Changes in serum collagen markers, IGF-I, and knee joint laxity across the menstrual cycle

Correlation of sex hormone levels with orthodontic tooth movement in the maxilla: a prospective cohort study

BACKGROUND

Sex hormones secreted during the menstrual cycle and the application of orthodontic forces to teeth can affect the metabolism of periodontal ligaments. This study aimed to determine whether there are any differences in orthodontic tooth displacement during the menstrual cycle and when using hormonal contraceptives and whether the amount of female sex hormones influences the efficiency of tooth displacement.

METHODS

A total of 120 women aged between 20 and 30 years with Angle Class II requiring transpalatal arch (TPA) to derotate teeth 16 and 26 were included in this study. The participants were divided into two groups: group A, which included women with regular menstruation, and control group B, which included women taking monophasic combined oral contraceptives. Group A was divided into subgroups according to the moment of TPA activation: menstruation (A1), ovulation phase (A2), and luteal phase (A3) (examination I). On intraoral scans, measurement points were marked on the proximal mesial cusps of teeth 16 and 26, and the intermolar distance (M1) was determined. The change in the position of the measurement points 6 weeks after activation (examination II) made it possible to determine the derotating extent of teeth 16 (O16) and 26 (O26) and the widening of the intermolar distance (M2-M1). In examinations I and II, tooth mobility in the alveoli was assessed using Periotest based on the periotest values (PTV) PTV1 and PTV2, respectively.

RESULTS

A significant difference in all parameters was observed among groups A1, A2, and A3 (P < 0.001). Group A3 showed the highest values of parameters O16, O26, and M2-M1, and group A2 showed the lowest values, which did not differ from the control group (P = 0.64). PTV2 and PTV1 were the highest in group A3 and the lowest in groups A1 and B. Intergroup differences were statistically significant (P < 0.001).

CONCLUSIONS

With the quantification of changes in tooth mobility in the alveoli during the menstrual cycle in women undergoing orthodontic treatment, it was possible to determine that female sex hormones affect the effectiveness of orthodontic treatment, and the optimal moment for TPA activation is the luteal phase of the menstrual cycle.

Knee Laxities Changes with Sex-steroids throughout the Menstrual Cycle Phases in Athlete and Non-athlete Females

Objective:  Our study investigated changes of knee laxities in athletes and non-athletes females and relationship between knee laxity and sex-steroid at menstrual cycle phases. Methods:  Forty six healthy females, twenty four athletes and twenty two non-athletes not on hormone contraceptive pills, had no previous knee injuries and with regular menstrual cycles for 3 consecutive months, participated in the study. Medial and lateral knee laxities were determined by varus-valgus tests at follicular, ovulatory and luteal phases. Serum level of relaxin, estrogen, progesterone and testosterone were determined by ELISA and radioimmunoassay. Results:  Knee laxities in athletes and non-athletes at 0° and 20° flexion were the highest in luteal phase with non-athletes possess greater laxity than athletes. Positive correlation between progesterone and relaxin levels with knee laxities were observed. Meanwhile, the levels of both hormones were highest in the luteal phase. Conclusion:  Increased medial and lateral knee laxities in athletes and non-athletes associated with high serum progesterone and relaxin levels in luteal phase may contribute toward increased risk of non-contact knee injury. However, lower knee laxity in athletes than non-athletes suggest that exercise could be a protective factor.

Sex differences in musculoskeletal injury and disease risks across the lifespan: Are there unique subsets of females at higher risk than males for these conditions at distinct stages of the life cycle?

Sex differences have been reported for diseases of the musculoskeletal system (MSK) as well as the risk for injuries to tissues of the MSK system. For females, some of these occur prior to the onset of puberty, following the onset of puberty, and following the onset of menopause. Therefore, they can occur across the lifespan. While some conditions are related to immune dysfunction, others are associated with specific tissues of the MSK more directly. Based on this life spectrum of sex differences in both risk for injury and onset of diseases, a role for sex hormones in the initiation and progression of this risk is somewhat variable. Sex hormone receptor expression and functioning can also vary with life events such as the menstrual cycle in females, with different tissues being affected. Furthermore, some sex hormone receptors can affect gene expression independent of sex hormones and some transitional events such as puberty are accompanied by epigenetic alterations that can further lead to sex differences in MSK gene regulation. Some of the sex differences in injury risk and the post-menopausal disease risk may be "imprinted" in the genomes of females and males during development and sex hormones and their consequences only modulators of such risks later in life as the sex hormone milieu changes. The purpose of this review is to discuss some of the relevant conditions associated with sex differences in risks for loss of MSK tissue integrity across the lifespan, and further discuss several of the implications of their variable relationship with sex hormones, their receptors and life events.

The effect of the menstrual cycle on collagen metabolism, growth hormones and strength in young physically active women

This study aimed to investigate the effect of the menstrual cycle on strength, functioning of the GH/IGF-1 axis and collagen metabolism in physically active women. Twenty-four physically active and eumenorrheic women volunteered to participate in the study (body mass 60.3 ± 9.18 kg, age 21.8 ± 0.92 years). Blood samples were obtained between the 5th and 8th days (the follicular phase) and between the 19th and 22th days (the luteal phase) of the menstrual cycle to determine sex steroid concentrations (follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), oestradiol (E2) and progesterone (P)). Also insulin-like growth factor 1 (IGF-1) and collagen metabolism markers (synthesis (PICP) and breakdown (ICTP)) and maximum voluntary contraction (MVC) were measured. MVC was higher in the luteal phase 164.1 ± 34.77 [N m] (F(1.23) = 4.59; p = 0.043). The recorded collagen synthesis marker (PICP = 296.4 ± 35.61 [ng/ml]) was at the upper level of the reference range (30-300), with an insignificant decrease in the luteal phase (Z = 1.612; p = 0.107) and a significant increase in oestradiol concentration (Z = 4.286; p = 0.0001). The marker of collagen breakdown (ICTP = 4.16 ± 0.68 [μg/l]) was reduced by 6.8% in the same phase (Z = 1.764; p = 0.137). The variability of physical abilities (MVC) during the menstrual cycle showed that menstrual status should be taken into account in determination of the training loads. Increasing the load in the luteal phase seems to be favoured by a beneficial change in collagen metabolism (lower synthesis decrease, lower breakdown increase) observed in physically active women.

The Menstrual Cycle May Affect Anterior Knee Laxity and the Rate of Anterior Cruciate Ligament Rupture: A Systematic Review and Meta-Analysis

BACKGROUND

Women have a higher risk of anterior cruciate ligament (ACL) tears than men, the causes of which are multifactorial. The menstrual cycle and its hormonal effect on the knee may contribute to knee laxity and ACL injury. This work reviewed published studies examining the effects of the phases of the menstrual cycle on anterior knee laxity and the rate of ACL tears.

METHODS

A systematic review with meta-analysis and meta-regression was performed. Studies with data comparing the menstrual cycle phase with ACL injury or anterior knee laxity were included for analysis. Data with regard to patient demographic characteristics, anterior knee laxity, ACL injury, and menstrual cycle phases were extracted from the included studies.

RESULTS

In this study, 1,308 search results yielded 396 articles for review, of which 28 met inclusion criteria. Nineteen studies of knee laxity with 573 combined subjects demonstrated a mean increase in laxity (and standard deviation) of 0.40 ± 0.29 mm in the ovulatory phase compared with the follicular phase and a mean increase in laxity of 0.21 ± 0.21 mm in the luteal phase compared with the follicular phase. Nine studies examining ACL tears with 2,519 combined subjects demonstrated a decreased relative risk (RR) of an ACL tear in the luteal phase compared with the follicular and ovulatory phases combined (RR, 0.72 [95% confidence interval, 0.56 to 0.89]). There were no differences in ACL tear risk between any of the other phases.

CONCLUSIONS

An increased risk of an ACL tear does not appear to be associated with periods of increased laxity in this meta-analysis. Although this suggests that hormonal effects on an ACL tear may not be directly related to increases in knee laxity, the methodologic heterogeneity between published studies limits the conclusions that can be drawn and warrants further investigation.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Influence of Second Generation Oral Contraceptive Use on Adaptations to Resistance Training in Young Untrained Women

Dalgaard, LB, Jørgensen, EB, Oxfeldt, M, Dalgaard, EB, Johansen, FT, Karlsson, M, Ringgaard, S, and Hansen, M. Influence of second generation oral contraceptive use on adaptations to resistance training in young untrained women. J Strength Cond Res XX(X): 000-000, 2020-The study purpose was to determine effects of using second generation oral contraceptives (OC) on muscle adaptations to resistance training in young untrained women. Twenty users and 18 nonusers of OC completed a 10-week supervised progressive resistance training program. Before and after the intervention, muscle cross-sectional area (mCSA) of the quadriceps was measured using magnetic resonance imaging and muscle fiber CSA (fCSA) was determined by immunohistochemistry. In addition, body composition (DXA, fat mass/fat-free mass), maximal isometric muscle strength (dynamometry), 5 repetition maximum (5RM) leg press strength, counter movement jump (CMJ) height, and average power using a modified Wingate test were determined. Serum hormone analysis ensured OC compliance and 4-day food records documented dietary intake. After the training period, quadriceps mCSA (OC: 11.0 ± 6.0% vs. non-OC: 9.2 ± 5.0%, p = 0.001), type II fCSA (OC: 19.9 ± 7.9% vs. non-OC: 16.6 ± 7.2%, p = 0.05), muscle strength (knee extension, knee flexion and 5RM, p < 0.001), and functional power (CMJ, AP, p < 0.001) were significantly increased with no significant difference between the groups. However, a tendency toward a greater increase in fat-free mass (FFM) in the OC group was observed (OC: 3.7 ± 3.8% vs. non-OC: 2.7 ± 3.5%, p = 0.08). Collectively, use of second generation OCs in young untrained women did not significantly improve adaptations to 10 weeks of resistance training compared with nonusers. The trend toward greater gains in FFM in the OC group warrant future studies.

Knee synovial fluid complement C3-β chain levels correlate with clinical symptoms of knee osteoarthritis

AIM

Early research found innate immune factor complement C3 in the synovial fluid (SF) and activated in serum of osteoarthritis (OA) patients. Whether synovial C3 comes from circulation, or is produced locally, is still unknown. It is also unclear whether synovial and circulating C3 is responsible to OA symptoms. A native C3 molecule consists of two chains, C3-α and C3-β. Small fragments breaking down from C3-α chain in serum and SF were reported to be related to OA severity. Little is known if C3-β chain is involved in the pathogenesis.

METHOD

In this study, we evaluated these important areas by biochemical analyses of C3-α and C3-β chains in both the SF and plasma of OA patients.

RESULTS

Our results showed that C3-α and C3-β levels in SF did not correlate with those in plasma, suggesting that synovial C3 is independently and locally produced, rather than being "leaked" from circulation. Synovial C3-β but not C3-α levels correlated with pain, other OA symptoms, function in daily living, and sports/recreational activities. Plasma C3-β levels only marginally correlated with pain, and plasma C3-α levels did not correlate with any of these OA symptoms.

CONCLUSION

We present first-hand evidence that the clinical symptoms of OA are mainly associated with C3 in the local SF rather than systemic circulation, suggesting local factors in the etiopathogenesis. Future local targeted therapies for pain management may be more effective and safer.

Reproductive factors and risk of total knee replacement due to severe knee osteoarthritis in women, the Singapore Chinese Health Study

OBJECTIVES

Knee osteoarthritis (OA) is more common in women, and may be related to reproductive or hormonal factors. We evaluated these factors with the risk of total knee replacement (TKR) for severe knee OA among women.

METHODS

The Singapore Chinese Health Study recruited 63,257 Chinese aged 45-74 years from 1993 to 1998, and among them, 35,298 were women. Information on height, weight, lifestyle factors, number of biological children, ages at menarche and menopause, and use of hormonal therapies was collected through interviews. Incident cases of TKR were identified via linkage with nationwide database.

RESULTS

There were 1,645 women with TKR after mean follow-up of 14.8 years. Higher parity was associated with increased TKR risk in a stepwise manner (P for trend <0.001). Compared to nulliparous women, those with ≥5 children had the highest risk [hazard ratio (HR) 2.01, 95% confidence intervals (CIs) 1.50-2.70]. The effect of parity on TKR risk was significantly stronger among lean women compared to heavier women; HRs (95% CIs) for highest parity was 4.86 (2.22-10.63) for women with body mass index (BMI) <23 kg/m² and 1.57 (1.14-2.14) for those ≥23 kg/m² (P for interaction = 0.001). Earlier age at menarche and use of oral contraceptives were significantly associated with TKR in a stepwise manner (P for trend ≤0.002). Age at menopause and use of hormonal therapy were not associated with TKR risk.

CONCLUSION

Higher parity, earlier age of menarche and use of oral contraceptives were associated with increased risk of TKR for severe knee OA among women.

Effect of Oral Contraceptives on Soft Tissue Injury Risk, Soft Tissue Laxity, and Muscle Strength: A Systematic Review of the Literature

Background

Female patients are more likely than male patients to experience various musculoskeletal (MSK) injuries. Because MSK tissues are sensitive to the female hormones relaxin, estrogen, and progesterone, studies have examined whether hormonal contraceptives, which change female hormone levels, can alter the female MSK injury risk. These studies have reached contradictory conclusions, leaving unclear the influence of hormonal contraception on female MSK injury risk.

Hypothesis

Hormonal contraceptives act to decrease female soft tissue injury risk and soft tissue laxity.

Study Design

Systematic review; Level of evidence, 3.

Methods

Reviewers searched for clinically relevant studies evaluating the relationship between hormonal contraceptive use and soft tissue injuries, soft tissue laxity, muscle injuries, and muscle strength in the PubMed, Cochrane, Scopus, CINAHL, and Embase databases. Studies meeting inclusion criteria were scored by 2 independent researchers for risk of bias, imprecision, inconsistency, and indirectness with a template designed using the British Medical Journal Clinical Evidence GRADE (Grades of Recommendation Assessment, Development and Evaluation) scoring system and GRADEPro guidelines. Scores were uploaded into the GRADEPro scoring system software, which calculated each study's final GRADE score (very low, low, moderate, or high quality).

Results

A total of 29 studies met inclusion criteria. Of the 7 studies evaluating oral contraceptive (OC) use and soft tissue injury risk, only 2 received a high quality-of-evidence score; all other studies received a very low score. The high-quality studies concluded that OC use decreases anterior cruciate ligament (ACL) injury risk. Only 1 of the 10 studies evaluating OC use and soft tissue laxity was found to have a high quality of evidence; this study determined that OC use decreases ACL laxity.

Conclusion

Higher quality studies suggest that OCs decrease a female patient's risk of ACL injuries and ACL laxity. The strength of these findings, however, is weak. Female patients are up to 8 times more likely to tear their ACLs than male patients. OCs may serve a therapeutic role in decreasing the sex disparity in ACL injury rates.

Effect of Estrogen on Musculoskeletal Performance and Injury Risk

Estrogen has a dramatic effect on musculoskeletal function. Beyond the known relationship between estrogen and bone, it directly affects the structure and function of other musculoskeletal tissues such as muscle, tendon, and ligament. In these other musculoskeletal tissues, estrogen improves muscle mass and strength, and increases the collagen content of connective tissues. However, unlike bone and muscle where estrogen improves function, in tendons and ligaments estrogen decreases stiffness, and this directly affects performance and injury rates. High estrogen levels can decrease power and performance and make women more prone for catastrophic ligament injury. The goal of the current work is to review the research that forms the basis of our understanding how estrogen affects muscle, tendon, and ligament and how hormonal manipulation can be used to optimize performance and promote female participation in an active lifestyle at any age.

Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history

The hypermobile type of Ehlers-Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue. It has been described largely in those with musculoskeletal complaints including joint hypermobility, joint subluxations/dislocations, as well as skin and soft tissue manifestations. Many patients report activity-related pain and some go on to have daily pain. Two undifferentiated syndromes have been used to describe these manifestations-joint hypermobility syndrome and hEDS. Both are clinical diagnoses in the absence of other causation. Current medical literature further complicates differentiation and describes multiple associated symptoms and disorders. The current EDS nosology combines these two entities into the hypermobile type of EDS. Herein, we review and summarize the literature as a better clinical description of this type of connective tissue disorder. © 2017 Wiley Periodicals, Inc.

Evaluation of an Algorithm to Predict Menstrual-Cycle Phase at the Time of Injury

CONTEXT

Women are 2 to 8 times more likely to sustain an anterior cruciate ligament (ACL) injury than men, and previous studies indicated an increased risk for injury during the preovulatory phase of the menstrual cycle (MC). However, investigations of risk rely on retrospective classification of MC phase, and no tools for this have been validated.

OBJECTIVE

To evaluate the accuracy of an algorithm for retrospectively classifying MC phase at the time of a mock injury based on MC history and salivary progesterone (P4) concentration.

DESIGN

Descriptive laboratory study.

SETTING

Research laboratory.

PARTICIPANTS

Thirty-one healthy female collegiate athletes (age range, 18-24 years) provided serum or saliva (or both) samples at 8 visits over 1 complete MC.

MAIN OUTCOME MEASURE(S)

Self-reported MC information was obtained on a randomized date (1-45 days) after mock injury, which is the typical timeframe in which researchers have access to ACL-injured study participants. The MC phase was classified using the algorithm as applied in a stand-alone computational fashion and also by 4 clinical experts using the algorithm and additional subjective hormonal history information to help inform their decision. To assess algorithm accuracy, phase classifications were compared with the actual MC phase at the time of mock injury (ascertained using urinary luteinizing hormone tests and serial serum P4 samples). Clinical expert and computed classifications were compared using κ statistics.

RESULTS

Fourteen participants (45%) experienced anovulatory cycles. The algorithm correctly classified MC phase for 23 participants (74%): 22 (76%) of 29 who were preovulatory/anovulatory and 1 (50%) of 2 who were postovulatory. Agreement between expert and algorithm classifications ranged from 80.6% (κ = 0.50) to 93% (κ = 0.83). Classifications based on same-day saliva sample and optimal P4 threshold were the same as those based on MC history alone (87.1% correct). Algorithm accuracy varied during the MC but at no time were both sensitivity and specificity levels acceptable.

CONCLUSIONS

These findings raise concerns about the accuracy of previous retrospective MC-phase classification systems, particularly in a population with a high occurrence of anovulatory cycles.

Estrogen inhibits lysyl oxidase and decreases mechanical function in engineered ligaments

Women are more likely to suffer an anterior cruciate ligament (ACL) rupture than men, and the incidence of ACL rupture in women rises with increasing estrogen levels. We used an engineered ligament model to determine how an acute rise in estrogen decreases the mechanical properties of ligaments. Using fibroblasts isolated from human ACLs from male or female donors, we engineered ligaments and determined that ligaments made from female ACL cells had more collagen and were equal in strength to those made from male ACL cells. We then treated engineered ligaments for 14 days with low (5 pg/ml), medium (50 pg/ml), or high (500 pg/ml) estrogen, corresponding to the range of in vivo serum estrogen concentrations and found that collagen within the grafts increased without a commensurate increase in mechanical strength. Mimicking the menstrual cycle, with 12 days of low estrogen followed by 2 days of physiologically high estrogen, resulted in a decrease in engineered ligament mechanical function with no change in the amount of collagen in the graft. The decrease in mechanical stiffness corresponded with a 61.7 and 76.9% decrease in the activity of collagen cross-linker lysyl oxidase with 24 and 48 h of high estrogen, respectively. Similarly, grafts treated with the lysyl oxidase inhibitor β-aminoproprionitrile (BAPN) for 24 h showed a significant decrease in ligament mechanical strength [control (CON) = 1.58 ± 0.06 N; BAPN = 1.06 ± 0.13 N] and stiffness (CON = 7.7 ± 0.46 MPa; BAPN = 6.1 ± 0.71 MPa) without changing overall collagen levels (CON = 396 ± 11.5 μg; BAPN = 382 ± 11.6 μg). Together, these data suggest that the rise in estrogen during the follicular phase decreases lysyl oxidase activity in our engineered ligament model and if this occurs in vivo may decrease the stiffness of ligaments and contribute to the elevated rate of ACL rupture in women.

Pregnancy and postpartum bowel changes: constipation and fecal incontinence

Pregnancy and the postpartum period are often associated with many gastrointestinal complaints, including nausea, vomiting, and heartburn; however, the most troublesome complaints in some women are defecatory disorders such as constipation and fecal incontinence, especially postpartum. These disorders are often multifactorial in etiology, and many studies have looked to see what risk factors lead to these complications. This review discusses the current knowledge of pelvic floor and anorectal physiology, especially during pregnancy, and reviews the current literature on causes and treatments of postpartum bowel symptoms of constipation and fecal incontinence.

The muscle stretch reflex throughout the menstrual cycle

INTRODUCTION

The significant sex disparity in sports-related knee injuries may be due to underlying differences in motor control. Although the development of sex-specific movement patterns is likely multifactorial, this study specifically focuses on the potential modulatory role of sex hormones.

PURPOSE

This study aimed to investigate the muscle stretch reflex (MSR) across the menstrual cycle. We hypothesized that the MSR would fluctuate throughout the menstrual cycle and that the lowest response would correspond with peak concentrations of estrogen.

METHODS

Nineteen healthy women age 18-35 yr participated in this study: 8 eumenorrheic women and 11 women taking oral contraceptives. Serum estradiol and progesterone concentrations, anterior knee laxity (AKL), and the MSR response of the quadriceps muscles were measured three times during the menstrual cycle.

RESULTS

The MSR response of the rectus femoris (RF) varied significantly across the menstrual cycle in both groups. Specifically, the RF MSR response was 2.4 times lower during the periovulatory phase when compared with the luteal phase (P = 0.007). The same trend was seen in the vastus medialis, but this did not reach statistical significance (P = 0.070). The MSR response of the vastus lateralis did not change significantly across the menstrual cycle (P = 0.494). A mixed model comparison did not show an association between endogenous concentrations of estradiol and progesterone, exposure to hormonal contraceptives or AKL, and the MSR response for any muscle.

CONCLUSIONS

Our results demonstrate that the RF MSR response varies throughout the menstrual cycle with the lowest response around the time of ovulation. Additional research is needed to clarify the exact relationship between sex hormones, AKL, and MSR response and to determine the specific origin of the change along the monosynaptic reflex arc.

Accuracy of calendar-based methods for assigning menstrual cycle phase in women

Background:

Sex steroid hormone fluctuations during the menstrual cycle are considered a risk factor for noncontact anterior cruciate ligament injuries.

Objective:

To determine whether self-reported menstrual history data can be used to accurately categorize menstrual cycle events using calendar-based counting methods.

Study Design:

Descriptive laboratory study.

Methods:

Seventy-three women completed a menstrual history questionnaire and submitted to blood sampling for the first 6 days of menses and 8 to 10 days after a positive ovulation test over 2 consecutive months. Frequency counts determined whether appropriate criterion hormone (progesterone) levels were achieved at predefined calendar days.

Results:

For the criterion of progesterone >2 ng/mL, 18% and 59% of women attained it when counting forward 10 to 14 days after the onset of menses and counting back 12 to 14 days from the end of the cycle, respectively. Most women (76%) attained the criterion for ovulation 1 to 3 days after a positive urinary ovulation test. Regardless of the counting method employed, the criterion of progesterone >4.5 ng/mL for identifying midluteal phase was attained in 67% of cases. Serial blood sampling for 3 to 5 days after the positive urinary ovulation test captured 68% to 81% of the hormone values indicative of ovulation and 58% to 75% indicative of the luteal phase.

Conclusion:

These data suggest that self-reported menstrual history and calendar-based counting methods should not be used alone if accurate identification of ovulation is essential. A urinary ovulation test and serial blood samples for verification of progesterone postovulation enhance the proper identification of menstrual cycle events.

Clinical Relevance:

Given the cost of serial blood sampling on numerous days, the use of urinary ovulation kits and strategically selected serial blood sampling could significantly reduce participant burden and provide cost-effective measures for clinical studies related to anterior cruciate ligament injury epidemiology.