Hi, I am Dr. Jim Miller, I am the president of the Sports Medicine Society for USA Swimming. This is a new entrance for this committee into ASCA. We happen to view family practitioners, the sports medicine crew in general, the physical therapist, the athlete, trainers, chiropractors, massage therapists and nutritionist, as well as anyone else I forgot to mention, as part of the health care team. Traditionally in America the USA Sports Medicine Society is kind of an event on it’s own, but this year as president of this society, we have moved our meetings (obviously) into the ASCA, because we feel like we’re part of this health care team that works with you in the care of your athletes. We feel that that is critical. If you and the people who are on trips with you, or whom you see on the pool deck are not on the same page, you don’t really have a team. The topics that you’ll see presented here today, as well as some tomorrow, are a combination of questions that have come to us from you. One of these questions concerns the world of asthma, the rules and regulations which are new (which I’ll be going through now). We certainly welcome your feedback into this.
As president of this society, I am very, very interested in what you have to feel about, and these presentations and the value that they have in helping you perform and produce more quality athletes. So going forward, first of all what is asthma? An asthma is an issue with breathing. Regarding definitions it’s reversible This is an old prior definition of reversible airway disease and we just thought that these were airways that went in spasm and that’s just kind of the way it was. Currently, we know that’s not the case, that there is an inflammatory component in the air ways that actually leads to the spasm. That’s a critical difference, because, unless the inflammatory cause is addressed, that athlete, that patient, however you want to term him, will end up with destructive damage to their airways and for all the world, looks like a smoker. So if I have an untreated asthmatic come to me at the age of 40, and I take a chest x-ray, they for all the world look like a pack a day smoker. So they can have irreversible destructive, chronic lung disease if it’s not addressed. So, current definitions have changed the way the world of sports medicine is viewing the way that your athletes are being approached. You’ll see a totally different group of drugs being used. Here are some statistics: 14.6 million Americans are known to have asthma with 5 million of them under the age of 18. It’s on the rise, showing a rise of 62.2% between 1982 and 1994. It tells you quite a bit about what we are doing to this air that we breathe. It’s rising at a higher rate in the kids that you are working with than in any other age group. It’s rising higher in the younger age groups that it is the older age groups. Data shows it’s increase of rise is 72 % over this same time frame for those age groups. Here is a startling one. 5200 deaths per year. Something that “used to be considered a reversible airway condition” clearly is much more aggressive than that. Severity is on the rise and asthma is the leading cause of chronic illness in these kids. I am kind of saying this to you folks because I could present this into the sports medicine world and they would be very surprised with this. But you guys know, you’re tripping over the inhalers on the pool deck. What’s the cost per year? Lots of ER visits. Lots of office visits.
Severity: untreated patients as we talked about end up with lung disease that is akin to that of smokers. Exercise induced asthmatics, (you’ll come across this term), the great majority of these people have undetected, underlying, asthmatic conditions, allergies, other things going on beneath the surface that are not just exercise related. So they usually have underlying disease also and indeed it’s made worse. So if I have somebody that has chronic allergies of any kind, and I actually do the testing on those people, as many as 72 % of them will show exercise induced asthma. They’ve got destructive airway disease going on already, but undetected. I can’t tell you the number of kids I have seen in my office age 12, 13 who are great 50, hundred freestylers. Once we fixed their breathing condition, suddenly they are 200, 400 freestylers. They just had no air. That’s as far as they could go without air. EIA (exercise induced asthama) is a term that you’ll see used. Incidence varies. The variety of asthma of those who have chronic asthma will show increase of their asthmatic symptoms to 90%. This is the quotes that we’re seeing. Anywhere between 40% and as many as 70% of the people that have underling allergies will show that the exercise induced component is there also, if you really test them. If you just do random testing, (just take a bunch of kids off the street and test them), you’ll see instances 7-15% of them having asthma totally asymptomatic. We’re not talking about the kids that have allergies; we’re not talking about the kids that have symptoms; we’re taking about the asymptomatic “normal” kids. Just in this past month, I’ve taken four elite level swimmers who felt like they had no trouble, tested them and they were all positive. The only thing we found was that they had runny nose that had some symptoms in the following spring of the year. That was it. But they had underlying disease all the time. Prevalence tends to be sports specific, the cold air of the cross county skiiers brings them to great risk. The elite athletes show the same incidence or higher. The reason is of course as the exertion levels increase, the expression of the symptoms of excercise induced asthma is also increasing which sets up the attack. Triggers, things to think about, and here’s where you guys really get involved. Environmental factors: your elite athletes are able to exchange 200 liters of air per minute, as they exercise. That’s a tremendous amount of volume and a tremendous amount of exposures to allergens, chemicals, other things that you’ll see. Before they were all the rules and regulations which USA swimming passed regarding smoking on the pool deck, how many of you guys found that the asthmatics that were having trouble already and that combined with cigarette smoking tossed them over the edge.
These numbers like this are some of the reasons that you saw that occurring. Cold air, dry air, dusty air, weather changes, what cold front comes through, my office fills up with patients. Mold, chemicals, exhaust, a guy that is mowing the lawn outside your pool during your meet, pouring gasoline fumes, so forth, cigarette smoke which we already talked about, respiratory infections. Think about medications. Aspirin is something to consider. If your kids are popping Aspirin and they’re are asthmatic, getting on that platform may seen an impaired function. Exercise in intensity, as we’ve already mentioned. Dehydration you can certainly do something about as a coach. Symptoms for you to consider (very subtle stuff). Chronic cough, how many of you are saying oh the chemicals are off or the air is not quite right today. Or some of our pools never have the right air, but wheezing, shortness of breath that is disporportionate to the level of exercise, chest tightness, sphena, (inaudible). This is the thing that bought all the attention and has caused all the fear. FINA is happy enough to pass this regulation and decide they were going to flex their muscle about two days before I left and had to face this on the pool deck at the world championships. Basically what this says, is in the world of asthma, we have a very different condition. These are the people that are allowed to use inhalers and here is the key. Written notification of asthma and/or exercise induced asthma by respiratory or team physicians necessary to the relevant medical authority and testing and verification of medical necessities shall be required. So no longer can your athlete head off to their physician with a call, he tosses them an inhaler, says try this, they say, oh it works and you’re fine, and he writes a note saying exercise induced asthma. That doesn’t fly. They have to have formal respiratory medical testing proving that this condition exists or it can be taken away from them on the pool deck at national championships or they may be disqualified. So they have to have the testing in the hands of the appropriate authorities before the swim occurs, and I’ll talk about that in just a moment. Now, this came out before, this is kind of physician that USA Swimming has at this moment.
Basically reiterating what I just said. No longer is a note from a physician saying “yep they got it, here take this”. You have to have the testing to back that up. If you have athletes currently who are on inhalers, or on these substances that are authorized only with confirmation as a necessity, the physicians caring for these individuals need totake them off they drugs. Now here is where you come in. You need to let those physicians know when that’s a practical thing to do. Obviously not heading into senior nationals, let’s take em off before they head to Lauderdale, that’s not good. But whatever is the most quiet time obviously. In most of your cases now is a fairly quiet time. They are taken off their medications, then they are tested, proven they have it, then they could back on. You obviously do not want them tested while on medication. If they pass the test, they’ve proven they don’t need it. So you need a “ positive test” to prove that they need it.
So your testing is done in two situations. Number one, this is done before anything is done to them off medications. In the ideal world, that medication should go on before they are ever treated. Two, if they are already on medication, they have to be taken off once again under a physician’s supervision and then tested. Number three, if it is felt as if they have exercise induced asthma on top of that, they are then tested beyond that to a form of level of exercise. That I’ll go into in a moment okay. Establishing a diagnosis. This came out before Salt Lake City, and here is talk about specific drugs to treat asthma. These are the traditional broncho dilators. Again, evidence that justifies the treatment shall be required to be submitted to the IOC laboratory,. Actually, this is one of the first cases, where they actually said, you have to have the test, you have to have the flow looks, you have to have the pulmonary readings to justify this, these athletes have to come off their drug. Okay, to that in just a second. So, this is being implemented and actively implemented. Okay, I accept questions about that. Yes sir. Question: How many days would be the athlete have to be without (medication?. Answer: I usually have them off for two weeks. There are a few exceptions to that; it depends on doses. Some kids are on such high doses, you can’t just “boom” stop them. Say two weeks later, I mean, they’ll be in trouble. You have to taper them off before that, so there are exceptions. Yes sir you’ve got a question? Okay. Question: (Inaudible)
Answer: Establishing a diagnosis, now there’s a lot of readings, a lot of stuff which may or may not make much sense to you. I see some of you in the audience that I know have asthma, so you know all this stuff. Ah, these are some of the ways, some of the things that we can test. 4, 6 expiratory volumes in one second is how fast they move air, vital capacity that’s how much air they have, how quickly can they move it, meaning flow rates, ratios between these two and so forth and so on. These are some of the tracings that your sports medicine physicians/respiratory physicians, pulmonary specialists and so forth should be able to produce, and must produce before your athletes can actually justifiably use these compounds that you’re stumbling over on the pool deck right now.
How do we test them? Well, there is a bronchodilator test, whereby we test them, then we give them a drug, test them again, see how much they’ve improved. Confirma-tion of asthma is demonstrated by an improvement of 12% in this specific number. So that’s one way of testing em. Test em, treat em and test em again. Another way to treat em, to test em, exercise challenge. Test em, exercise em, test them again. Okay. I am probably doing three or four of these a week, right now in my office. Referrals of all different types of athletes (mostly swimmers right now) because we pulled them all off drugs, so they are trying to get air. No warm up is allowed when this test is done. Warm ups can actually make it so that the test is not positive when it should be, and repeated phorometry, which is testing in five minutes following competition in completion of the exercise. They have to get to heart rates around 85%. One of the things I’ve been impressed with is: if I take a bunch of swimmers and I stress em by running em, I get there very quickly, (they’re are horrible runners).
Many times we’ll take them back into the room, we’ll say “Man, we have two pieces of information, one is we can help them, and two, don’t ever let this child run.” Okay, mild exercise induced asthma, this gives percentiles as to restrictions and the amount of impairment, 15-20% is moderate. Aand you guessed it, so there (and there are all by gradations of how severely they go), they get into trouble. This is a test which we induced more often than I would like. It’s something called Amethocolene test, whereby the athlete actually has a medication administered to them and then we see the effect on the airways. This is required when you have a test that you think in falsely negative. You can actually confirm or not confirm this, as well as if you have an athlete who is not giving you a full effort. If I have somebody and we give them little thing to blow into, and they go boo, and you know, that’s all they’ll do, this is a way or proving or disproving. So, this is a test that is required by the Armed Forces; they do not accept any other tests. This is the only one they’ll take. So, even if you have an athlete that is malingering or not, or you think that you have a bad test, they are confirmatory ways of checking. For all the physicians, trainers, everybody else in the room, document this and send the tapes. So when I put a kid on an inhaler, if they are on that A-team, if they are up in the elite levels, if they are an NCTOA, upper level athlete, I fill out the paperwork. I write the letter, I do the flow loops, and I send them all to Colorado Springs at the same time. They are not sent all over the globe, they are sent straight to Colorado Springs. Stacy Michaels does an incredible job with this and she coordinates the paperwork across the globe.
If you try to bypass that and go straight to Switzerland or straight to Japan or straight to where ever you want to send it you are going to miss somebody on the way. USA Swimming has the people in place to look out for you and your athlete, but make sure that all of the paperwork is done before that kid heads off on that next elite trip with their little inhaler sitting in their pocket. TREATMENT: here are the basics first. Avoid the triggers whenever possible. Keep your athletes hydrated. You will find that there are times that it just doesn’t work – that the breathing just isn’t as good. We have parts of the time in the city of Richmond, Virginia (where I come from) where you come out and it doesn’t matter what color your car is – it is all going to be the same color – they all come out yellow from the pine pollen and these kids have trouble during that time. Documentation: you are going to keep seeing that over and over and over, the FINA declaration of drug use, the US anti-doping agency restricted substances uses, all of these things should be filled out by the physician and in some cases your parents and so forth need to be aware of the forms that are required.
Other treatment: these are the inhalers. There are short acting inhalers, long acting inhalers and several kinds of intermediate inhalers that are out there. Proventilin and Proventil are probably one of the two common ones that you see. If it is blue or I think it is yellow and orange – we got these on hand, but you don’t see many of these because they are not helpful acutely, but you will see these all over the deck. Other treatments: inhaled steroids since we know that this is an inflammatory disease. Inhaled steroids are pretty much the state of the art, particularly if they are used in combination with some of these other compounds. There are all kinds of versions of these. There are mist inhalers. There are tablets that are broken up that you inhale (some pretty sophisticated methods) to address the destructive aspects of asthma which we did not formerly know existed and all of this requires notification through USA Swimming. Kromolin is another compound which is an anti-inflammatory also. It is a longer acting, you won’t see as many of these on the pool deck. I have got probably 10% of my asthmatics who use it in that scenario, but not most. By the way, we have some handouts that were out there for you. If you did not get one and you want one – Stacy – do you just want to take a count and we can make some more – where is Stacy? She is busy doing it as we speak.
That has all my information on there to so you can reference with this as you need to. Are there any questions for me?
Yes sir – the question was “Are there questions regarding certification for age group level?” The non-elite? You know, I think you can approach the non-elite in different ways. You can approach them as non-elite or you can actually educate the process. How often do you have a non-elite swimmer that suddenly gets a growth spurt and suddenly you have an elite athlete that is on these drugs on your hands. Wow, they did this at a Junior National level and whoops – now you are in trouble. I do not think there is ever a problem with documenting that the treatment that is being delivered to your athlete is the correct treatment so whenever we are diagnosing the topic of asthma any where, we go through these phases. Now obviously I am not taking 9 year olds and filling out the forms and stuffing Stacy’s mailbox with them all, but I am documenting the need. So I treat all the athletes the same – athlete or non-athlete. I want to know that they are on the drug for the right reasons so I do this for all of them across the board. I do not have anybody on an inhaler without justification and need.
Yes sir – I was really hoping to get out of here without answering that – the question was you have breathing enhancement devices that are being promoted to you as being of benefit. You have to understand in the world of lung function it is a bellows and there are smooth muscle portions of the villae that contract and so forth and so on so if you pass out you still breathe. You do not volitionally have to do it. Okay? When you are sleeping you are breathing without thinking about it and then there are muscles which actually are active skeletal muscles that you have control of that allows you to take that big breath when you want to, okay? So two groups of muscles. The devices that you are seeing that are being promoted to you and actually the first ones of these I saw – got out of the water having swum 100 freestyle at Nationals two weeks ago and I had a vendor sitting in my face handing me these things. I said “I am having enough trouble breathing without that right now”. What they are trying to do is that they are trying to enhance the performance of the skeletal muscle (the one you can control). You cannot enhance the one you do not control so the question is “Do those devices enhance performance of the skeletal muscle so that your breathing is indeed assisted by these devices?” Most of the research that is behind all of this was attempted on people who have chronic lung disease because obviously anything that we can do to them that helps them move air the better off we are, the less disability they have and so forth and so on. It was not shown to be helpful in those people. Will it be shown to be helpful in people with active “healthy” lungs? I don’t know. I think the jury is still out because the do have a trainable muscle group and that is of course what they are promoting to you. Plus you know, there are pretty colors and so on and so forth again, but I think that jury is still out. Any of the other physicians or practitioners who are in the audience want to address that or are you just going to let me fall on my head with that one? You are nodding. Do you want me to fall on my head on that one? Well, I think I just did so. Yes, Robbie?
The question was a very good one: if you have an athlete who is having an asthma attack when do you know to bail? When you are uncomfortable, you bail. I don’t care what the rest of the relay team says. That 5200 deaths per year is a scary number. You have the kid who is in a bad chlorinated environment at the wrong season, dehydrated, tired and in trouble. I don’t care how good an athlete you have, No air is no air. They get into lactic acidosis following their swim. They get into some arrhythmias and you may a 911. You do not want to have to call an ambulance. It is time to bail. I think you have the done the right thing. I think you address the topic of hydration and I think you have gotten them out of the environment. If that attack continues coming, there are feedback systems here so it may do that. I think you are wise in just saying “That’s it and you are out.” Does that answer that question? It is a critical question and I thank you for bring that up.
Yes sir . The question that is being asked of me is “How long should I be in trouble before I get in trouble?” I think it depends on the athlete. It depends on their lungs. It depends on the severity of allergies. It depends on how many drugs are in their box already. How much are they using? Have they been ill already? It is a real tough question. If you have a kid with a simple viral infection and it is set up by the scenarios I just presented, you could get in trouble in a hurry. So I think that you would use your gut instinct. I would. If you get them out of the environment and the attack continues, either escalating or just isn’t letting go, just get out of there. It is something that you don’t want. Plus how do you find the Natatorium when you go in a facility? You smell it at the front door. I mean you know, you and I can all find these things because they all smell the same so getting them out away from the chlorine environment and away from the environmental gases you have really got to go some distance. Yes sir. The question that was asked is “How do I know that I have an athlete who in the middle of practice has an asthma attack?” Are you witnessing wheezing or any of those things I listed up there? Should you recommend that they get to their physician and the answer is unequivocally yes because chances are that athlete has an underlying destructive process that is quietly eating away at their capacity.
Okay, now the question is what physician should you have them see? Ideally you will have an association with a Sports Medicine group with primary care background that does these things. I have come across physicians all the time (I don’t care what their speciality or what their background is) who will say “Well you just don’t exercise to that level.” American Academy of Pediatrics came out two years ago with a physician statement opposing organized sports and published it to the nation is the least fit on the planet. Tell me that makes sense. So, I think you have to be careful with the physicians. You know, if you keep sending your kids out and you keep seeing resignations to the swim team coming back, then I would obviously not encourage doing that. There is a huge network that USA Swimming has right now of 300 practicing physicians, trainers and other people who can help you in your areas. There is nothing wrong with consulting them. We have a task force that actually will answer your individual questions and give you recommendations. I do those all the time. I get a couple a week. Any of us would be happy to help you or link somebody in your area who can help you if you find that there is a gap there. Now, let me turn the podium over to the next lecturer rather than throw the rest of them behind. I will be in the back and will be obviously here during the break because I have the next first lecture coming up in the next segment. I would be happy to answer any other questions. Thank you for your attention.
NEXT SPEAKER: While we are getting set up I will give you just a quick intro to let you know who I am and what I am going to be speaking about. My name is DR. Becky Morgan. Like Dr. Miller, I am a family doctor who has had extra training in Sports Medicine. My current position is I am the medical director of women’s athletics at the University of Tennessee so I take care of ten varsity sports (one of which is swimming). I am a volunteer physician for USA Swimming. My talk is going to be a very hot topic among swim coaches and adolescent and college age female swimmers – oral contraceptives and performance. Well, the reason I consented to talk about this is that Charlene and I have had a running email dialogue about oral contraceptives and their role. Some of the problems that we have. So what I wanted to do is basically give you some good major points to take home today. I don’t want you to get caught up in any details or any. I am not going to talk about brand names of pills or anything like that. I just want to give you some good high points, give you some data and have you go away with some information that maybe will help you assist your athletes in making some decisions. We are going to review the potential problems of the menstrual cycle. We are going to define the function of the birth control pill and define potential problems and benefits of the birth control pill (the affects on physiology). Then I am going to summarize some of the current data. The menstrual cycle actually is a very complex thing. It was something that gave all of us in training major headaches trying to learn, but you can boil it down into something you are fairly able to grasp. It is a cycle of secretion of the female sex hormones that occurs in pulses and these pulses have certain responses that the body, specifically the female reproductive tract. The main player there is the uterus. It will respond to these pulses and different things can happen. You have three phases – the follicular, luteal and menstrual. I am going to put this little chart up here and before you run screaming from the room I will be brief with it. It is a 28 day cycle generally and I don’t really like the way that this one is set up because the have the menstrual cycle at the beginning. I f you look, the follicular phase is where you have a little bit of estrogen, very little progesterone.
Then you see this mid-cycle surge of another hormone we are not going to talk about that creates ovulation which is this little triangle here. Then you have the luteal phase which is where both progesterone and estrogen are high. Then when those fall off because pregnancy hasn’t occurred you get this little part here where the hormones are low. That is called the menstrual phase. All of this is designed to support a pregnancy so the uterus builds its lining up. When pregnancy does not occur the uterus says” Well, I don’t have anything else to do”, so it just sheds its lining and that is where you get menstrual bleeding. Now any kind of physiologic stress, specifically elite level training can mess up that hormone secretion. It can take these pulses away and you get a very low level. You may see the loss of the menstrual cycle or absence of menses which is called amenorrhea. Now just to talk about what birth control pills do. We are going to focus on oral contraceptives.
There are some different preparations now – a patch and a shot, but we are going to focus on the pill that people take on a daily basis. There are two varieties of pills, the combination which includes both of the female hormones (estrogen and progesterone). Then there is another type of pill which contains progesterone only. I am not going to talk about that pill. I do not recommend it in my athletes so we are just not going to address that. We are going to talk about the major players which are the combination pills. There are basically two types of combination pills – one that is monophasic which contains the same amount of estrogen and the same of progesterone in each pill for three weeks, then the fourth week has what we call placebos or sugar pills. There is no hormone in the fourth week. You also have a triphasic type pill. It is a newer pill. It is the big popular Orthrotricycline. This has decreasing levels of estrogen every week so the first week will have a higher dose than the second week and the second week will have a higher dose than the third week and then you get to your fourth week where there is no hormone. Generally the progesterone levels stay the same throughout that three week period. There are some newer pills coming out now looking at different progesterone levels, but for the purpose of this talk we are going to talk about just the ones where the estrogen changes. Now, I think that one of the most important things you can ask yourself if you have an athlete who is on a birth control pill that you think the birth control pill may be interfering with their performances, well – why are they on it?
The number 1 reason for a birth control pill is to prevent pregnancy. Even though I get all kinds of kids that come in every year for their physicals and say”Yeah, my cycle was irregular”, but if you ask them are you sexually active the answer is yes. They are sexually active in high school, in college and I would say clearly 50% of the athletes that I am interviewing on their entry level exam are sexually active. Do not kid yourself, this is the big reason for using it. Cycle regulation: there are a lot of young ladies who train very hard who don’t lose their periods, but their periods are everywhere. They are 20 days and then 45 days later they will have another one. Then 15 days they may have another one. That gets to be very tiresome, particularly in swimmers because they have a whole other issue to deal with when they are bleeding. Cycle regulation is an important thing. Hormone replacement and amenorrhea: we talked about that physiologic stress that takes that pulsatile hormone release away. They don’t have periods. Well, what is the big deal? Not a huge deal about bleeding once a month. We don’t really care if they bleed, but there is a big deal about estrogen. It is not just the hormone that helps build up endometrium in the uterus. It is a hormone that has a lot of other functions in the body.
We are going to talk a little bit more about this later, but if they don’t have estrogen, there are a lot of organ systems that do not do well. So you may want to replace that estrogen and the easiest way to do it in a young female is by birth control pills. Then another (what I think is the most unsung positive reason for using oral contraceptives) is controlling menstrual side-effects. There are a lot of kids who have terrible PMS. They are fatigued. They have no motivation. They feel bloated. They feel slow. I had a kid tell me it felt like she was moving through Jello for an entire week before her period. Dysmenorrhea – terrible cramping. Just radiating cramps where they get pain in their legs and their back. A lot of kids will get terrible gastrointestinal side-effects (vomiting, diarrhea). All of these things are related to the hormonal cycling that goes on with a period and then the final thing is heavy bleeding. I mean, iron is a big issue in our female athletes. If they are bleeding very heavily for seven days out of the month, you can bet that they are going to have an iron deficiency.
Well, what is the mechanism of action of birth control pills? You put a constant level of hormone in the body every day so it supplies a steady state level that will feed back into the pituitary which helps drive all of this. It gives you a nice steady estrogen/progesterone level so you do not get that build up of endometrium. You don’t get the shedding of endometrium. Thankfully you don’t get a lot of those bad side-effects we were talking about: the bloating, the fluid retention, the fatigue. The other bonus is that with these steady levels of hormones you don’t get the really thick endometrium or lining of the uterus which leads to the heavier bleeding. So quickly, if we look at our chart again, instead of seeing this type of cycle when you are on birth control pills, you just see basically a little steady state. Then it drops off and during the days of the menstrual period you do not have any hormone so it works pretty well. Well, what are the benefits of using an oral contraceptive? Again, decreasing the dysmenorrhea symptoms which is huge. There are a lot of kids who will miss days of practice if their periods are bad enough. There are kids who will miss school if their periods are bad enough. If you can stop that from happening I think that is a good thing. That has been a benefit in their training. You can decrease iron loss and then later in life the bonuses are reducing ovarian and endometrial cancers, reducing benign breast disease i.e. all those lumps that women who are in their 30’s and 40’s are having taken out. Ovarian cyst which does quite often come up in our adolescent athletes. I had a swimmer two or three years ago on her winter training trip had to have an emergency surgery for a cyst and then pelvic inflammatory disease which is an infectious disease – sexually transmitted. But using birth control pills can cut down on that.
Then probably the hottest topic that we will talk about today is that probably there is a benefit in bone development. Is the individual estrogen deficient? The girls who are not having periods because they are training really hard may see some benefit in their bone development.
Okay, here is the proverbial can of worms. Let’s talk about the risks. Number 1 is what every coach I have ever talked to about birth control pills harps on, that is weight gain and fluid retention. And if you look at the scientific data, it says that weight gain is negligible in a combination pill. But I am also a real live doctor who sees real live patients and I will tell you there is a population of women who will gain weight on birth control pills. You cannot predict that. You do not know who is going to gain weight and who is not. You do not know what pill is going to make some person gain weight and another person not gain weight. I will tell you one thing: that most of the patients I have put on the new preparations recently such as the desogens, the orthrotricocylins are not gaining significant weight. We are talking two or three pounds at the most and that is over a year. I will tell you the quickest things that puts weight on a college age swimmer are beer and the midnight pizza runs and the fact that mom and dad are not there with them telling them what to eat and the fact that it is very easy living in the dorm to run out with the non-athletic roommates that they have to get M&M’s from the 24 hour Circle-K. Before you automatically blast the birth control pills for weight gain, look at everything else first because there is no weight gain like a pregnant woman – 25 to 35 pounds in pregnancy. So, if you want to see some weight gain you take a sexually active adolescent off their birth control pills and you will see some weight gain.
Mid-cycle breakthrough bleeding. This can occur on almost any pill. It depends on the individual response, but it can be a little bit of a problem. What happens is that they bleed around the time that they would normally ovulate and it is annoying, but it is not dangerous.
Altered carbohydrate metabolism. We are going to talk about this in about two more slides and in a little more detail.
Modification in lipid profile. There have been some questions about whether we get a really good boost in our good cholesterol (HDL) and if that is counteracted by an increase in the bad cholesterol or LDL. You get two hormones working on two different pathways. I think the net result is that you don’t get a terrible change in your cholesterol. Then you do have a small, but important risk of blood clot formation. There are some women who have something called a Factor 5 mutation and if they take birth control pills that increases their clotting factors. They can form blood clots in their legs and that is the one reason on this screen that you must come off birth control pills. Fortunately it is in less than 1% of the population who takes them.
Okay, now talking about the specific things. I have some articles that I have used for this and I will explain to you why I don’t have a bibliography for you. The metabolic changes that appear to be significant in birth control pills that are progesterone and estrogen containing is that you may see a change in the way carbohydrates are metabolized. Why is that important? Well, it is important because #1 you need a fuel source and #2 you don’t want bad byproducts. The good thing is that when they look at this metabolism the one thing that you are probably interested is that they did not see a change in is lactate levels so it does not appear that you are going to make more lactic acid if you are on a birth control pill as opposed to somebody who is not. There is also another hormone called growth hormone that seems to be a very hot topic of interest and it does not appear to be affected by birth control pills as well.
Respiratory effects: you do see some change in ventilation. Progesterone is a ventilatory drive hormone but if you look at the changes in the ventilation they diminish in time so that after three to six months you see no change in the amount of ventilation. If you look at oxygen consumption there is no difference between women who are on birth control pills and women who are not on birth control pills so effectively it does not appear to change your respiratory function.
Cardiovascular changes: again, no substantial changes have been detected in the MAX heart rate or in hemoglobin which is the part of the red blood cell that carries oxygen to the cells. There is some evidence that shows that you may have an increase in what is called cardiac output which is the volume of blood that comes out of the heart with each pump. They looked at that and it doesn’t seem to translate really well into the field. So when you put them in the pool, that increase in cardiac output probably doesn’t make a huge difference. It sounds good on paper, but it does not translate well.
Then strength: there is really again no change in strength. In the old birth control pills that had really high doses of estrogen you would get some peripheral conversion to a male type hormone or an androgen hormone and you did see some strength changes, but since we have gone to a much safer pill with lower estrogen, we do not see any strength changes that appear to be significant.
The question is the carbohydrate metabolism alterations. I was going to sneak out of here without having to go into great detail. What they were looking at is utilization of carbohydrate stores versus mobilizing free fatty acids. If you look at it, the data is not really good because it is really old data, but basically what it showed is that there was probably more free fatty acid utilization in women who were on birth control pills. But they also had more insulin so they tended to store and have a fat rate distribution. So what looked like it was going to be a really good thing with utilizing more free fatty acids in the end turned out to be not very beneficial at all because it changes how you tend to store things so what you are using up you tend to go right back and store them. Yes, that would. The question again “Was if you have increased insulin levels would you tend to gain weight because insulin tends to be a storage hormone?” It tends to want you to put weight on and you can draw that conclusion. Again, I think the changes that they saw in insulin were somewhat dampened by the growth hormone changes and I speaking off the top of my head. I would have to look at the article again, but I think the net effect was there might be a little tendency to try and store and that may be where weight gain comes from when we were talking about that. I believe that was done with 50 microgram pills so we cannot use that data very well because we are all using 35 or less now of estrogen in the pill.
So what does this mean? Well, we are going to talk about bone density first and then we will talk about conclusions. Bone density is something that I have great interest in because I was in private practice for two years before I went to a University setting. I was seeing women in their 30’s and 40’s who were having fractures – pathological fractures in their feet. I had one lady who was 48 and had a hip fracture which is way too young for a hip fracture. So what are we doing to our kids when we train them so much that they don’t have periods? What are we doing to their bone density? Well, peak bone mass you only get until you are age 35. Tthen it is all down hill from there so you have got to make the best bone you can before you are 35. If you look at puberty you start putting on about 2% of your total bone mass per year from puberty until you get to that magical age of 30-35. If you all of a sudden take away your estrogen which is the major hormone link to bone formation you can lose bone at 1-2% a year if you keep that low estrogen level. Now, we have seen this in post-menopausal women for years. That is why we harp, that is why the (I don’t remember her name), the ex-model talks about taking hormone replacement because she was losing bone. Well, we have known that forever in post-menopausal women. We are now learning that in our young ladies who are amenorrheic the same thing goes.
So if you start with someone who is 15 and she is supposed to be making bone at 2% a year, but in actuality you take her estrogen away she is losing what she already has. She is not gaining any, but she is supposed to be gaining. So you have a really big net loss of bone. Well, this also can pop up in as little as six months. So if somebody has been amenorrheic for six months they are already losing bone and we are talking about swimmers who do not do a ton of weight bearing exercise which is another very protective thing in bone density. So what do we know about birth control pills? Well the sad truth is we don’t know a whole lot. There is really no evidence from current studies that birth control pills can restore normal bone density in amenorrheic athletes. So this hypothetical 15 year old I talked about that wasn’t having periods and was losing bone, there is no guarantee that an oral contraceptive is going to bring her back to a normal bone setting. Again, we know that there is good evidence supporting estrogen replacement reduces bone loss in low estrogen states, but it is all in post-menopausal women. We haven’t done any studies in our amenorrheic athletes. Looking at the pathways one could assume that we may have some protection but we cannot say that for sure. There was recently an article that came out from, I think it was a Canadian study, where they actually said that if you took oral contraceptives and you exercise that you would actually decrease how good or how dense your bones would be. But if you really dissect that study, it was not a good study. There was a huge dropout rate. There was a huge loss to follow-up. Like after three months, over half the study was no longer participating so it was really not a very good study, but it did get a lot of press.
Conclusions about birth control pills: much of our existing data involves older pills with higher estrogen doses or the more recent studies do not use the same new pills. They use a variety of new pills and we need some good data that has a lot of consistency in the product that we are using and in the populations at which we are looking. We need to look at larger numbers. If we could get a large population on a combination pill with a long follow up, we would have some good data, but unfortunately, we are working with a lot of fragmented data right now. So there are a lot of positive benefits of oral contraceptives that are difficult to quantify. That is, maybe some bone protection, definitely a lot of decrease in those bad dysmenorrhea side-effects and certainly keeping somebody from getting pregnant. There really is a conflict in data and regarding the role of estrogen replacement on how well we maintain our bone density. One thing that is important to remember is that medals have been won and world records have been set in any phase of the menstrual cycle and by women on oral contraceptives. Therefore, I don’t think that this is the one thing that is going to keep somebody from getting where they need to be. I think there is still data out there that can help us decide who the right individual to use that particular pill is.
So again, finally, we are talking about hormonal compounds which are highly variable from individual to individual. I would say in many cases the benefits will outweigh the disadvantages. But you have to inform the athlete. You have to look at the reasons why they might want to be on oral contraceptives. Then you have to use the information that you have to decide if this is a good thing or a bad thing for this particular individual. The other thing that I would say is have this person follow up with their physician frequently. If I put a young lady on birth control pills I see them at two months, four months and six months and we talk about performance. We talk about how their clothes are fitting. We talk about how they feel. How they are training and if it is not working, we change. We either change pills or we stop pills. It is something that you have to go into this knowing that there are risks and benefits and being willing to change your plan if things are not working. Thank you.
Any questions? Yeah, I don’t know right off the top of my head if there are any studies. I do know that there is a big theory in the world of nutrition that the more acidic compounds we have at any one time in our body the more we tend to leach out our calcium from our bones. That is one reason that we tend to keep kids from consuming a lot of coke and diet coke and that kind of stuff. As far as being able to quote you a study I cannot do that. The question is there are quite a few people that will skip their placebo pills so they do not have to have a period and I do that all the time with my swimmers. They need to probably have what we call a wash out period of every three months where they actually have a period because the endometrium will get thicker and thicker and thicker if you do not ever have a period. It is not uncommon to have a young lady come in and say I am scheduled to have my period during NCAA’s. And I will just say, “Skip your placebos” and you can do that for up to three months without any problem. Again, bleeding is not the issue – hormones are the issue. But if you wait longer than three months, they are going to get some funky bleeding that is really not going to make them very happy. So I usually will have them cycle three months and have a period and then three months and have a period. That is not uncommon and if you read the OB/GYN literature they are very supportive of that. Pardon?