From Olympian to Olympic “Doc”: Focus on the Female Athlete

Dr. Connie Lebrun MDCM, MPE, CCFP (SEM), Dip. Sport Med, FACSM Glen Sather Sports Medicine Clinic Professor, Department of Family Medicine Faculty of Medicine & Dentistry University of Alberta, Edmonton, Alberta, CANADA Outline of Presentation

• History as an Olympic athlete () • History as a “doc” at the • Clinical complexities of female Olympic athletes: – Energy availability, menstrual function, bone density – Specific Injury patterns • ACL injuries • Concussion – Sex testing/hyperandrogenism/transgender issues – Pregnancy Volleyball Career • Started sports in Grade 9 • Gr. 10 teacher (Mr. Baluta) said I should keep on with volleyball - might get to go to Pan Ams! • University of Manitoba Bisonettes Volleyball Career

• Moved to 1974 - National team • Practiced 6 days/wk • 11 months/year • 6 h/day in summer • 3½ h/day in winter • November “off” to catch up on school, prepare for exams Volleyball Career

• 1973, 1977 • Multiple World Championships • Pan Ams 1975 Mexico City • Olympics 1976 Montreal Pan-American Games 1975

Dr. Ted Dr. Peter Percy Fowler

Olympics – Montreal 1976

Medical Career

• Rotating internship • Family Practice for 5 years – North Vancouver • Sport Medicine Fellowship (UBC) + Masters’ degree in Exercise Physiology • Transitioned to full-time academic sport medicine in 1995: – ON (UWO) – Edmonton (U of Alberta) Sport Medicine Event Coverage

• Local events – Marathon, • University/varsity, collegiate/high school • Regional/Provincial Games • : – Summer, Winter – CMO 2001 – London Ontario • World Transplant Games • World University Games • Pan-American Games – 1987 Indianapolis Assistant CMO Canadian National Rowing Team

Beach Volleyball – Bondi Beach Torino 2006….. Integrated Support Team (IST)

• Therapist (physiotherapist, athletic therapist) • Team Physicians (Medical Director, others) • Exercise Physiologist • Strength and Conditioning Coach • Nutritionist • Biomechanist • Sports psychologist 2010 Canadian Olympic Snowboard Team Winter Olympics

Chief Doctor Snowboard Success 2010

20 concussions (7%) THANK YOU

GO CANADA GO! 1986 History of the Ancient Olympics

. Held in Olympia, Greece . 776 BC to 336 AD . Only men allowed - competed in the nude . “Gymnasium” from Greek “gymnos” meaning nude History of the “Modern” Olympics

• Baron Pierre de Coubertin • “A healthy active body and a healthy active mind” History of the Olympics

• First modern Olympics – 1896

• NO WOMEN!! “their presence would be impractical, uninteresting, unaesthetic and incorrect” Women in the Olympics

Female Participation in Olympics

By Qwfp - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=20681539 Women in the Olympics

1948 - Fanny Blankers-Koen 1984 – Joan Benoit 4 gold medals 1st women’s marathon IOC Medical Commission Statement on Female Reproductive System in Sport

“No female athlete should be denied the opportunity to participate in any Olympic sport on the basis that she might sustain an injury to her reproductive organs.

A survey of injury data has failed to find any evidence of an increased risk of acute or chronic damage to the female reproductive organs occurring as a direct result of participation in sport.” Olympics – Montreal 1976

Olga Korbut Nadia Comaneci The Female Athlete Triad

1. 1992 – “Think Tank” Washington DC ACSM Position Stand: The Female Athlete Triad Otis et al., 1997 LowDisordered Energy Availability Eating and/or(Including Eating Eating Disorders)Disorder

Amenorrhea Osteoporosis (Menstrual Dysfunction) (Osteopenia) Risk of Injury, Triad

Health, Fitness, Longevity “New” Female Athlete Triad ACSM Position Stand 2007

Nattiv et al. MSSE 2007

ACSM Position Statement, 2007 • Female Athlete Triad Coalition: – Established in 2002 – Under umbrella of ACSM – 25 organizations – Educational, research, policy and clinical issues • 2014 Consensus Statement on RTP: – Decision tool – risk stratification www.FemaleAthleteTriad.org Return to Play Issues

Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, Meyer N,IOC Sherman Consensus R, Steffan K, Statement:Budgett R, LjungqvistMeetingA. in Lausanne November 2013 Br. J. SportsPublication Med 2014;48:491 April 2014-497 Health Consequences Performance Consequences Injuries in Female Olympic Athletes

20 concussions (7%) Medical Monitoring ACL Injuries in Women

FIFA 11+ Program Female Athletes and Concussion?

• Higher incidence of concussion? • More honest in reporting symptoms • Neck muscles less well-developed?

• Hormonal differences? Female Athletes and Concussion

• More prone – Physiologic • Neck strength • Center of rotation • ROM of neck • BMI (smaller size) • Brain morphology • Lacking experience in body checking? Gender Verification

1932 Olympics Stella Walsh (Stanislawa Walasiewicz ) Gender Verification

• To ensure “athletes are competing on an equal basis considering their physical status”

• Direct visualisation of genitals? – 1966 European T&F Championships – 1967 Pan Am Games • Replaced by buccal smear • Polymerase chain reaction (PCR) Gender Verification Last carried out on a full-scale basis in Atlanta in 1996 – 3,387 athletes - 8 tested “positive” 58 professionals donated from 18-90 days of time at lab cost alone was more than $150,000 Gender Verification at the 2012 Olympics: New IOC Regulations for Female Athletes

Serum testosterone < 10 nmol/L 2015 Dutee Chand

“..endogenous testosterone….. not indisputably proven to provide …. an athletic advantage” Rio 2016 Olympics Trans Gender Issues?

Bruce Jenner – Decathlon GOLD Montreal Olympics 1976 …"the world's greatest athlete." Issues of Sexual Identity

• ‘Intersex’  Disordered sexual development (DSD)

• Androgen insensitivity – Faulty androgen receptor • Genetic mutations – 5 alpha reductase deficiency – 17 alpha reductase deficiency – C17 hydroxylase deficiency – Lead to Congenital Adrenal Hyperplasia IOC 2015 Consensus Meeting on Sex Reassignment and Hyperandrogenism • • “Living document” • Transgender athletes not excluded • Not necessary to have reassignment surgery • Total testosterone less than 10 nmol/L for at least 12 months TAEKWONDO

By William Gildea August 4, 1992 BARCELONA, AUG. 3 -- It was a strange afternoon at taekwondo.

Lynnette Love, of Temple Hills, Md., won a bronze medal today although she actually didn't win a match.

Love's opponent in the heavyweight division quarterfinals today, a Canadian, failed to submit the results of a pregnancy test.

So Love went on to the semifinals but lost to a Spaniard after five officials conferred and awarded the fight to Coral Bistuer, the obvious hometown favorite, after the two women fought to a scoreless tie.

Cyclist believed to be first U.S. athlete to pass on Rio Olympics due to Zika concern

Tejay van Garderen Oksana Chusovitina

Average age of Olympic gymnasts in Rio: 19.9 years

Ibtihaj Muhammad USA

Kimia Alizadeh Zenoorin, Iran Zenoorin, Iran

Hedaya Wahba, Egypt

Sara Ahmed, Egypt Canadian women: 16 of 22 medals (first 12) USA women: • 61 of 121 medals • Would have placed 3rd as a country behind behind (70) and Britain (67) and just ahead of the American men (60)