Response of women using oral contraception to exercise in the heat

Effects of Hormonal Contraception and the Menstrual Cycle on Fatigability and Recovery From an Anaerobic Exercise Test

ABSTRACT

Cabre, HE, Ladan, AN, Moore, SR, Joniak, KE, Blue, MNM, Pietrosimone, BG, Hackney, AC, and Smith-Ryan, AE. Effects of hormonal contraception and the menstrual cycle on fatigability and recovery from an anaerobic exercise test. J Strength Cond Res 38(7): 1256-1265, 2024-This study sought to evaluate the effects of oral contraceptive (OC) and hormonal intrauterine device (H-IUD) use, compared with a eumenorrheic (EUM) cycle, on fatigability and recovery between hormone the phases. Peak power (PP), average power (AP), fatigue index (FI), blood lactate, vessel diameter, and blood flow (BF) were measured from a repeated sprint cycle test (10 × 6 seconds) in 60, healthy, active women (mean ± SD ; age: 26.5 ± 7.0 years, BMI: 22.5 ± 3.7 kg·m -2 ) who used monophasic OC (≥6 months; n = 21), had a H-IUD (≥6 months; n = 20), or had regular naturally occurring menstrual cycle (≥3 months) or had a nonhormonal IUD (EUM; n = 19). Subjects were randomly assigned to begin in either the low-hormone phase (LHP) or high-hormone phase (HHP) and were tested once in each phase. Separate univariate analyses of covariances assessed the change from HHP to LHP between the groups, covaried for progesterone, with significance set at p ≤ 0.05. All groups demonstrated similar changes in PP, AP, FI, blood lactate, vessel diameter, and BF between the phases ( p > 0.05). Although not significant, AP was higher in LHP for OC (Δ -248.2 ± 1,301.4 W) and EUM (Δ -19.5 ± 977.7 W) and higher in HHP for H-IUD (Δ 369.3 ± 1,123.0 W). Oral contraceptive group exhibited a higher FI (Δ 2.0%) and reduced blood lactate clearance (Δ 2.5%) in HHP. In recreationally active women, hormonal contraception and hormone phases may minimally impact fatigue and recovery. Individual elite female athletes may benefit from understanding hormonal contraception type as performance and recovery may slightly vary across the cycle.

Effects of the Menstrual Cycle and Hormonal Contraceptive Use on Metabolic Outcomes, Strength Performance, and Recovery: A Narrative Review

The effects of female sex hormones on optimal performance have been increasingly recognized as an important consideration in exercise and sport science research. This narrative review explores the findings of studies evaluating the effects of menstrual cycle phase in eumenorrheic women and the use of hormonal contraception (oral contraceptives and hormonal intrauterine devices) on metabolism, muscular strength, and recovery in active females. Ovarian hormones are known to influence metabolism because estrogen is a master regulator of bioenergetics. Importantly, the menstrual cycle may impact protein synthesis, impacting skeletal muscle quality and strength. Studies investigating muscular strength in eumenorrheic women report equivocal findings between the follicular phase and luteal phase with no differences compared to oral contraceptive users. Studies examining recovery measures (using biomarkers, blood lactate, and blood flow) do not report clear or consistent effects of the impact of the menstrual cycle or hormonal contraception use on recovery. Overall, the current literature may be limited by the evaluation of only one menstrual cycle and the use of group means for statistical significance. Hence, to optimize training and performance in females, regardless of hormonal contraception use, there is a need for future research to quantify the intra-individual impact of the menstrual cycle phases and hormonal contraceptive use in active females.

Female Athletes and the Menstrual Cycle in Team Sports: Current State of Play and Considerations for Future Research

Over the past ten years there has been a dramatic rise in female sport participation and accompanying female professional national leagues across multiple sports, yet research has not followed suit. Although there are known variations between female and male physiology, training protocols in female sport are predominantly underpinned by research undertaken in male athletes. The hormonal variability experienced by women across the menstrual cycle, as well as the menstrual cycle variability between women, may contribute to the complexity of conducting rigorous physiological studies, leading to a paucity of robust sports-specific research that can be confidently applied to female athletes. Moreover, barriers exist in female sport that potentially limit the ability to conduct research, including the lack of full-time programs and limited resources. Recently, there has been increased interest in the potential effects of fluctuations in the female sex hormones, progesterone and oestrogen, on sport performance across different phases of the menstrual cycle. However, current research evaluating the menstrual cycle and physical performance (such as strength, speed, aerobic fitness, and athletes' perception of their performance) have shown inconsistent results. Additionally, methodological design across studies has shown little consistency, making it difficult to draw firm conclusions, which potentially prevents female athletes optimising their physical and sporting performance. It further impacts coaches and sports science researchers in their ability to provide appropriate training recommendations and educational opportunities. It is important to progress in female athlete research with an understanding of how the unique physiology of female athletes may influence their ability to physically perform in their respective sport, which requires representation in sports science research. This paper will provide an overview on current evidence and limitations within menstrual cycle research and provide considerations and directions for future research in this space within team sports.

Menstrual cycle hormones and oral contraceptives: a multimethod systems physiology-based review of their impact on key aspects of female physiology

Hormonal changes around ovulation divide the menstrual cycle (MC) into the follicular and luteal phases. In addition, oral contraceptives (OCs) have active (higher hormone) and placebo phases. Although there are some MC-based effects on various physiological outcomes, we found these differences relatively subtle and difficult to attribute to specific hormones, as estrogen and progesterone fluctuate rather than operating in a complete on/off pattern as observed in cellular or preclinical models often used to substantiate human data. A broad review reveals that the differences between the follicular and luteal phases and between OC active and placebo phases are not associated with marked differences in exercise performance and appear unlikely to influence muscular hypertrophy in response to resistance exercise training. A systematic review and meta-analysis of substrate oxidation between MC phases revealed no difference between phases in the relative carbohydrate and fat oxidation at rest and during acute aerobic exercise. Vascular differences between MC phases are also relatively small or nonexistent. Although OCs can vary in composition and androgenicity, we acknowledge that much more work remains to be done in this area; however, based on what little evidence is currently available, we do not find compelling support for the notion that OC use significantly influences exercise performance, substrate oxidation, or hypertrophy. It is important to note that the study of females requires better methodological control in many areas. Previous studies lacking such rigor have contributed to premature or incorrect conclusions regarding the effects of the MC and systemic hormones on outcomes. While we acknowledge that the evidence in certain research areas is limited, the consensus view is that the impact of the MC and OC use on various aspects of physiology is small or nonexistent.

Reduced running performance and greater perceived exertion, but similar post-exercise neuromuscular fatigue in tropical natives subjected to a 10 km self-paced run in a hot compared to a temperate environment

Environmental heat stress impairs endurance performance by enhancing exercise-induced physiological and perceptual responses. However, the time course of these responses during self-paced running, particularly when comparing hot and temperate conditions, still needs further clarification. Moreover, monitoring fatigue induced by exercise is paramount to prescribing training and recovery adequately, but investigations on the effects of a hot environment on post-exercise neuromuscular fatigue are scarce. This study compared the time course of physiological and perceptual responses during a 10 km self-paced treadmill run (as fast as possible) between temperate (25°C) and hot (35°C) conditions. We also investigated the changes in countermovement jump (CMJ) performance following exercise in these two ambient temperatures. Thirteen recreational long-distance runners (11 men and 2 women), inhabitants of a tropical region, completed the two experimental trials in a randomized order. Compared to 25°C, participants had transiently higher body core temperature (TCORE) and consistently greater perceived exertion while running at 35°C (p < 0.05). These changes were associated with a slower pace, evidenced by an additional 14 ± 5 min (mean ± SD) to complete the 10 km at 35°C than at 25°C (p < 0.05). Before, immediately after, and 1 h after the self-paced run, the participants performed CMJs to evaluate lower limb neuromuscular fatigue. CMJ height was reduced by 7.0% (2.3 ± 2.4 cm) at 1 h after the race (p < 0.05) compared to pre-exercise values; environmental conditions did not influence this reduction. In conclusion, despite the reduced endurance performance, higher perceived exertion, and transiently augmented TCORE caused by environmental heat stress, post-exercise neuromuscular fatigue is similar between temperate and hot conditions. This finding suggests that the higher external load (faster speed) at 25°C compensates for the effects of more significant perceptual responses at 35°C in inducing neuromuscular fatigue.

Predicting the body core temperature of recreational athletes at the end of a 10 km self-paced run under environmental heat stress

NEW FINDINGS

What is the central question of this study? The aim was to identify the factors predicting the body core temperature of athletes at the end of a 10 km self-paced run in a hot environment. What is the main finding and its importance? Hyperthermia in athletes subjected to self-paced running depends on several factors, highlighting the integrated control of core temperature during exercise under environmental heat stress. Five of the seven variables that significantly predicted core temperature are not invasive and, therefore, practical for use outside the laboratory environment: heart rate, sweat rate, wet-bulb globe temperature, running speed and maximal oxygen consumption.

ABSTRACT

Measurement of body core temperature (Tcore ) is paramount to determining the thermoregulatory strain of athletes. However, standard measurement procedures of Tcore are not practical for extended use outside the laboratory environment. Therefore, determining the factors that predict Tcore during a self-paced run is crucial for creating more effective strategies to minimize the heat-induced impairment of endurance performance and reduce the occurrence of exertional heatstroke. The aim of this study was to identify the factors predicting Tcore values attained at the end of a 10 km time trial (end-Tcore ) under environmental heat stress. Initially, we extracted data obtained from 75 recordings of recreationally trained men and women. Next, we ran hierarchical multiple linear regression analyses to understand the predictive power of the following variables: wet-bulb globe temperature, average running speed, initial Tcore , body mass, differences between Tcore and skin temperature (Tskin ), sweat rate, maximal oxygen uptake, heart rate and change in body mass. Our data indicated that Tcore increased continuously during exercise, attaining 39.6 ± 0.5°C (mean ± SD) after 53.9 ± 7.5 min of treadmill running. This end-Tcore value was primarily predicted by heart rate, sweat rate, differences between Tcore and Tskin , wet-bulb globe temperature, initial Tcore , running speed and maximal oxygen uptake, in this order of importance (β power values corresponded to 0.462, -0.395, 0.393, 0.327, 0.277, 0.244 and 0.228, respectively). In conclusion, several factors predict Tcore in athletes subjected to self-paced running under environmental heat stress. Moreover, considering the conditions investigated, heart rate and sweat rate, two practical (non-invasive) variables, have the highest predictive power.

Sex-based differences in body core temperature response across repeat work bouts in the heat

OBJECTIVE

To investigate the effects of repeated work bouts in the heat on peak body core temperature and to explore sex-based differences in body core temperature responses.

METHODS

Fourteen males and fifteen females performed four work bouts (two heavy and two moderate, alternating) in 32.5 °C Wet Bulb Globe Temperature (WBGT), each separated by 30-min seated rest in 28.0 °C WBGT. Participants wore a military combat uniform with body armour and helmet (10 kg load) during the work bouts, removing the vest and helmet during recovery periods.

RESULTS

Body core temperature elevation over time was faster in the first compared with subsequent work bouts of each intensity. Body core temperature elevation was similar between males and females during the first heavy work bout, then remained significantly lower in females for the reminder of the trial.

CONCLUSIONS

Contrary to the assumed progressive elevation in strain, but in agreement with recent literature, a gradual reduction in heat storage in subsequent exercise bouts prevented a cumulative increase in heat strain in the conditions tested.

Female (Under) Representation in Exercise Thermoregulation Research

BACKGROUND

Despite an increasing rate of women participating in professional sports, emergency services, and military settings where they are exposed to exertional heat stress, our understanding of female thermoregulation and the detrimental effects of heat on women's performance, especially regarding the menstrual cycle, is limited. This review aimed to quantify the representation of women in exercise thermoregulation research between 2010 and 2019 and the frequency that these articles reported details pertaining to female participants' menstrual cycle to determine the volume of novel research that is directly relevant to this growing population.

METHODS

Original exercise thermoregulatory studies published in three major sports medicine databases (PubMed, MEDLINE, and SPORTDiscus) between 2010 and 2019 were surveyed. Articles were screened to determine the number of female and male participants in the study and whether studies involving women reported menstrual orientation or phase. Research involving healthy adult participants and an exercise protocol with a thermoregulatory outcome measure were included in the review.

RESULTS

A total of 1407 articles were included in the review, involving 28,030 participants. The annual representation of women ranged from a mean of 11.6% [95% credible interval (CI); 9.2, 14.3] to 17.8% [95% CI; 15.2, 20.6] across the 10 years, indicating studies predominantly included men. Nonetheless, there was a small statistical increase in the overall proportion of women, with a mean overall proportion change of 0.7% [95% CI; 0.2, 1.2] per year. The increase appeared to be driven by a reduction in the number of studies including only men, rather than studies including more women alongside men, or increased women-only studies. Less than one third of articles involving women reported the menstrual orientation of participants and less than one quarter reported both menstrual orientation and phase. This study shows that women were proportionally underrepresented in exercise thermoregulation research during the past decade and the majority of studies did not report menstrual cycle details of female participants. Researchers should consider including women in future work where their inclusion could contribute meaningful data that enhance the evidence-based and ultimately improves our comprehension of women's thermal physiology.

Methodological Considerations for Studies in Sport and Exercise Science with Women as Participants: A Working Guide for Standards of Practice for Research on Women

Until recently, there has been less demand for and interest in female-specific sport and exercise science data. As a result, the vast majority of high-quality sport and exercise science data have been derived from studies with men as participants, which reduces the application of these data due to the known physiological differences between the sexes, specifically with regard to reproductive endocrinology. Furthermore, a shortage of specialist knowledge on female physiology in the sport science community, coupled with a reluctance to effectively adapt experimental designs to incorporate female-specific considerations, such as the menstrual cycle, hormonal contraceptive use, pregnancy and the menopause, has slowed the pursuit of knowledge in this field of research. In addition, a lack of agreement on the terminology and methodological approaches (i.e., gold-standard techniques) used within this research area has further hindered the ability of researchers to adequately develop evidenced-based guidelines for female exercisers. The purpose of this paper was to highlight the specific considerations needed when employing women (i.e., from athletes to non-athletes) as participants in sport and exercise science-based research. These considerations relate to participant selection criteria and adaptations for experimental design and address the diversity and complexities associated with female reproductive endocrinology across the lifespan. This statement intends to promote an increase in the inclusion of women as participants in studies related to sport and exercise science and an enhanced execution of these studies resulting in more high-quality female-specific data.

The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis

BACKGROUND

Oral contraceptive pills (OCPs) are double agents, which downregulate endogenous concentrations of oestradiol and progesterone whilst simultaneously providing daily supplementation of exogenous oestrogen and progestin during the OCP-taking days. This altered hormonal milieu differs significantly from that of eumenorrheic women and might impact exercise performance, due to changes in ovarian hormone-mediated physiological processes.

OBJECTIVE

To explore the effects of OCPs on exercise performance in women and to provide evidence-based performance recommendations to users.

METHODS

This review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A between-group analysis was performed, wherein performance of OCP users was compared with naturally menstruating women, and a within-group analysis was conducted, wherein performance during OCP consumption was compared with OCP withdrawal. For the between-group analysis, women were phase matched in two ways: (1) OCP withdrawal versus the early follicular phase of the menstrual cycle and (2) OCP consumption versus all phases of the menstrual cycle except for the early follicular phase. Study quality was assessed using a modified Downs and Black Checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation working group. All meta-analyses were conducted within a Bayesian framework to facilitate probabilistic interpretations.

RESULTS

42 studies and 590 participants were included. Most studies (83%) were graded as moderate, low or very low quality, with 17% achieving high quality. For the between-group meta-analysis comparing OCP users with naturally menstruating women, posterior estimates of the pooled effect were used to calculate the probability of at least a small effect (d ≥ 0.2). Across the two between-group comparison methods, the probability of a small effect on performance favouring habitual OCP users was effectually zero (p < 0.001). In contrast, the probability of a small effect on performance favouring naturally menstruating women was moderate under comparison method (1) (d ≥ 0.2; p = 0.40) and small under comparison method (2) (d ≥ 0.2; p = 0.19). Relatively large between-study variance was identified for both between-group comparisons ([Formula: see text]0.5 = 0.16 [95% credible interval (CrI) 0.01-0.44] and [Formula: see text]0.5 = 0.22 [95% CrI 0.06-0.45]). For the within-group analysis comparing OCP consumption with withdrawal, posterior estimates of the pooled effect size identified almost zero probability of a small effect on performance in either direction (d ≥ 0.2; p ≤ 0.001).

CONCLUSIONS

OCP use might result in slightly inferior exercise performance on average when compared to naturally menstruating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and variable across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle.

Sex differences in muscle activity emerge during sustained low-intensity contractions but not during intermittent low-intensity contractions

Sex differences in motor performance may arise depending on the mode of contraction being performed. In particular, contractions that are held for long durations, rather than contractions that are interspersed with rest periods, may induce greater levels of fatigue in men compared to women. The purpose of this study was to examine fatigue responses in a cohort of healthy men (n = 7, age [mean] = 21.6 ± [SD] 1.1 year) and women (n = 7, age: 22.0 ± 2.0 year) during sustained isometric and intermittent isometric contractions. Two contraction protocols were matched for intensity (20% MVC) and total contraction time (600-s). Biceps brachii EMG and elbow flexion torque steadiness were examined throughout each protocol, and motor nerve stimulation was used to quantify central and peripheral fatigue. Overall, there were few sex-related differences in the fatigue responses during intermittent contractions. However, men exhibited progressively lower maximal torque generation (39% versus 27% decrease), progressively greater muscle activity (220% versus 144% increase), progressively greater declines in elbow flexion steadiness (354% versus 285% decrease), and progressively greater self-perception of fatigue (Borg scale: 8.8 ± 1.2 versus 6.3 ± 1.1) throughout the sustained contractions. The mechanism underlying fatigue responses had a muscle component, as voluntary activation of the biceps brachii did not differ between sexes, but the amplitude of resting twitches decreased throughout the sustained contractions (m: 32%, w: 10% decrease). As generating large sustained forces causes a progressive increase in intramuscular pressure and mechanical occlusion-which has the effect of enhancing metabolite accumulation and peripheral fatigue-it is likely that the greater maximal strength of men contributed to their exacerbated levels of fatigue.

Practice does not make perfect: A brief view of athletes' knowledge on the menstrual cycle and oral contraceptives

OBJECTIVES

To assess the knowledge of Australian elite female athletes surrounding the menstrual cycle and oral contraceptives.

DESIGN

Cross sectional survey.

METHODS

Australian female athletes (n=189) representing their state and/or country in their respective sport completed a questionnaire comprising questions (multiple choice and short answer) relating to the menstrual cycle and oral contraceptives. A knowledge 'score' was calculated by allocating one point for each correct answer; the highest knowledge score that could be achieved was 14. Linear regression analysis was used to identify variables that were independently associated with menstrual cycle and oral contraceptive knowledge.

RESULTS

Almost half (47.1 %) of the athletes surveyed were currently using hormonal contraception, the majority (75.3 %) of which used an oral contraceptive pill. Nevertheless, the mean knowledge score achieved by athletes on the questionnaire was 5.03±3.06, with only 8.5 % of athletes achieving a knowledge score of 10 or above. Hormonal contraceptive use and 'identifying as an individual athlete' were two factors that were significantly associated with overall knowledge score (p≤0.004), with current hormonal contraceptive users and individual athletes scoring 1.79 and 1.66 points on average higher than non-users and team sport athletes, respectively.

CONCLUSIONS

Our findings indicate that knowledge surrounding the menstrual cycle and oral contraceptives was low in most elite athletes. Further education is warranted to enable athletes to make informed decisions regarding hormonal contraception, and any educational interventions should be implemented across all athlete groups.

Cerebral oxygenation declines but does not impair peak oxygen uptake during incremental cycling in women using oral contraceptives

PURPOSE

To compare prefrontal cortex oxygenation in recreationally-active women using oral contraceptives (WomenOC; n = 8) to women with a natural menstrual cycle (WomenNC; n = 8) during incremental exercise to exhaustion.

METHODS

Participants performed incremental cycling to exhaustion to determine lactate threshold 1 (LT1) and 2 (LT2) and peak oxygen uptake (VO₂peak). Prefrontal cortex oxygenation was monitored via near-infrared spectroscopy through concentration changes in oxy-haemoglobin (Δ[HbO₂]), deoxy-haemoglobin (Δ[HHb]), total-haemoglobin (Δ[tHb]) and tissue saturation index (TSI).

RESULTS

17β-oestradiol and progesterone were lower in WomenOC (35 ± 26; 318 ± 127 pmol·L^-1, respectively) than WomenNC (261 ± 156; 858 ± 541 pmol·L^-1, respectively). There were no differences in full blood examination results or serum nitric oxide (p > 0.05). However, WomenOC presented lower concentrations in ferric-reducing ability of plasma (- 8%; effect size; ES - 0.52 ± 0.61), bilirubin (- 32%; ES - 0.56 ± 0.62) and uric acid (- 17%; ES - 0.53 ± 0.61). Cardiopulmonary parameters were similar between groups during cycling, including VO₂peak (p = 0.99). While there was a significant effect of time on all parameters measured by near-infrared spectroscopy during incremental cycling, there was no effect of OC at LT1, LT2 or exhaustion calculated as a change from baseline (TSI; p = 0.096, Δ[HbO₂]; p = 0.143, Δ[HHb]; p = 0.085 and Δ[tHb]; p = 0.226). The change in TSI from LT1 to LT2 was significantly different between groups (WomenNC; mean difference + 2.06%, WomenOC; mean difference - 1.73%; p = 0.003).

CONCLUSION

Prefrontal tissue oxygenation declined at a lower relative exercise intensity in WomenOC as compared to WomenNC, however, this did not influence VO₂peak. The results provide the first evidence for variance in the cerebral oxygenation response to exercise, which may be associated with female sex hormones.