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José L. Areta

figure specifies period of no menses (amenorrhea), irregular menses (oligomenorrhea), and the period in which regular menses resumed (eumenorrhea). The insert in the figure reports the body mass (average ±  SD ) for the period prior to a body mass gain episode in November 2017 to February 2018 versus the

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Nura Alwan, Samantha L. Moss, Kirsty J. Elliott-Sale, Ian G. Davies, and Kevin Enright

various forms of reproductive dysfunction, including oligomenorrhea, amenorrhea, and luteal phase defects ( Manore, 2002 ). LEA causes alterations in the hypothalamic–pituitary–ovarian axis, namely diminished secretion of luteinizing hormone pulses and follicle-stimulating hormone, which subsequently

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Nancy Clark

Some of the nutritional concerns of female athletes are highlighted in this case study of a 20-year-old woman who wants to lose 16% of her body weight to qualify for the position of coxswain on a national crew team. These concerns include adequacy of vitamin, mineral, protein, and carbohydrate intake as well as amenorrhea and pathogenic eating behaviors.

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Marc Bonis, Mark Loftin, Richard Speaker, and Anthony Kontos

The purpose of the study was to investigate the seasonal relationship of athletic amenorrhea and body composition in elite, adolescent, cross-country runners. The participants consisted of 28 female adolescent cross-country runners (mean age ± SD = 15.4 ± 1.5 years); 17 eumenorrheics and 11 amenorrheics. The participants’ body composition was measured pre- and postseason using dual-energy X-ray Absorptiometer (DXA). The eumenorrheics’ postseason BMD was significantly greater than the amenorrheics’ postseason BMD (F(1,54) = 16.22, p < .05, partial η 2 = .231). The eumenorrheics’ postseason bodyweight (F(1,54) = 7.65, p < .05, partial η 2 = .124), BF (F(1,54) = 8.56, p < .05, partial η 2 = .137), and BMC (F(1,54) = 8.52, p < .05, partial η 2 = .136) were significantly greater than the amenorrheic subgroup. There was also a significant seasonal increase in BMD (t(27) = –4.01, p < .05) for the overall group and the eumenorrheic subgroup (t(16) = –3.90, p < .05). Bodyweight best predicted BMD (F(1,26) = 46.434, p < .05, R2 = .641). In the study, athletic amenorrhea was highly associated with lower levels of BMD in the participants, and crosscountry running was highly associated with increased BMD.

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Jack H. Wilmore

This paper presents an overview of eating disorders, including definitions, clinical criteria for appropriate diagnosis, and a discussion of the potential for increased risk for eating disorders in special populations of female athletes. This is followed by a discussion of the prevalence of eating disorders in normal and athletic populations. From this discussion, it seems clear that female athletes in endurance or appearance sports are at an increased risk for disordered eating. Finally, the paper focuses on related disorders—a triad associating eating disorders, menstrual dysfunction, and bone mineral disorders. It is clear that secondary amenorrhea is associated with malnutrition and disordered eating. Further, bone mineral disorders are related to menstrual dysfunction. Disordered eating may represent the initiating factor of this triad.

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Nancy I. Williams, Clara V. Etter, and Jay L. Lieberman

An understanding of the health consequences of abnormal menstrual function is an important consideration for all exercising women. Menstrual disturbances in exercising women are quite common and range in severity from mild to severe and are often associated with bone loss, low energy availability, stress fractures, eating disorders, and poor performance. The key factor that causes menstrual disturbances is low energy availability created by an imbalance of energy intake and energy expenditure that leads to an energy deficit and compensatory metabolic adaptations to maintain energy balance. Practical guidelines for preventing and treating amenorrhea in exercising women include evidence-based dietary practices designed to achieve optimal energy availability. Other factors such as gynecological age, genetics, and one’s susceptibility to psychological stress can modify an individual’s susceptibility to menstrual disturbances caused by low energy availability. Future research should explore the magnitude of these effects in an effort to move toward more individualized prevention and treatment approaches.

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Sheila A. Kopp-Woodroffe, Melinda M. Manore, Christine A. Dueck, James S. Skinner, and Kathleen S. Matt

Chronic energy deficit is one of the strongest factors contributing to exercise-induced menstrual dysfunction. In such cases, macro- and micronutrient intakes may also be low. This study presents the results of a diet and exercise training intervention program, designed to reverse athletic amenorrhea, on improving energy balance and nutritional status in 4 amenorrheic athletes. The 20-week program provided a daily sport nutrition supplement and 1 day of rest/week. The intervention improved self-reported energy intake (El) and balance in all participants. The program increased protein intakes for the 3 athletes with a protein deficit to within the recommended levels for active individuals. Micronutrient intakes increased, as did serum concentrations of vitamin B12, folate, zinc, iron, and ferritin. These results indicate that some amenorrheic athletes have poor nutritional status due to restricted Els and poor food selections. A sport nutrition supplement may improve energy balance and nutritional status in active amenorrheic women.

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Sharon H. Thompson, Presley Smith, and Rita DiGioacchino

A serious commitment to sport and exercise may predispose female athletes to the development of eating disorders. The energy restriction and accompanying menstrual disorders that are often associated with eating disorders may increase female athletes’ injury risks. The purpose of this study was to assess NCAA Division I, II, and III female collegiate cross country athletes’ weekly exercise time, rates of injury, menstrual dysfunction, and subclinical eating disorder risks. A paper-pencil survey was completed by athletes (mean age = 19.64 years) from NCAA Division I (n = 82), Division II (n = 103) and Division III (n = 115) colleges across the United States. Division I athletes spent significantly more weekly exercise time (M = 687.97 minutes) than Division II (M = 512.38 minutes, p = .0007) or Division III (M = 501.32 minutes, p = .0003) athletes. When examining rates of menstrual dysfunction, 23 percent reported amenorrhea or oligomenorrhea. Over 60 percent (64.3%) of the athletes reported a performance-related injury, with the knee being the most commonly injured site. 24 percent (23.7%) of the athletes reported having stress fractures. Scores for subclinical eating disorders for Division I athletes were significantly higher (M = 87.11) than Division III athletes (M = 82.94, p = .0042). Division I female athletes may be at an increased risk of developing subclinical eating disorders compared to those competing in Division II or III. Because early identification of those with subclinical eating disorders prevents the progression to eating disorders, further study is warranted.

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Susan M. Kleiner, Terry L. Bazzarre, and Barbara E. Ainsworth

The nutritional status of 11 female and 13 male elite bodybuilders at the first drug-tested USA Championship was examined through food records kept by subjects. Diets were repetitive and monotonous, and average daily energy and protein contents were relatively similar for men and women. Percent calories from protein, fat, and carbohydrate were 39%, 12%, and 48% for females, and 40%, 11%, and 49% for males, respectively. Females consumed 0% vitamin D, 52% calcium, 76% zinc (as percents of RDA) and below the Estimated Safe and Adequate Dietary Allowance amounts for copper and chromium. Males consumed 46% of vitamin D RDA. Although dietary magnesium intakes were above the RDA, serum magnesium levels in females were below reference values, which should be investigated. Serum zinc levels were high in men and women. Eighty-one percent of females reported recurrent contest-related amenorrhea for 2 ± 1 months precontest. Dietary intakes of men were adequate but the restrictive intakes of women may place them at risk for calcium, copper, and chromium deficiencies.

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Eric C. Haakonssen, David T. Martin, David G. Jenkins, and Louise M. Burke


This study investigated the satisfaction of elite female cyclists with their body weight (BW) in the context of race performance, the magnitude of BW manipulation, and the association of these variables with menstrual function.


Female competitors in the Australian National Road Cycling Championships (n = 32) and the Oceania Championships (n = 5) completed a questionnaire to identify current BW, BW fluctuations, perceived ideal BW for performance, frequency of weight consciousness, weight-loss techniques used, and menstrual regularity.


All but 1 cyclist reported that female cyclists are “a weight-conscious population,” and 54% reported having a desire to change BW at least once weekly; 62% reported that their current BW was not ideal for performance. Their perceived ideal BW was (mean ± SD) 1.6 ± 1.6 kg (2.5% ± 2.5%) less than their current weight (P < .01), and 73% reported that their career-lowest BW was either “beneficial” or “extremely beneficial” for performance. 65% reported successfully reducing BW in the previous 12 months with a mean loss of 2.4 ± 1.0 kg (4.1% ± 1.9%). The most common weight-loss technique was reduced energy intake (76%). Five cyclists (14%) had been previously diagnosed as having an eating disorder by a physician. Of the 18 athletes not using a hormonal contraceptive, 11 reported menstrual dysfunction (oligomenorrhea or amenorrhea).


Elite Australian female cyclists are a weight-conscious population who may not be satisfied with their BW leading into a major competition and in some cases are frequently weight conscious.