Madhva Prasad Sarvothaman

As the adage goes, “the biggest sophistication is simplicity”. Many a time we prefer to advocate modern and advanced methods of treatment, but overlook simple solutions. One may recall that the WHO definition of health states it not to be merely the absence of disease. In the context of the twenty first century, lack of physical activity, and life-style disorders are threatening to setback all medical achievements. No medical professional should neglect this aspect of a woman’s life - physical activity. Though it appears trivial, the relevance of this aspect to women’s health is profound.

A brief discussion on the inter-relationship of physical activities, physical fitness, exercise and sports, with women’s health is presented here. Physical activity usually gains importance during the first two decades, where many females may enrol in sporting activities. It may be noted that till the turn of the 20th century, there was a Victorian-era belief that sports was exclusive for men. For example, though modern Olympics started many years prior, athletics and gymnastics were allowed for women only in 1928.
Brings us to the problems faced by female athletes. A recent meta-analysis (Teixeira, 2018) showed that a 36% prevalence of urinary incontinence among female athletes. This is much higher than the average population. Similarly, it has been reported (Nygaard, 2016) that there is a higher likelihood of anal incontinence among women engaging in intense activity, when compared with sedentary women. It is a matter of responsibility of the trainers, coaches and other caregivers of these athletes to sensitize them about possible urogynecological problems. Further research in this matter should be encouraged (Goldstick, 2014).
The female athlete triad consisting of eating disorders (low energy availability), osteopenia and oligo/amenorrhea is a peculiar condition among competitive athletes with lifelong gynaecological consequences. The knowledge of this triad among specialty physicians has been demonstrated to be low (Curry, 2015) and there is need for improving awareness about the same. 
Moving onto the reproductive age group, the first condition that comes to mind in relation to physical activity is PCOS. It is to be noted that while hormonal manipulation treats menstrual issues and hyperandrogenism, a regular structured effective physical activity serves to improve cardiac, metabolic and pulmonary profile of these patients (Orio, 2016). The overall advantages of physical activity in PCOS is imperative. Moving on to fertility issues, it has been shown that lifestyle with adequate physical activity in the year preceding the artificial reproduction therapy, favourably impacted outcomes in IVF (Evenson, 2014).
In today’s context, what kind of physical activity a pregnant woman can engage in, forms a part of any antenatal counselling session. It has been shown that moderate-intensity walking resulted in improvement of the levels of physical fitness in pregnant women, who are otherwise healthy, but previously led sedentary lifestyles. Simple benefits include reduced occurrence of pelvic girdle pain during pregnancy. It was also shown that such activity did not have any detrimental effect on fetal growth or fetoplacental blood flow (Oliveira Melo, 2012). Similarly, there is data to show that supervised prenatal exercises minimizes the chance of having a large new born, without altering the chance of delivering a small newborn (Wiebe, 2015). There has been consensus that those engaged in the healthcare of pregnant women should encourage them to undertake moderate exercise (Barakat, 2015). Reduction of preeclampsia risk has been noted (Wolf, 2014).  In the Indian context, structured physical activity has also resulted in reduction of the risk of GDM and improved outcomes (Uma, 2017).
It is noteworthy that published structured guidelines for physicians regarding how to advice patients on physical activity are freely available (ACOG, 2017). One study has also evaluated and concluded that following such structured guidelines were particularly beneficial (Davari Tanha, 2014). Despite the availability of such resources, there appears to be a gap between the existing knowledge and actual practice by physicians in this aspect (Watson, 2015). An introspection into whether we can add encouragement of moderate physical activity to all our antenatal clientele is called for.

It is important to know the contraindications to physical activity in pregnancy. The absolute contraindications are haemodynamically significant heart disease, restrictive lung disease, incompetent cervix/cerclage, multiple gestation, persistent second or third trimester bleeding, placenta praevia after 26 weeks, premature labour and pregnancy induced hypertension. Other relative contraindications exist.  Physical activity and exercise promoting methods in labour such as “birthing ball” have also been tried, but such options are in the nascent stage of research. (Luces Lago 2014)

Moving back briefly to sports, there are some interesting areas where little knowledge is available. “Should oral contraceptives be offered to reduce ligament injury?” One study showed 20% reduction in the risk of anterior cruciate ligament injury among women on OCPs. (Herzberg, 2017) “Is it safe for women who are pregnant to undergo scuba diving/ parachuting?” While some opine that a pregnancy test is mandatory, generating reliable evidence in such matters can be a real squabble. (Damnon, 2016; Ebner, 2014)

Next on the common gynecological symptomatology. Women who present with pelvic organ prolapse needing surgery are more likely to give history of heavy work when compared to the average population. On the other hand, mild to moderate physical activity actually reduces the risk of developing urinary and fecal incontinence (in contrast to sportswomen who have a higher risk). Hence it is clear that the nature and amount of physical activity impacts the gynaecological symptomatology. A balance between apt amount to avoid sedentary and obesity risks, and excessive amount which may cause gynaecological issues appears necessary.

Menopause is one aspect where exercise training has consistently been shown to reduce symptomatology such as hot flushes, blood lipid levels and body weight. (Mendosa, 2016) Finally, a trial – REWARD (Revving-up Exercise for sustained Weight loss by Altering neurological Reward and Drive) has noted beneficial effects of physical activity among women being treated for endometrial cancer.
As is seen above, the beneficial effects of appropriate moderate amount of physical activity on women’s health is obvious. The onus lies on the healthcare provider to advocate this simple tool to significantly improve women’s health.

With this, we welcome you to yet another interesting edition of this journal, featuring a variety of cases. One article is dedicated to the enigmatic and controversial Dr James Marion Sims. We hope that you will enjoy this month’s fare.