Women and Diving Medical Problems

At the onset of menses the girl usually has reached 95% of her terminal height, most often reaching full adult size and stature within 1-2 years. There is a phase of rapid fat deposition in this 13-15 year old period, sometimes with a significant decrease in power and aerobic capacity. Performance measures peak at age 13 and then level off and decline. For some, this becomes a problem in the management of heavy scuba gear. Minimum size for comfort with conventional scuba gear is 45 kg (105-108 lb.) and 150 cm ( 60 inches). There is ossification of long bones in this period and concerns directed to the possibility of nitrogen bubble localization in the growth plates. This ossification (closure of growth plates) takes place one to three years sooner in girls than in boys, varying with the bone involved.

Young divers have several metabolic disadvantages. They become hypovolemic (low blood volume) much more rapidly than adults, generate more metabolic heat and burn more energy from a larger surface area to body mass ratio. Girls get colder more quickly than older women under similar environmental conditions, there being a 20 fold increase of conductivity into water. Greater thermal protection is needed for the young diver and the importance of a properly fitted wet suit is stressed.

There is no pool of diving data to indicate that women are at any more or less risk of DCS or osteonecrosis when perimenopausal or post menopausal. Average menopausal age is 50, osteopoross usually starts between ages 60-65 and fractures average at 70-75. Osteonecrosis and osteoporosis have differing pathophysiologic mechanisms; osteonecrosis resulting from blockage of the small blood vessels of the bone, while osteoporosis comes from changes in cellular activity. Diving does not seem to have any effect on the changes in the osteoblasts and -clasts that occur with aging and diminished estrogen.

There has been one study done with implants placed in a hyperbaric chamber. This study included silicone, saline and silicone/saline filled at various depth/time profiles that would be seen during recreational diving. The study indicated a 1-4% increase in size of bubbles during the study. Saline implants absorbed less nitrogen, N2 being more soluble in the silicone. The amount of volume increase was not enough to cause rupture and the bubbles resolved over time. This study did not answer the question of implants in situ in in vivo conditions (Implanted in the living human).

Silicone implants are heavier than water and possibly can alter buoyancy and attitude in the water, particularly if large. Diving should not be attempted until completely released by the surgeon and some thought should be directed toward change in body configuration, wet suits, gear straps and appropriate weighting so as to avoid undue pressure over the implant bag and buoyancy problems.

There is some concern among divers who are nursing that their infants might be harmed by 'nitrogen bubbles' in breast milk. This of no concern as nitrogen does not seem to form bubbles in the milk located in the breast glands. Even if the nitrogen were in bubbles, it would do the infant no harm. Ingesting bubbles, even if microscopic, would in no way be harmful to the child, as it would reside in the gastrointestinal tract where gas is a prominent feature already.

Breast engorgement can occur during the dive excursion since the infant will be away from the breast for several hours. This engorgement can be uncomfortable due to snug dive suits and gear straps. Some accommodation should be made for this eventuality. The changes in pressure of diving would not effect the engorged breasts in any way. Thought should be directed toward possible use of a breast pump, saving the milk in refrigeration for the infant.

There are some further concerns about possibility of transmission of marine pathogens from the nipple to the infant, with the production of a particularly stubborn infectious diarrhea. These same bacteria are fully capable of causing a severe mastitis if the exposed nipple ducts and skin have any irritations or skin breaks.

Finally, Dr. Maida Taylor has stated (Medical Seminars, 1998), that there are some concerns about the combined energy expenditure of nursing and diving, and the associated dehydration related to immersion causing a decrease in the amount of breast milk. Should this happen, the mother should be prepared to supplement with some formula approved by the Pediatrician. In this regard, it might be wise to consider postponing diving until the infant is weaned, which is usually around the sixth month in Western culture.

PMS is an ill-defined group of symptoms that are associated with the hormonal changes that occur in the week or so prior to menses. When severe, the personality and anti-social behavior associated with PMS could be a definite problem in diver interaction on a dive-boat and with a buddy. If the PMS is severe, there seems to be an association with underlying psychiatric disorders. It also worsens as the diver ages, associated with the widening range of estrogen swings. Hormonal replacement works well with PMS. SSRI's have been found beneficial.

After vaginal delivery, diving can be resumed after released by the obstetrician. This is usually after the cervix closes, about 21 days. In another week, most muscle tone has returned, depending upon the level of activity of the mother. Barring any pregnancy related complications, such as anemia and poorly healed episiotomy return to diving is usually advised at 4 weeks.

Most obstetricians advise a wait of 4-6 weeks before returning to full activity after caesarian delivery. Couple this with the need for conditioning, complete wound healing and the possibility of need for blood regeneration - a period of 8 weeks would be advised before diving. A post partum hemoglobin determination should be performed and anything below 10 Gm Hgb should be corrected before allowing diving.

Multiple births, medically complicated pregnancies with underlying medical conditions, complications of both vaginal and caesarian births all have to be individually assessed in the decision as to approval for return to diving.