Over the years there has been a huge debate and
controversy regarding women and decompression illness
(DCI). Many articles have been published in diving
journals, presentations made at conferences, and anyone
trawling the Net will find even more opinion — some
from well-informed authors, but many by “cocktail party
scientists.”
What is the current state of play regarding our knowledge
of women and DCI? Since the 1970s, controversy
has centred on the possible relationship between DCI and
the time or phase in the menstrual cycle. Although many
nondiving studies compare the effect of the menstrual
cycle and sporting performance, few investigate DCI and
the menstrual cycle. However, studies over a span of 18
years, from both past and prospective records (observing
things as they happen) from aerospace and diving environments
and from military and civilian disciplines, have
had consistent conclusions. They suggest a possible
risk of DCI or other problems while diving
at different times over a typical 28-day menstrual
cycle.
Three studies, all different but with similar
conclusions, have been published in the last
three years. The first study (Lee 2003) looked
at the records of women who had been treated
for diving DCI in recompression chambers all
over the world. Lee found many more reports
of physician-diagnosed-and-treated DCI at the
beginning and end of the menstrual cycle, with
the fewest number of DCI cases in the third week
of a typical 28-day cycle.
The second study (Webb 2003), from aerospace
research, found a greater incidence of
altitude DCI at the beginning of the menstrual
cycle, with the risk decreasing after the first week.
The third and largest study (St. Leger-Dowse M,
Gunby A, Moncad R, Fife C, Morsman J, Bryson P) of its
kind was published this year in the Journal of Obstetrics and
Gynaecology. The work was carried out by the UK-based
charity, the Diving Diseases Research Centre (DDRC),
which, for 25 years, has been conducting research on the
effects of the undersea environment on humans. One
project has involved collecting female-specific data from
recreational divers for the past 16 years, starting with a
comparative study between men and women divers in the
early 1990s.
In this latest study (I headed up the research team)
a large number of female recreational scuba divers kept
diving and menstrual diaries for up to three consecutive
years. This was a Herculean task started in the 1990s and
designed to study any interaction between reported problems during diving (RPDD) and the day in
a typical 28-day menstrual cycle. Five hundred
and seventy women took part, with
61 percent returning diaries for the full
three consecutive years. More than 50,000
dives with more than 11,000 menstrual
cycles were recorded, making this the largest
study of its kind.
Figure 1
Sixty five per cent of women reported
at least one problem during diving, including
an inability to cope with equipment;
feeling colder than usual; inablilty to control
buoyancy; symptoms of DCI; feeling
unwell; and an inability to cope with low
visibility.
Additionally, there were reports of
feelings of nitrogen narcosis, inability to
clear ears, and feelings of uncertainty and
panic. Because of the way the data from
the diaries were gathered, we knew the
time in every single menstrual cycle of
every single dive, and therefore we knew
the time in the cycle of every reported diving
problem.
The diving had taken place evenly over
the menstrual cycles, so one would expect
the reported problems to be distributed
evenly, as well. So imagine our interest
when we divided up a typical 28-day cycle
into four weeks (week one being days one
to seven and so on) and found many more
reported problems in most categories in
weeks one and four of the menstrual cycle
(see Figure 1).
This proved to be statistically significant.
Of particular interest were the data
regarding problems with equipment. One would expect
these to be reported evenly and to be a rare occurrence
given the reliability of dive gear. But there were many
more occurrences of equipment problems in week four
than would be expected, suggesting that some reports
may be due to judgement or procedural errors. There
were also more reports of feeling cold and an inability to
control buoyancy in week one.
We also knew whether the women were taking an oral
contraceptive pill (OCP). However, the issue regarding
whether there was more risk attached if one were taking
the pill was less clear. It may depend on whether women
were extending their cycles for social reasons (that is,
continuing to take the pill to avoid a bleed) or what type
of pill they were taking.
Though this study was not looking at DCI and the
menstrual cycle per se, the trends of reported problems
during diving were similar. The mechanism for these
and the DCI findings is unclear, but researchers believe
that it may be hormone fluctuation–related.
Table 1
Supporting Studies |
The Literature |
Conclusions |
Dixon GA, Krutz RW, Fischer
MS. Decompression Sickness and
Bubble Formation in Females
Exposed to a Simulated 7.8 PSIA
Suit Environment. 1988 |
All 5/30 female subjects with hypobaric
DCS were in menses or early
phase of cycle. |
Rudge FW. Relationship of
Menstrual History to Altitude
Chamber Decompression Sickness.
1990 |
Significant inverse linear correlation
between number of days since start of
LMP and DCS incident, highest risk
at the beginning of a 28 day cycle. 81
retrospective records studied |
Dunford RG, Hampson NB.
Gender-Related Risk of
Decompression Sickness in
Hyperbaric Chamber Inside
Attendants: A Case Control Study.
1992 |
Menses was a significant risk factor
for inside chamber attendants, but
not for divers in open water. This
study was based on small numbers, 9
in total. |
Krause KM, Pilmanis AA, Webb
JT. The Effect of Menstrual Day
on Decompression Sickness (DCS)
Incidence in Female Research
Subjects. 1998 |
Correlation between menstrual day
and DCS: greatest probability being
on day two of bleed. 62 retrospective
DCS records |
Lee V, St Leger Dowse M, Edge
C, Gunby A, Bryson P.
Decompression Sickness in Women:
A Possible Relationship with the
Menstrual Cycle. 2003 |
Suggested the risk of DCS may be
dependent on the phase of the menstrual
cycle with greatest risk of DCS,
in the non-ocp group, being in the
1st week of a 28 day cycle, the lowest
risk being in week 3. 150 prospective
records |
Webb T, Kannan N, Pilmanis A.
Gender Not a Factor for Altitude
Decompression Sickness Risk. 2003 |
Data from the non-ocp women agreed
with Dunford, Krause, Lee, & Rudge,
showing a reduction in susceptibility
from week one through week four of
the menstrual cycle. 70 women, 269
altitude exposures |
Of course, this study and the others have been based
on self-reporting by divers or trawling through past
records. Researchers now need to conduct a physiological
study to investigate in a more scientific way exactly
what is happening and why.
•••••
Author Marguerite St. Leger-Dowse has been associated
with the Diving Diseases Research Centre (DDRC)
in Plymouth (UK) since 1989, where she initiated the
first study “Men and Women in Diving.” As a research
coordinator, she launched the second phase “Women
in Diving,” in 1996 — the largest female-specific sport
study ever conducted — which was published in 2006.
Other studies include diving and pregnancy, diving and
diabetes, diving and asthma, and reverse dive profiles. She has presented at numerous international conferences
and contributes regularly to UK diving journals. She is a
member of the Women’s Hall of Fame of Diving.
Undercurrent asked her if she could be make recommendations
for women divers and she replied:
“DDRC do not really give out recommendations.
However, if a woman feels well and in control, then it
is up to her to make the decision whether to dive. She
should decide based on what she knows regarding current
research, what she feels, and discussion with her
dive instructor or buddy. As you can see from the literature,
most of the data are ‘record’ based or self-reporting
and we need more ‘hard science’ before any official recommendations
regarding diving and the menstrual cycle
can be made.”