Case history

Julie is a 15-year-old girl, who has participated in gymnastics at a national competitive level since the age of 8 years. Currently, she is active in sport 6 hours a week. Julie is healthy and takes no medication. There is no indication of anorexia. Julie's birth weight and length were 3.0 kg and 49 cm. Her mother experienced late puberty with menarche at age 15 years. At the age of 15, Julie is in breast stage 2 and pubic hair stage 1 with sign of early pubertal growth spurt (Fig. 3.4.4). Note that weight for height is well within the normal limits, between the 25th and the 50th percentile.

Marie is also 15 years old and she has been active in swimming at a competitive level since the age of 8 years. She is swimming 9 hours a week. She is healthy, takes no medication, and has normal eating habits. She is in breast and pubic hair stage 5, and Marie had menarche at the age of 11.4 years. Marie's birth weight and length were 3.4 kg and 52 cm. Her mother had menarche at the age of 12 years. She has a growth pattern in keeping with her early maturation (Fig. 3.4.4) with age at peak height velocity at 9.5 years. Note that her weight for height is similar to Julie's up to a height of approximately 150 cm.

Comment. These two girls represent the extremes of growth and maturation among girls participating in sport. Their growth patterns are in accordance with the literature; however, it should be noted that both girls have followed their initial growth pattern, and the gymnast has a genetic disposition for late puberty in contrast to the swimmer whose mother had first menstruation at the age of 12 years. Both girls had normal birth weights and lengths, and both girls had similar body mass indices up to a height of 150 cm.

Table 3.4.2 Prevalence of eating disorders in female athletes.

Activity N

Eating disorder (%)

Non-athletes 101


Activities emphasizing leanness

Dancing 55


Gymnastics 19


Track 40


Combined activities 35


Activities without emphasis on leanness

Tennis 25


Volleyball 14


Combined activities 32


Adapted from [81] and [82],with permission.

Adapted from [81] and [82],with permission.

clear, however, whether excess of exercise per se results in disturbances of female reproductive function. In a study of 22 female gymnasts and 22 healthy girls, a significantly reduced energy intake compared to nutritional recommendations was found in both groups, but more so in the group of gymnasts who also had the highest energy expenditure [57].

The sports associated with primary and secondary amenorrhea (gymnastics, figure skating, running and ballet) are also sports in which a slender physique is valued. Thus, a low body weight is prevalent in women participating in these sports. A high prevalence of eating disorders including anorexia nervosa and bulimia is also associated with these sports (Table 3.4.2). A comparison of body composition in female distance runners, gymnasts and anorexia nervosa patients showed no difference, indicating that the specific phe-notype may be achieved by different mechanisms [58]. Measurements of serum leptin showing comparable low levels in elite gymnasts and patients with anorexia nervosa have also indicated similarities between the two conditions [59].

The above mentioned menstrual disturbances are associated with low serum levels of estrogens and progesterone. Both steroids are of paramount importance for accretion of calcium into the skeleton during adolescence. Therefore, athletes with primary or secondary amenorrhea or even anovulatory cycles are at high risk of reduced bone mineral content and subsequent osteoporosis and spontaneous fractures. The research field of bone mineral content is associated with methodologic difficulties; however, available data suggest that female athletes have bone deficits of 0.9-20% (for review, see [60]). The pathogenesis of the reduced bone mineralization is most likely decreased sex steroid production possibly combined with insufficient calcium intake, since physical activity is known to promote bone accretion.

In summary, certain female sports are associated with eating disorders, both anorexia and bulimia, and the consequences of an excess energy expenditure compared to energy intake may lead to delayed menar-che and secondary amenorrhea, which in its turn may cause decreased bone mineral content. There is no evidence that physical activity per se results in disturbances of gonadal function and bone mineralization.

Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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