Women and sport

Abstract

Regular physical activity is important for the health of both sexes. However, the physiological, anatomical, psychological and socio-cultural specificities of women require special considerations in all aspects of their sports. Puberty brings gender differences that result from different sexual functioning of endocrine axis. Despite the identical mechanisms of adaptation to physical activity, sexually mature women and men have inherited anatomical and physiological differences in body composition, aerobic capacity-building and muscle strength. In particular, it relates to the more complex female reproductive system. The female reproductive system is a functional part of the human body most sensitive to stress caused by heavy physical exertion. The most common disorders whose risk was significantly increased in physically active women are eating disorder, disturbed menstrual cycle, infertility, intimidated fractures, rupture of the anterior cruciate ligament, or even death. Mainly those are result of blunders and ignorance. Fortunately, they are largely preventable.

Full text

1
SUMMARY
Regular physical activity is important for the health of both sexes. However, the physiological,
anatomical, psychological and socio-cultural specicities of women require special considerations in
all aspects of their sports. Puberty brings gender differences that result from different sexual function-
ing of endocrine axis. Despite the identical mechanisms of adaptation to physical activity, sexually
mature women and men have inherited anatomical and physiological differences in body composition,
aerobic capacity-building and muscle strength. In particular, it relates to the more complex female
reproductive system. The female reproductive system is a functional part of the human body most
sensitive to stress caused by heavy physical exertion. The most common disorders whose risk was
signicantly increased in physically active women are eating disorder, disturbed menstrual cycle, in-
fertility, intimidated fractures, rupture of the anterior cruciate ligament, or even death. Mainly those
are result of blunders and ignorance. Fortunately, they are largely preventable.
Key Words: physical activity, eating, menstrzal cycle, intimedated fractures, female athlete triad.
WOMEN AND SPORT
Nenad Ponorac1, Stanislav Palija2, and Mira Popović3
1School of Medicine, University of Banja Luka, Bosnia and Herzegovina
2Institute of Physical Medcine and Rehabilitation “Dr Miroslav Zotović”, Banja Luka,
Bosnia and Herzegovina
3Institute of Occupational and Sports Medicine of The Republic of Srpska, Banja Luka,
Bosnia and Herzegovina
EDITORIAL ARTICLE
OWERVIEV PAPER
doi: 10.5550/sgia.130901.en.001P COBISS.BH-ID: 3812888 UDC: 796.035-055.2
INTRODUCTION
Historical medical record U.S. Surgeon General’s
Report on Physical Activity and Health gave solid
scientic evidence that regular physical activity is very
important for the health of both men and women,
with the recommendation of active participation in
all aspects of physical activity and sports (U.S. Depart-
ment of Health and Human Services, 1996). How-
ever, the physiological, anatomical, psychological and
socio-cultural specicities of females require special
considerations in all aspects of their sports (Grey-
danaus & Patel, 2002). Women now have available all
sports venues, but it was not always the case. The rst
Olympic Games (776 B.C.) were privilege and pleasure
of men only. Women have sought their satisfaction
in the Games in honour of the goddess Hera, the
protector of women of that age. First modern Olym-
pic Games, held in 1896, had a similar trend for
women, meaning they were without the possibility to
participate (Ponorac, 2008).
Beginning of the 20 century made progress in this
regard and women were slowly included in a broader
range of sporting activities. That is how, slowly but
surely, they became a part of sporting life. On the
other Olympics 12 women were competing in tennis
and golf, so-called upper class sports (Pster, 2000).
The increase in female participation in sports hap-
pened in the second half of the 20th century, and on
23 July 1972 dawned another 8 March, this time in
sports. U.S. President Nixon signed the famous Title
IX (Education Amendment Act) which provides that
“no person in the United States may not, on the basis
of sex, be excluded from participation in, denied the
benets of, or be subjected to discrimination in any
educational program or activity nanced by public
funds “(Mitchell & Ennis, 2007).
Since the signing of the Title IX until the 80’s of
the last century, the number of awarded scholarships
SportLogia
2013, 9(1), 1–7
e-ISSN 1986-6119
www.SportLogia.com

Ponorac, N. et al.: WOMEN AND SPORT SportLogia 2013, 9(1), 1–7
2
and so women actively involved in the sport as well,
has increased by 700%, and during the 90’s for an-
other 50%. At the beginning of the new millennium,
one of three high school students in the United States
was actively involved in the sport as opposed to one
of 27 in 1972 (Ireland & Ott, 2004). The London
2012 achieved yet another record, a record number
of participants, 46% of over 10.000 participants, while
in 1908 the ratio was 53:1 in favour of men.
Playing sports gives women many benets. It is
proven that girls active in sports have better success
in school, are less likely to face unwanted pregnancies
in their teen age, have higher self-esteem and self-
condence, more easily and more often enrol in col-
leges and universities, and less frequently have prob-
lems with drug abuse and dependence diseases.
Exercises with weight load have inestimable benet
to the development and maintenance of bone mass
in females at all ages (Hagen, 2005).
However, nature has not signed the declaration
on gender equality in sport. As for the physical activ-
ity a long time ago people said that women are “the
weaker gender”. Along with the trend that all sports
can be practiced for the sake of gender equality, in
women it leads to the development of many features
that evolutionarily characterized men. According to
Nikola Grujic, during the evolution biology already
made gender differences in the relation to especially
their reproductive role, so the “interference in her affairs”
responses with the consequences that are unforeseen
and which price is extremely expensive in every case.
This price can be paid as an eating disorder, disturbed
menstrual cycle, infertility, intimidated fractures,
rupture of the anterior crossed ligament, or even
death. Is it worth? These aspects will be discussed in
the following sections.
SPECIFIC PHYSIOLOGICAL AND
ANATOMICAL CHARACTERIS-
TICS OF FEMALE ATHLETES
Since today most sports are equally available to
both genders, the sports results are often surprising.
Differences in world records in men’s and women’s
events are not as drastic and they vary within a range
of 15%. For science, especially of sports, raise new
questions, whether it is the result of real biological
differences between the genders and where is the ne
line between physiology and pathology?
Pre-puberty boys and girls have comparable
physical abilities, in general, they can play in the same
teams and compete against each other until the age
of 10 (Ireland & Ott, 2004).
Puberty causes signicant differences between the
genders as a result of various sexual functioning of
endocrine axis, and the presence of testosterone and
one with oestrogen and progesterone on the other.
In particular, it relates to the more complex female
reproductive system.
Despite the identical mechanisms of adaptation
to physical activity, sexually mature women and men
have inherited anatomical and physiological differ-
ences that are reected in body composition, aerobic
capacity and muscle strength.
Body composition of women is characterized by
lower total mass, a lower percentage of muscle tissue
and increasing percentage of fat.
The smaller muscle mass mainly refers to small
diameter of single muscle bre. This is logical given
the anabolic effect of testosterone and a slight pre-
dominance of type I muscle bres, which have a
smaller diameter. Thus, women have less ability to
generate absolute power, especially in the upper ex-
tremities, which is as much as 50% less than men. But
when power is expressed in relative muscle mass, body
mass and cross-section of muscle those differences
are signicantly reduced. Women have an average of
5-15% less aerobic capacity. These differences do not
stem from differences in muscle bres (capillarization,
mitochondrial content and enzymes of aerobic me-
tabolism) than in the ability to receive oxygen.
Women have a lower stroke volume and thus cardiac
output. The smaller blood volume, hematocrit and
haemoglobin contribute to a lower aerobic capacity.
This difference is also attributed to testosterone, which
besides an anabolic effect also serves as a stimulus
for erythropoietin (Kenney, Wilmore, & Costil, 2012)
A higher percentage of body fat females owe to
estrogens. It stimulates the disposal of fat in the
subcutaneous tissue, breast tissue, especially in the
gluteus region and thighs. High lipoprotein lipase
activity during puberty causes the deposition of fat
in these areas which is hard to lose. Along with the
expansion of the pelvis this causes a distinctive feature
of the female gure. Often this look is a source of
great dissatisfaction with women, with high neglects
of its real role. During the last trimester of preg-
nancy and throughout lactation activity of lipoprotein
lipase is reduced and decomposition begins, which
suggests that fat is stored here only as an energy sup-
port to pregnancy and breastfeeding and extension
of our species (Bjorntorp, 1986).
The most striking anatomical difference is related
to the dimensions of the pelvis, which is by a greater
width subordinated to the birth process. Conse-
quently it is altered to anatomical position and man-

Ponorac, N. et al.: WOMEN AND SPORT SportLogia 2013, 9(1), 1–7
3
ner of movement of the lower limbs (Ireland & Ott,
2004). The so-called Miserable Misalignment Syndrome
is a set of anatomical variations of the lower ex-
tremities, which probably make women predisposed
to instability, knee pain and nally frequent anterior
cruciate ligament injury (Myer & Ford, 2004). In
extreme cases it is composed out of femoral antever-
sion, accompanied by a quadriceps angle (Q-angle)
greater than 15 degrees, external tibial torsion, increased
foot pronation, attening foot (pes planus) and hy-
poplastic musculus vastus medial obliqus (Figure 1).
This syndrome, with differences in neuromuscular
response, hormonal status (effect of estrogen recep-
tors on ligaments), and of course, differences in
training, causes up to 7 times more common injuries
of anterior cruciate ligament and patellar syndrome
with female than male athletes (Ireland & Ott, 2004).
MEDICAL
ASPECTS OF
FEMALE SPORTS
Female athlete triad
Increasing number of females participating in
sports has increased the risk for any negative conse-
quences that follow sports. The danger is accentu-
ated because women are starting to compete in the
endurance sports without any limitations. А number of
typically female prole sporting disciplines with a
strong emphasis on the external appearance of a
woman is also increasing.
The female reproductive system is a functional
part of human body most sensitive to the stress caused
by hard physical labor and sports (Yeager, Agostini,
Nattiv, & Drinkwater, 1993).
FIGURE 1
Misalignment Syndrome.
In the early 90`s of the last century the connection
between women athlete eating disorders, menstrual cycle
disorders and disorders of bone metabolism (mineralization)
became apparent. Yeager et al. (1993)included them in
the syndrome known as the Female Athlete Triad. Since
the gymnast Christy Henrich died in 1994 in the age
of 22 and with 29 kg in weight due to a bizarre remark
of her trainer that she is “too fat” for the Olympic
team, the medical community turned on red warning
light for each of the individual symptoms of the
Triad. The potential impact of each disorder or a
combination of several of them has proven to be
harmful for the health and success in sports (Drink-
water, Loucks, Sherman, Sundgot-Borgen, & Thomp-
son, 2005).
Three angles of the Triad are mutually multiply
intertwined by physiological and psychological
mechanisms, and the presence of one of the symptoms
requires immediate testing for the presence of others
(Barrack, Ackerman, & Gibbs, 2013).
Eating disorders
Eating disorders are disorders of the continuous
model. It ranges from abnormal eating habits in order
to reduce weight to serious clinical conditions that
result even with death (Goldstein, Dechant, & Bere-
sin, 2011).
In the continuum there are clinical disorders An-
orexia Nervosa, Bulimia Nervosa and special category Eating
disorders not otherwise specied - EDNOS (“Diagnostic
and statistical manual of mental disorders”, 1994).
• Anorexia Nervosa is the most severe eating dis-
order that often results in fatal outcome. The
sick person sees himself “too fat” and suffers
from a fear of weight gain, although it often
weights even 15% less than the expected.
•
Bulimia Nervosa is characterized by cycles of
restrictions in diet or fasting to track the phases
of uncontrolled overeating for so-called psy-

Ponorac, N. et al.: WOMEN AND SPORT SportLogia 2013, 9(1), 1–7
4
chological hunger, followed by a phase of clean-
ing. Cleaning includes induced vomiting, use of
laxatives or diuretics (purging type) and starva-
tion and extreme exercise (non-purging type),
with the aim of returning to the old state.
Women athletes with bulimia are often normal
weight (Sundgot-Borgen & Larsen,1993).
•
Eating disorders not otherwise specified
(EDNOS) apply to a wide range of eating dis-
orders that do not meet all the criteria of clini-
cal disorders. People have normal weight;
however, there is a preoccupation with diet, body
weight, shape and body composition.
•
Subclinical forms of eating disorders exist in many
cases of eating disorder where woman athlete
is trying to reduce body weight or fat percentage
by exposing herself to the restrictions on food
(diet), avoiding certain food or practicing other
abnormal eating habits without reaching the
criterion for eating disorders (Sabatini, 2001).
• Low Energy Availability is the state in sports that
is caused by decreased energy intake, diet or
signicantly increased energy use through
physical activity. Energy decit without eating
disorder is often associated with disturbances
of the menstrual cycle and presents a “starting
point” for the development of the Triad.
The exact percentage of athletes with eating dis-
order is difcult to determine because it is a symptom
of Triad that is often overlooked and unspoken.
Studies show a higher incidence of eating disorders
in athletes compared to non-athletes, women athletes
compared to men athletes (Coelho et al., 2013). Female
athletes who participate in sports with strong aes-
thetic appearance (dance, gymnastics, ballet), endur-
ance sports (athletics, swimming, cycling) and those
that compete in weight categories (martial arts) are at
the higher risk level. The incidence of anorexia and
bulimia by DSM-IV criteria in normal population
ranges from 1% to 3%, while the percentage of eat-
ing disorders in athlete population ranges from 15%
to 62%, depending on the type of sports (Sundgot-
Borgen & Torstveit, 2004).
Literature states following possible causes for eat-
ing disorders:
• Diets - Restrictive diet to reduce weight is the pri-
mary cause for the development of eating dis-
orders.
• Calorie Decit. The rapid increase in the volume
of training can cause a calorie decit.
• Start of sport-specic exercise before puberty. Female
athletes with identied eating disorders began
with their careers earlier than other athletes
(Thomson & Sherman, 1999). If sport-specic
exercise begins before puberty, rapid growth and
development can lead to a mismatch between
the body shapes and requires of the chosen
sport, which as a consequence can have a change
of body composition by strong restriction diet
(Deimel & Dunlap, 2012).
•
Traumatic experiences. The most common trau-
matic experiences that inuence the development
of eating disorders are changes or loss of coach
and athlete’s illness or injury, manifested by dif-
culties in training. This often leads to weight
gain, or in some cases, the fear of it, leading to
subsequent compensatory reduction of food
intake. Possible trauma are also random inter-
ruptions and comments regarding physical ap-
pearance, poor school success, problems with
your partner or parents, death of a friend, and
nally, and often, sexual abuse by a coach (Drink-
water et al., 2005).
•
Beliefs that reduce of body weight or fat percentage leads
to improved physical tness. The initial weight loss
can often improve physical tness. This initial
success can stimulate the athlete to continue
with mass loss until the very development of
eating disorder. Athletes often commented, “It
just happened, it was never planned”.
Coaches often give a contribution to this risk fac-
tor by stimulating this unhealthy and unnatural way
of improving physical tness of their athletes.
Ofcial stance of the IOC is that coaches cannot assess
body composition of athlete nor make suggestions. It is recom-
mended that they can only express their concern or attitude
about it and direct athlete to a doctor or dietitian-nutritionists
specialist. He will, after careful consideration and review, to-
gether with the athlete decide on the measures on how to correct
body mass (Ibid).
Health effects that eating disorders leave behind
affect many systems, and mortality caused by an-
orexia nervosa, as the most severe one, is 6%.
The early effects are decrease in basal metabolic
rate, extraction of glycogen from muscle and liver,
decreased in muscle mass and dehydration. This makes
the athlete more susceptible to fatigue and musculo-
skeletal injuries due to disturbed endurance, strength,
movement coordination and concentration. Electro-
lyte imbalance can lead to serious heart rhythm dis-
orders, and endocrine system and thermoregulation
are also affected. Bulimics suffer from severe gastro-
intestinal problems and enlargement of parotid gland
and erosion of tooth enamel as a result of frequent
vomiting (Otis, Drinkawater, Johnson, Loucks, &
Wikmore, 1997).

Ponorac, N. et al.: WOMEN AND SPORT SportLogia 2013, 9(1), 1–7
5
Late effects are estrogen decit and menstrual
cycle disorder, which presents the link between rst two
symptoms of Triad.
Menstrual cycle disorders
Monthly menstrual cycle is a complex interaction
between the endocrine and reproductive system of a
women. Normal, regular menstrual cycle (eumenorrhea)
lasts 24-36 days, an average of 28 days. It most com-
monly begins with menarche - rst menstrual bleeding
in the average age of 12.88 years in North America
and 13 in Europe (Ibid).
A wide range of menstrual cycle disorders can be
found in physically active women, especially athletes.
• Oligomenorrhea as a term refers to irregular men-
strual cycles with bleeding interval longer than
36 days or 3 to 6 times per year.
•
Primary amenorrhea is dened as the non-appear-
ance of menstrual cycle by age of 16 in girls
with the presence of secondary sexual charac-
teristics or non-menstrual bleeding and by 14
years with the underdevelopment of secondary
sexual characteristics.
•
Secondary amenorrhea is dened as the absence of
three or more consecutive menstrual cycles after
menarche in the absence of pregnancy, or less
than three periods per year (Nativ et al., 2007).
Frequency of menstrual dysfunctions with normal,
adult population ranges from 2% to 5%, while in
sports it varies signicantly depending the type of
sports, competition rang and a lot of other parameters,
and they range from 20% to incredible 70% in certain
samples (Elford & Spence, 2002). In general, the
highest frequency was noticed in endurance sports,
sports with weight categories and sports with empha-
sized aestetic performance. Ponorac derived similar
results when he examined the sample of elite na-
tional women athletes. The frequency of all men-
strual dysfunctions was greater in groups of athletes
in relation to the control group. Primary amenorrhea
was determined in 8.33% and oligomenorrhea in
13.09% of female athletes (Ponorac, Rašeta, Radovanović,
Matavulj, & Popadić-Gaćeša, 2011)
One of the most appropriate mechanisms of
menstrual disorders in sports includes also eating
disorders. Energy access/availability is dened as the
energy calorie intake minus the energy consumed
during physical activity. The imbalance between en-
ergy expenditure during exercise and caloric intake
causes the body to receive information about the
inadequate energy storage necessary to support re
-
production and fetal development. The body then
enters a state of “energy conservation” and the re-
productive system, as a luxury feature, is very effec-
tively extinguished with the goal of self-defense, or
by informal terminology enters a “shut down” state.
This type of amenorrhea is named Functional hypotha-
lamic amenorrhea (HPA), and often as a synonym appears
the term Sports amenorrhea (Catherine & Gordon, 2010).
Amenorrhea is neither desired nor “normal”
condition caused by sports. In amenorrheic female
athletes ovulation is difcult to predict, what causes
the possibility of unwanted pregnancy, which is es-
pecially difcult in the season of important events.
The risk of endometrial hyperplasia and adenocarci-
noma of the uterus is also increased.
However, the most severe consequence, and at the
same time the third symptom of the Triad, is bone mass loss
and subsequent osteoporosis (Thein-Nissenbaum, 2013).
Disorder of bone
metabolism (Osteoporosis)
Bone is a metabolically active tissue, and bone
remodeling involves the reabsorption and bone for-
mation, a process that takes a lifetime. The balance
between these two processes enables the maintenance
of overall bone mass and bone morphology. At least
60-70% of the maximum bone mass is gained during
puberty and adolescence, the so-called “window of
opportunity”, and to 90% by the end of the second
decade of life (Barnekow-Bergkvist, 2005). Positive
effects for reaching the maximum (peak) bone mass
of young female come from various forms of phys-
ical activity, the level of growth hormone and IGF-I,
and preserved physiological menstrual cycle (Jurimae
& Jurimae, 2008).
Low energy availability with or without eating
disorder, amenorrhea and osteoporosis, individually
or connected as Triad, present a signicant health risk
for a women bone. Estrogen decit caused by the
HPA undermines the achievement of maximum bone
mass in young women and can signicantly reduce
the positive effect of physical activity on bone
(Ducher & Eser, 2009). Consequentially arises the
osteoporosis, one of the most difcult bone diseases,
when mineral content and bone may be so reduced
that stress fractures occur even after a minimal load
(Barrack et al., 2013).
Additional decit of calcium and protein due to
an eating disorder, plus delayed menarche, are more
favorable to premature osteoporosis of female athlete.
In accordance with the latest recommendations,
the primary treatment of Triad begins with ght
against eating disorders. As the best solution proved
to be an increase in energy intake and reduced train-
ing volume in order to increase the energy level to

Ponorac, N. et al.: WOMEN AND SPORT SportLogia 2013, 9(1), 1–7
6
the extent that would allow reestablishment gender
shaft of a woman. That also solves the third symptom,
by stopping the loss of bone density, including os-
teoporosis (Ibid).
CONCLUSION
In response to one of these questions at the begin-
ning of the text, we can conclude the following. Most
of these medical conditions that often affect physi-
cally active women and female athletes have a high
price for sports, essentially healthy activity. Also, the
intention was to show the delicate border where sports
ends and medicine begins. Fortunately, most of the
described disorders are the result of errors during the
training process and can be prevented with certain
measures. It has long been said that “prevention is
better than the cure”. Introducing female athletes,
coaches, parents and doctors with this problem is also
the rst step.
REFERENCES
Barnekow-Bergkvist, M., Hadberg, G., Pettersson,
U., & Lorentzon, R. (2005). Relationships
between physical activity and physical capacity
in adolescent females and bone mass in
adulthood. Scand J Med Sci Sports, 14, 1–9.
Barrack, M. T., Ackerman, K. E., & Gibbs J. C.
(2013). Update on the female athlete triad. Curr
Rev Musculoskelet Med, 6(2), 195–204. doi:
10.1007/s12178-013-9168-9; PMid: 23613226
Bjorntorp, P. (1986). Fat cells and obesity. In K. D.
Bronwell (Ed.), Handbook of eating disorders (pp.
88–98). New York, NY: Basic Books.
Catherine, M., Gordon, M. D. (2010). Functional
Hypothalamic Amenorrhea. N Engl J Med, 363,
365–371.
Coelho, G. M., de Farias, M. L., de Mendonça, L.
M., de Mello, D. B., Lanzillotti, H. S., Ribeiro, B.
G., Soares Ede, A. (2013). The prevalence of
disordered eating and possible health
consequences in adolescent female tennis
players from Rio de Janeiro, Brazil. Appetite, 64,
39–47. doi: 10.1016/j.appet.2013.01.001; PMid:
23318655
Deimel, J. F., & Dunlap, B. J. (2012). The female
athlete triad. Clin Sports Med, 31(2), 247–254.
doi: 10.1016/j.csm.2011.09.007; PMid:
22341014
Diagnostic and statistical manual of mental
disorders, DSM-IV (1994). In: Diagnostic and
statisticl manual of mental disorders, DSM-IV.
American Psychiatric Association (1st ed)
Washington D.C.
Drinkwater, B., Loucks, A., Sherman, R. T.,
Sundgot-Borgen, J., Thompson, R. A. (2005).
IOC Medical Comissission Working Group: Position
Stand on The Female Athlete Triad. Retrived from
httc://www.olympic.ogr.
Ducher, G., Eser, P., Hill, B,. & Bass, S. (2009).
History of amenorrhea compromises some of
the exercise-induced benets in cortical and
trabecular bone in the peripheral and axial
skeleton: a study in retired elite gymnasts. Bone,
45, 760–767. doi: 10.1016/j.bone.2009.06.021;
PMid: 19573632
Elford, K. J., & Spence, J. H. (2002). The forgotten
female: Pediatric and adolescent gynecological
concerns and their reproductive consequences. J
Pediatr Adolesc Gynecol, 15, 65–77. doi: 10.1016/
S1083-3188(01)00146-2
Goldstein, M. A., Dechant, E. J., & Beresin, E. V.
(2011). Eating disorders. Pediatr Rev., 32(12),
508–521. doi: 10.1542/pir.32-12-508; PMid:
22135421
Greydanaus, D., & Patel, D. (2002). The female
athlete before and beyond puberty. Pediatr Clin
N Am., 49, 553–580. doi: 10.1016/S0031-
3955(02)00005-6
Hagen T. (2005). Sports medicine and the
adolescent female. J Pediatr Adolesc Gynecol, 18,
9–15. doi: 10.1016/j.jpag.2004.11.005; PMid:
15749579
Ireland, M., & Ott, S. (2004). Special conserns of
the female athlete. Clin Sports Med, 23, 281–289.
doi: 10.1016/j.csm.2004.04.003; PMid:
15183572
Jurimae, J., & Jurimae, T. (2008). Bone Metabolism
In Young Female. Kinesiology, 1, 39–49.
Kenney, L. W., Wilmore, H. J., & Costil, L. D.
(2012). Physical Activity for Health and Fitness. In:
Physiology of sport and exercise. 5th ed.
Champaign. IL: Human Kinetics.
Mitchell, N., & Ennis, L. A. (2007). Encyclopedia of
Title IX and Sports. Westport: Greenwood Press.
Myer, G., & Ford, K. (2004). Methodological
approach and rationale for training to prevent
anterior cruciate ligament injuries in female
athlete. Scand J Sci Sports, 14, 275–285. doi:
10.1111/j.1600-0838.2004.00410.x; PMid:
15387801
Nativ, A., Loucks, A., Manore, M., Sanborn, C.,
Sundgot-Borgen, J., & Warren, M. (2007).
ACSM Position Stand; The Female Athlete
Triad. Med Sci Sports Exerc, 39, 1867–1882. doi:

Ponorac, N. et al.: WOMEN AND SPORT SportLogia 2013, 9(1), 1–7
7
10.1249/mss.0b013e318149f111; PMid:
17909417
Otis, C. L., Drinkwater, B., Johnson, M., Loucks,
A., & Wilmore, J. (1997). American College of
Sports Medicine: Position stand; The female
athlete triad. Med Sci Sports Exerc, 29, 5–16. doi:
http://dx.doi.org/10.1097/00005768-
199705000-00037
Pster, G. (2000). Women and the Olympic Games.
In B. L. Drinkwater (Ed.), Women in sport.
Oxford, GB: Blackwell Science Ltd. doi:
10.1002/9780470757093.ch1
Ponorac, N. (2008). Sport kao rizik za nastanak
poremećaja ishrane, menstrualnog ciklusa i metabolizma
kosti [Sport as a risk of eating disorders,
menstrual cycle and bone metabolism].
Unpublished doctoral dissertation, University of
Banja Luka, Medical Faculty.
Ponorac, N., Rašeta, N., Radovanović, D., Matavulj,
A., Popadić-Gaćeša, J. (2011). Bone metabolism
markers in sportswomen with menstrual cycle
dysfunctions. J Med Biochem, 30(2), 1–5.
Sabatini, S. (2001). The female athlete triad. Am J
Med Sci, 322, 193–195. doi: 10.1097/00000441-
200110000-00007; PMid: 11678514
Sundgot-Borgen, J., & Larsen, J. (1993). Pathogenic
weight-control methods and self-reported eatig
disorders in female elite athletes and controls.
Scand J Med Sci Sports, 3, 150–155. doi: 10.1111/
j.1600-0838.1993.tb00379.x
Sundgot-Borgen, J., & Torstveit, M. (2004).
Prevalence of eatin disorders in elite athletes is
higher than in the general population. Clin J
Sport Med, 14, 25–32. doi: 10.1097/00042752-
200401000-00005; PMid: 14712163
Thein-Nissenbaum, J. (2013). Long term
consequences of the female athlete triad.
Maturitas, 75(2), 107–112. doi: 10.1016/j.
maturitas.2013.02.010; PMid: 23541905
Thomson, R., & Sherman, T. (1999). Good Athlete
traits and characteristice of anorexia nervosa:
Are they similar? Eating Disorders, 7, 181–190.
doi: 10.1080/10640269908249284
U.S. Department of Health and Human Services.
(1996). Physical activity and health: A report of the
Surgeon General. Atlanta, GA: U.S. Department
of Health and Human Services, Centers for
Disease Control and Prevention, National
Center for Chronic Disease Prevention and
Health Promotion.
Yeager, K., Agostini, A., Nattiv, A., & Drinkwater,
B. (1993). The female athlete triad: disordered
eating, amenorrhea, osteoporosis. Med Sci Sports
Exerc, 25, 775–777. doi: 10.1249/00005768-
199307000-00003; PMid:8350697
Received: May 23, 2013
Revision received: Jun 19, 2013
Accepted: Jun 19, 2013
Correspondence to:
Nenad Ponorac, PhD
Medica school
Save Mrkalja 14
78000 Banja Luka
Bosni and Herzegovina
Phone: 00387 65 51 52 64
E-mail: ponorac051@yahoo.com