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Am Fam Physician. 2022;106(1):52-60

Patient information: See related handout on RED-S in the active female, written by the authors.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Physical activity has many health-related benefits, including prevention and management of chronic disease, weight management, and improved mental health. Active girls and women of all ages and abilities are at risk of relative energy deficiency in sport, a syndrome encompassing low energy availability, menstrual irregularities, and disordered bone metabolism. Presence of amenorrhea or oligomenorrhea may suggest reduced energy availability. Active females are at risk of overuse injuries, including patellofemoral pain syndrome, iliotibial band syndrome, and stress fractures; treatment usually includes activity modification, a period of rest, and physical therapy. Active females are also at risk of acute injuries, including concussion and anterior cruciate ligament injuries. Pregnant patients without contraindications who were physically active before pregnancy can continue these activities, and those who were not previously active may gradually increase their activity level to a goal of 150 minutes per week. Moderate exercise during pregnancy reduces the risk of gestational diabetes mellitus, preeclampsia, and cesarean delivery. Postpartum exercise focused on core and pelvic floor strengthening can improve pelvic floor dysfunction. Supervised exercise programs focused on strength and balance have been consistently shown to reduce the risk of falls and injurious falls in older women.

Since the passing of Title IX in 1972, female participation in sports at all levels has steadily increased1; however, overall, females continue to be less active than males, starting in childhood.2 Active play in childhood has a major impact on weight management, socialization, and self-confidence. Girls can be encouraged to be physically active during early childhood to cultivate a lifetime enjoyment of sport. Education on participation in multiple sports as opposed to early specialization can help promote this enjoyment because children who participate in multiple sports are less likely to experience overuse injury and burnout.3,4 The benefits from athletics in childhood continue throughout adulthood. In adult women, exercise is associated with myriad benefits, including reduced risk of depression, chronic diseases (e.g., cardiovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, obesity), breast and ovarian cancers, and falls and fractures. Although there are significant benefits of exercise across all populations and ages, active females are also at risk of overuse and traumatic injuries. This article discusses special considerations for the active, female-gender-assigned-at-birth patient. Information about caring for transgender athletes can be found in a previous issue of American Family Physician (AFP).5,6

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