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Julie C. Arends, Min-Yuen C. Cheung, Michelle T. Barrack and Aurelia Nattiv

Background:

Functional hypothalamic amenorrhea is common among female athletes and may be difficult to treat. Restoration of menses (ROM) is crucial to prevent deleterious effects to skeletal and reproductive health.

Objectives:

To determine the natural history of menstrual disturbances in female college athletes managed with nonpharmacologic therapies including increased dietary intake and/or decreased exercise expenditure and to identify factors associated with ROM.

Study Design:

A 5-yr retrospective study of college athletes at a major Division I university.

Methods:

373 female athletes’ charts were reviewed. For athletes with menstrual disturbances, morphometric variables were noted. Months to ROM were recorded for each athlete.

Results:

Fifty-one female athletes (19.7%) had menstrual disturbances (14.7% oligomenorrheic, 5.0% amenorrheic). In all, 17.6% of oligo-/amenorrheic athletes experienced ROM with nonpharmacologic therapy. Mean time to ROM among all athletes with menstrual disturbances was 15.6 ± 2.6 mo. Total absolute (5.3 ± 1.1 kg vs. 1.3 ± 1.1 kg, p < .05) and percentage (9.3% ± 1.9% vs. 2.3% ± 1.9%, p < .05) weight gain and increase in body-mass index (BMI; 1.9 ± 0.4 kg/m2 vs. 0.5 ± 0.4 kg/m2, p < .05) emerged as the primary differentiating characteristics between athletes with ROM and those without ROM. Percent weight gain was identified as a significant positive predictor of ROM, OR (95% CI) = 1.25 (1.01, 1.56), p < .05.

Conclusions:

Nonpharmacologic intervention in college athletes with menstrual disturbances can restore regular menstrual cycles, although ROM may take more than 1 yr. Weight gain or an increase in BMI may be important predictors of ROM.

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Jenna C. Gibbs, Nancy I. Williams, Jennifer L. Scheid, Rebecca J. Toombs and Mary Jane De Souza

A high drive-for-thinness (DT) score obtained from the Eating Disorder Inventory-2 is associated with surrogate markers of energy deficiency in exercising women. The purposes of this study were to confirm the association between DT and energy deficiency in a larger population of exercising women that was previously published and to compare the distribution of menstrual status in exercising women when categorized as high vs. normal DT. A high DT was defined as a score ≥7, corresponding to the 75th percentile for college-age women. Exercising women age 22.9 ± 4.3 yr with a BMI of 21.2±2.2 kg/m2 were retrospectively grouped as high DT (n = 27) or normal DT (n = 90) to compare psychometric, energetic, and reproductive characteristics. Chi-square analyses were performed to compare the distribution of menstrual disturbances between groups. Measures of resting energy expenditure (REE) (4,949 ± 494 kJ/day vs. 5,406 ± 560 kJ/day, p < .001) and adjusted REE (123 ± 16 kJ/LBM vs. 130 ± 9 kJ/LBM, p = .027) were suppressed in exercising women with high DT vs. normal DT, respectively. Ratio of measured REE to predicted REE (pREE) in the high-DT group was 0.85 ± 0.10, meeting the authors’ operational definition for an energy deficiency (REE:pREE <0.90). A greater prevalence of severe menstrual disturbances such as amenorrhea and oligomenorrhea was observed in the high-DT group (χ2 = 9.3, p = .003) than in the normal-DT group. The current study confirms the association between a high DT score and energy deficiency in exercising women and demonstrates a greater prevalence of severe menstrual disturbances in exercising women with high DT.

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Nicole C.A. Strock, Kristen J. Koltun, Emily A. Southmayd, Nancy I. Williams and Mary Jane De Souza

(i.e., growth and reproduction). This results in suppression of metabolism, energy expenditure, and thyroid hormones ( Wade et al., 1996 ), contributing to the development of exercise-associated menstrual disturbances ( Loucks et al., 1998 ). Exercise-associated menstrual disturbances can range in

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Stephanie M. Miller, Sonja Kukuljan, Anne I. Turner, Paige van der Pligt and Gaele Ducher

Purpose:

Prevention of the female athlete triad is essential to protect female athletes’ health. The aim of this study was to investigate the knowledge, attitudes, and behaviors of regularly exercising adult women in Australia toward eating patterns, menstrual cycles, and bone health.

Methods:

A total of 191 female exercisers, age 18–40 yr, engaging in ≥2 hr/wk of strenuous activity, completed a survey. After 11 surveys were excluded (due to incomplete answers), the 180 participants were categorized into lean-build sports (n = 82; running/athletics, triathlon, swimming, cycling, dancing, rowing), non-lean-build sports (n = 94; basketball, netball, soccer, hockey, volleyball, tennis, trampoline, squash, Australian football), or gym/fitness activities (n = 4).

Results:

Mean (± SD) training volume was 9.0 ± 5.5 hr/wk, with participants competing from local up to international level. Only 10% of respondents could name the 3 components of the female athlete triad. Regardless of reported history of stress fracture, 45% of the respondents did not think that amenorrhea (absence of menses for ≥3 months) could affect bone health, and 22% of those involved in lean-build sports would do nothing if experiencing amenorrhea (vs. 3.2% in non-lean-build sports, p = .005). Lean-build sports, history of amenorrhea, and history of stress fracture were all significantly associated with not taking action in the presence of amenorrhea (all p < .005).

Conclusions:

Few active Australian women are aware of the detrimental effects of menstrual dysfunction on bone health. Education programs are needed to prevent the female athlete triad and ensure that appropriate actions are taken by athletes when experiencing amenorrhea.

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Noel Pollock, Claire Grogan, Mark Perry, Charles Pedlar, Karl Cooke, Dylan Morrissey and Lygeri Dimitriou

Low bone-mineral density (BMD) is associated with menstrual dysfunction and negative energy balance in the female athlete triad. This study determines BMD in elite female endurance runners and the associations between BMD, menstrual status, disordered eating, and training volume. Forty-four elite endurance runners participated in the cross-sectional study, and 7 provided longitudinal data. Low BMD was noted in 34.2% of the athletes at the lumbar spine, and osteoporosis in 33% at the radius. In cross-sectional analysis, there were no significant relationships between BMD and the possible associations. Menstrual dysfunction, disordered eating, and low BMD were coexistent in 15.9% of athletes. Longitudinal analysis identified a positive association between the BMD reduction at the lumbar spine and training volume (p = .026). This study confirms the presence of aspects of the female athlete triad in elite female endurance athletes and notes a substantial prevalence of low BMD and osteoporosis. Normal menstrual status was not significantly associated with normal BMD, and it is the authors’ practice that all elite female endurance athletes undergo dual-X-ray absorptiometry screening. The association between increased training volume, trend for menstrual dysfunction, and increased loss of lumbar BMD may support the concept that negative energy balance contributes to bone loss in athletes.

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José L. Areta

deficiency in sport models ( Mountjoy et al., 2018 ; Nattiv et al., 2007 ), with field data. The menstrual disturbances observed through the period fell within a continuum ranging from amenorrhea to oligomenorrhea, as it has previously been reported in exercising women ( De Souza et al., 2010 ). These

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Margo Mountjoy, Jorunn Sundgot-Borgen, Louise Burke, Kathryn E. Ackerman, Cheri Blauwet, Naama Constantini, Constance Lebrun, Bronwen Lundy, Anna Melin, Nanna Meyer, Roberta Sherman, Adam S. Tenforde, Monica Klungland Torstveit and Richard Budgett

disturbances (including luteal phase defects, anovulation, and oligomenorrhea) was affected by the magnitude of energy deficit compared to baseline needs ( Williams et al., 2015 ), but a specific threshold of EA below which menstrual disturbances occurred was not identified ( Lieberman et al., 2018

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Kirsty J. Elliott-Sale, Adam S. Tenforde, Allyson L. Parziale, Bryan Holtzman and Kathryn E. Ackerman

). There was a dose–response relationship between relative energy deficit (percentage decrease in EA from baseline) and frequency of menstrual disturbances (luteal phase defects, anovulation, and oligomenorrhea), but the severity of menstrual disturbances did not correlate with the magnitude of energy

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Jennifer Sygo, Alexandra M. Coates, Erik Sesbreno, Margo L. Mountjoy and Jamie F. Burr

. Secondary indicators of LEA were selected based on previous studies associating prolonged energy restriction, LEA, or menstrual disturbances with changes in glucose ( Melin et al., 2015 ), triiodothyronine ( Hulmi et al., 2017 ), low-density lipoprotein cholesterol ( Rickenlund et al., 2005 ), insulin

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Louise M. Burke, Bronwen Lundy, Ida L. Fahrenholtz and Anna K. Melin

energy conservation or health impairment such as disruption to metabolic hormones ( Heikura et al., 2018 ; Koehler et al., 2013 ) and menstrual disturbances ( Liebermann et al., 2018 ; Melin et al., 2015 ; Reed et al., 2013 ; Williams et al., 2015 ). Some primary difficulties in measuring EA in free