with careful focus on including, and executing, appropriate recovery time into the training program) and on early diagnosis of NFOR and OTS, which at least in principle might shorten the recovery time”

Treatment

“Like a massive orthopedic injury, OTS is just as debilitating and takes a substantial time for recovery to occur spontaneously”
Rest and very light training – the only therapeutic agents capable of effecting recovery

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“Women are not small men” – Stacy Sims, PhD

Sports can be incredibly beneficial for women across the lifespan
Dramatic progress has been made in the last 50 years. Now widely accepted that women belong in sports and derive immense benefit
However, needs to be more widely understood that women’s physiology differs in important ways and this affects their athletic trajectory (less likely to be linear) and susceptibility to conditions including REDs and OTS
Help women work with their physiology, not against it