 Dr. Kimson Olika. Dr. Olika is the pediatric and adolescent gynecologist at Texas Children's Hospital, the Woodlands. I'm gonna just read a couple of things she wrote personally. I am excited, passionate, and driven by purpose. University of Louisville School of Medicine. And then finally, another personal statement. I hope to empower young women to take charge of their reproductive and sexual health providing a safe outlet for discussion, dialogue, and growth. Ladies and gentlemen, welcome, Dr. Olika. So thank you so much for that introduction. I am so excited to have this opportunity. So I'm going to talk to you guys say about how understanding the menstrual cycle can prevent injury in female athletes. I have no disclosures. And the objectives of this talk are really to educate on the components of a normal menstrual cycle, to describe metabolic changes that occur during a normal menstrual cycle as it relates to exercise, to theorize how the risk of injury can be increased during particular phases of the menstrual cycle, and also to highlight the need for additional research in this area. So I am talking to you because I can relate to this topic. I have a personal sports history with multiple sports anywhere from ballet to track and field, which I did competitively, as well as my own fair share of personal athletic injuries ranging from hip pain to even rhabdomyolysis. I also have an academic interest in this topic as I published an article, a commentary article, in the Journal of Pediatric and Elysian Gynecology this year entitled, The Use of the Menstrual Cycles to Enhance Female Sports Performance and Decrease Sports-Related Injury. So let's start at Title IX. So Title IX of the Education Amendments was established in 1972. And it was established to provide equal access to any program or activity that receives federal financial assistance, including sports. Since the enactment of Title IX, we have seen participation of women and girls in sports increased by 700%. We all saw in the 2016 Rio Olympics as women won 28th, I believe, out of the 46 gold medals awarded to the United States Olympic team. But like we all know, with any increased participation, there also comes the risk of increased injury. Many female athlete teams are beginning to explore the link between player injuries and the menstrual cycle. We all saw as the United States women's national soccer team popularize the idea of period tracking in order to increase performance as they won in a record-breaking and amazing way the World Cup last summer. And the haze of Chelsea FC stated that women have always been treated like small men. The application of rehab and anything tactical or strengthening conditioning, they all come from the basis of what men do. So that means that there's still a lot that we just don't know. There is a significant under-representation of women included in sport and exercise medicine research studies. Despite over 6 million participants from 2011 to 2013, women were only represented in 39% of exercise research studies. And of the women that were represented, majority of them were in the early follicular phase of their menstrual cycle, which means that the hormones were at their lowest point. So it's hard to infer what elevated hormones or decreasing hormones actually do to a female body during sports and exercise. Complexities of the menstrual cycle have long been considered major barriers to the inclusion of women in sport and exercise medicine research. And much of the research on exercise physiology has primarily included men, which makes it very difficult to generalize these findings to women. So let's talk about the menstrual cycle. The menstrual cycle is a physiologic event that's driven by beautiful cyclical cascade of hormones that rise and fall within it. Estrogen and progesterone are the two dominant or main hormones. They influence a lot of other physiological systems. It's their action on exercise that may have implications for performance, injury risk and prevention. So for simplicity, we'll talk about the menstrual cycle in three phases from an ovarian standpoint. The first phase is gonna be the follicular phase. This is going to be estrogen dominant. Then second phase is gonna be the ovulation where the ovary is releasing an egg. And the third phase is gonna be progesterone dominant or the luteal phase. Menstrual cycles are regulated by access called the HPO axis or the hypothalamic pituitary ovarian axis. Most menstrual cycles are gonna be on average 28 days, but average can arrange appropriate range can be anywhere from 21 to 45 days for teenagers or 21 to 35 days for adult women, starting with day one being the first day of flow. So the first phase is the estrogen dominant or the follicular phase. And you can see it indicated here, start of the cycle, day one of bleeding, which goes until roughly day 14 when ovulation in the second phase begin. In the first phase, estrogen is dominant, which means estrogen is increasing our basal metabolic rate. It's increasing insulin sensitivity and carb storage in use. It's decreasing our appetite and it's improving anabolic properties. During the follicular phase, your body adapts and responds better. This is the optimal time to build muscle mass, strength, strength and to increase power. You have a higher pain tolerance. You have a maximum voluntary force generation, capacity and endurance. You have efficient recovery. This is also an idle time to do workouts like HIIT workouts or high intensity training exercise. You feel good. During ovulation, it's still pretty estrogen dominant as you can see here marked by this gray outline here. And when it's in ovulation estrogen dominant, your muscles are warmer. Your appetite is increased. There also is this promotion of contraction-stimulated glucose update in your muscle fibers. So your strength levels are high. You have this increased sheer force generation capacity. And if you're going for a PR, now is the time. Next, we enter into the progesterone dominant phase or the luteal phase. And this is the almost the exact opposite of the estrogen dominant phase. You have an increased appetite, but you have decreased energy. You're craving carbs, but you're not using them. You have increased insulin resistance, greater protein breakdown, your muscles fatigued quicker. So it takes more energy to do some of the similar tasks that you could do easily before. And you can see this highlighted here with a progesterone dominant phase of phase three. During this phase, you may need to fuel with external carbohydrate sources because there actually is this depression of gluconeogenesis. You want to increase your hydration because there is this increase in body temperature as you can see down here, what we call basal body temperature during a luteal phase. And this can make running in the heat a little bit more difficult for an untrained athlete. You also want to increase your protein intake because you're having this increase in protein breakdown during this time. So specific injuries in female athletes do occur. And we're starting to see that more obviously with an increase in female athletes overall. There are a couple of different things, static factors versus dynamic factors that may contribute to injury. Static factors are going to be injuries that are due to a broader pelvis, a greater knee valgus, whereas dynamic factors are injuries that may occur while running or jumping or landing or changing direction. The latter, the dynamic injuries can often be due to tendon laxity. And tendon laxity can be what causes, well, one of the reasons that cause non-contact anterior cruciate ligament or ACL injuries. It also may be a cause of patellofemoral pain and instability. There also is a component, I think, maybe altered concentration due to menstrual cycle dysfunction. Things like painful cycles or PMS that can affect overall mood and overall decision making or alertness and responsiveness during training and activity and sports. There also is energy deficiency in hypoestrogenemia in female athlete triad or relative energy deficiency in sport, which can predispose to stress factors, which I will not be discussing that last one today. So we know that the anterior cruciate ligament is one of the major stabilizing intercapsular ligaments in the knee joint. Short and long-term consequences of ACL injuries can be both numerous and costly. It can also be career ending, given that the rate of return to sport is less than 50%. We know that female athletes are two to eight times more likely than male athletes to suffer from an ACL injury. And there's a couple theories about why that gender difference exists and it can be due to hormonal issues, anatomic issues, neuro muscular issues or biomechanical issues as well as environment. The mechanism of non-contact ACL injury is usually a one-step stop deceleration, cutting movements, sudden change of direction, landing from a jump with inadequate knee and hip flexion or a lapse of concentration that may result from an unanticipated change in the direction of play. That lapse of concentration is gonna be more important when we get to some of the menstrual dysfunction issues. So let's look at estrogen and ACL injury in female athletes. The ACL contains both estrogen and progesterone receptors. It's this exposure to increasing levels of estrogen that can cause this dose-dependent decrease in cellular proliferation and type one collagen synthesis within the ACL fibroblast. What this does is it reduces overall ACL strength, integrity and the ability to withstand higher loads. And you can see here again depicted estradiol in red, progesterone in purple, and the area where the exposure causes the down regulation is right here in this area. But as you remember, is when we feel good, we wanna attempt our PR, but we also may be at an increased risk of ACL injury during this time. But the interesting thing about this field of study is that it's rapidly evolving and sometimes there's a lot of conflicting evidence. As we can see here, one study noticed, noted that there was a statistically significant increase in ACL injury in the pre-ovulatory phase or right before ovulation occurs when estrogen is high. But then another study found that ACL injury rate was actually decreased during that same timeframe. There were limitations in both in that they did ask the girls to recall their menstrual cycle instead of having the girls actively track their menstrual cycle. And this does open up a room for error in terms of level of accuracy. However, while we're suspicious that most likely estrogen does play a role in changing the makeup of the ACL ligament, we don't have any conclusive evidence at this time that directly links an increase in ACL injury to a predictable time within the menstrual cycle. Further research is definitely needed and encouraged in this area. Patellar thermal pain instability in female athletes or PFPS is a common cause of anterior knee pain. And this most commonly affects young women without any structural change. It's a multifactorial etiology. It's believed that the patella is hypermobile and that that corresponds with this increase in pain. The hypermobile patella could be due to hormonally mediated laxity of surrounding supporting structures. But I was unable to find these specific studies looking at PFPS as it relates to menstrual cycles and female athletes. So there's certainly room for more research on that topic. So we know that a laxin concentration can increase the risk or is one of the mechanisms of possible injury for the ACL ligament. And there are certain menstrual dysfunctions that can alter concentration as well, that being PMS and dysmenorrhea just to name two today. PMS occurs in over 50% of menstruating women and dysmenorrhea are painful cycles. Occurs in 50 to 90% of adolescent girls and women. In regards to PMS, this is really due to a sensitivity to normal hormone exposure, sex hormone exposure and withdrawal. It has physical symptoms, as well as emotional and behavioral symptoms, which include joint and muscle pain, headaches, mood swings, poor concentration, irritability, or difficulty you're sleeping or sleeping too often. With painful cycles of dysmenorrhea, it can either be primary, meaning that there's painful menstruation without pathology and usually this is due to underlying increased inflammation or sensitivity to the inflammatory markers. And there's also secondary dysmenorrhea, just painful menses as it relates to some type of pelvic pathology or recognized medical condition. Symptoms of dysmenorrhea also include inability to sleep properly, nausea, vomiting, diarrhea, headaches and muscle cramps. These are critical changes that can happen on a monthly basis. When this is happening at an elite level of competition, even when this is happening at elite level, we know that even the smallest margins of error can be decisive and or can increase the risk of injury. So let's base solutions based here. So potential solutions could include menstrual cycle tracking. So what that means is we're tracking our menstrual cycles. We're allowing for better data collection. This can be a way to incorporate a new type of conversation between athletes, coaches and trainers. And the important thing is to know that talking about your menstrual cycle can be a really personal thing for a female athlete, but you do want to exercise some sensitivity in broaching this topic and forming this line of communication amongst athletes, coaches and trainers. This is really important because it can help to obtain a more accurate understanding of when injuries are occurring within the menstrual cycle, which can guide additional research, attention and treatment and preventional treatments. There's also the opportunity to evaluate for and correct any menstrual cycle dysfunction. So doing a better job of figuring out if any of the athletes are having any type of menstrual irregularity dysfunction and then talking about how that can be treated in order to decrease some of the unfavorable side effects that they may be experiencing that could be affecting their ability to perform to the level of their highest potential or could be placing them at the increased risk. There's also the need to involve sports nutritionists and dietitians. And that's important because we've seen the metabolic changes that are occurring and we need their help in order to help to assess how to change lifestyle and how to improve nutrition. We also know that inadequate nutrition can actually potentiate the metabolic response to a variant hormone. So does the menstrual cycle have sex boarding performance? Yeah, it can. But the menstrual cycle doesn't make us weak. It's not a deficit, it's not a hindrance, but it is some things that happens to most women every month and it has real effects on performance and could potentially increase the risk of injury. And so what we need to do is do a better job of just understanding the menstrual cycle and understanding how it affects female athletes so that we can better understand how we can optimize it and work with it in order to reach our fullest athletic potential and decrease the risk of injury. Just as this former British player said, that it's personal to every athlete and by no means should the menstrual cycle ever be used as an excuse. But at the same time, it does have an effect. As gynecologists, we say all the time that the menstrual cycle is the fifth vital sign and it's just as important to our health as our heart rate, our blood pressure, our pulse, and our body temperature. And we know that the United States women's national soccer team got it right. But when you track menstrual cycles and you pay attention to them, you get what every athlete wants, championships. Thank you so much for allowing me to do this talk. I'm so happy to take any questions at this time and looking forward to seeing you guys in the Q&A session.