Combined Oral Contraceptives Increase High-Sensitivity C-Reactive Protein but Not Haptoglobin in Female Athletes

Perspectives on Concurrent Strength and Endurance Training in Healthy Adult Females: A Systematic Review

BACKGROUND

Both strength and endurance training are included in global exercise recommendations and are the main components of training programs for competitive sports. While an abundance of research has been published regarding concurrent strength and endurance training, only a small portion of this research has been conducted in females or has addressed their unique physiological circumstances (e.g., hormonal profiles related to menstrual cycle phase, menstrual dysfunction, and hormonal contraceptive use), which may influence training responses and adaptations.

OBJECTIVE

The aim was to complete a systematic review of the scientific literature regarding training adaptations following concurrent strength and endurance training in apparently healthy adult females.

METHODS

A systematic electronic search for articles was performed in July 2021 and again in December 2022 using PubMed and Medline. This review followed, where applicable, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of the included studies was assessed using a modified Downs and Black checklist. Inclusion criteria were (1) fully published peer-reviewed publications; (2) study published in English; (3) participants were healthy normal weight or overweight females of reproductive age (mean age between > 18 and < 50) or presented as a group (n > 5) in studies including both females and males and where female results were reported separately; (4) participants were randomly assigned to intervention groups, when warranted, and the study included measures of maximal strength and endurance performance; and (5) the duration of the intervention was ≥ 8 weeks to ensure a meaningful training duration.

RESULTS

Fourteen studies met the inclusion criteria (seven combined strength training with running, four with cycling, and three with rowing or cross-country skiing). These studies indicated that concurrent strength and endurance training generally increases parameters associated with strength and endurance performance in female participants, while several other health benefits such as, e.g., improved body composition and blood lipid profile were reported in individual studies. The presence of an "interference effect" in females could not be assessed from the included studies as this was not the focus of any included research and single-mode training groups were not always included alongside concurrent training groups. Importantly, the influence of concurrent training on fast-force production was limited, while the unique circumstances affecting females were not considered/reported in most studies. Overall study quality was low to moderate.

CONCLUSION

Concurrent strength and endurance training appears to be beneficial in increasing strength and endurance capacity in females; however, multiple research paradigms must be explored to better understand the influence of concurrent training modalities in females. Future research should explore the influence of concurrent strength and endurance training on fast-force production, the possible presence of an "interference effect" in athletic populations, and the influence of unique circumstances, such as hormone profile, on training responses and adaptations.

Effect of combined oral contraceptive on cardiorespiratory function and immune activation in premenopausal women involved in exercise: A systematic review protocol

BACKGROUND

The use of combined oral contraceptive (COC) is common among women of reproductive age despite the potential risk of them developing thrombotic events. There is a need to understand how COC affects cardiorespiratory function and markers of immune activation in premenopausal women involved in exercise. This highlights a need for a systematic review to enhance our understanding of how the use of COC affects cardiovascular health in premenopausal women subjected to exercise.

METHOD

This systematic review protocol was prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 statement. An extensive search of relevant literature by two independent reviewers will be conducted through the EBSCOhost interface to access databases such as MEDLINE, EMBASE, and CINAHL. Other health sources, including Cochrane CENTRAL, unpublished studies and grey literature, will also be searched. The search will include all studies that report the effect of COC on essential parameters of cardiorespiratory function and markers of immune activation in premenopausal women involved in exercise. All included studies will be appraised using appraisal tools, while appropriate extraction tools will be used for data extraction. Where possible, eligible studies will be pooled for meta-analysis. If statistical pooling is not feasible, our findings will be presented in a narrative format. The certainty of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation Assessment (GRADE) tool.

TRIAL REGISTRATION

PROSPERO registration number: CRD42021265257.

Cardiovascular Effects of Chronic Hormone Therapy: Study on Olympic Female Athletes

Female physiology is regulated after puberty by the menstrual cycle, whose hormonal fluctuations create a multitude of effects on several systems, including the cardiovascular one. The use of hormone therapy (HT) is quite common in female athletes, and data on cardiovascular effects in this population are lacking. We sought to investigate the effects of HT in highly trained athletes to assess any difference associated with HT on cardiac remodeling, exercise capacity, and clinical correlates. We studied 380 female elite athletes (mean age 25.5 ± 4.8) competing in endurance and mixed sports; 67 athletes (18%) were in chronic HT therapy. All athletes underwent baseline electrocardiography, exercise electrocardiography stress test, transthoracic echocardiogram, and complete blood tests, including lipid profile and inflammation indexes. The echocardiographic study showed a characteristic left ventricular (LV) remodeling, defined by lower LV mass index (86.2 vs 92.5 g/m2, p <0.006), end-diastolic LV diameter (28.3 vs 29.4 mm/m2, p <0.004), and end-diastolic LV volume (61.82 vs 67.09 ml/m2, p <0.010) compared with controls, without changes in systolic function and diastolic relaxation/filling indexes. A lower burden of ventricular arrhythmias on exercise was observed in HT athletes (1.5% vs 8.6% in those without therapy, p = 0.040). Linear regression analysis showed that HT had an independent effect on LV end-diastolic diameter indexed (p = 0.014), LV end-diastolic volume indexed (p = 0.030), and LV mass indexed (p = 0.020). In conclusion, chronic treatment with HT in female athletes is associated with less cardiac remodeling, including a lower LV cavity, volume, and mass, with preserved systolic and diastolic function, and decreased burden of exercise-induced ventricular arrhythmias. HT, therefore, appears to be responsible for a more economic but equally efficient cardiac adaptation to intensive athletic conditioning.

Comparison of the cytokine responses to acute strength exercise between oral contraceptive users and naturally cycling women

PURPOSE

Cytokines are released as part of an inflammatory reaction in response to strength exercise to initiate muscle repair and morphological adaptations. Whether hormonal fluctuations induced by the menstrual cycle or oral contraceptives affect inflammatory responses to strength exercise remains unknown. Therefore, we aimed to compare the response of cytokines after acute strength exercise in naturally menstruating women and oral contraceptive users.

METHODS

Naturally menstruating women (MC, n = 13, 24 ± 4 years, weekly strength training: 4.3 ± 1.7 h) and women using a monophasic combined pill (> 9 months) (OC, n = 8, 22 ± 3 years, weekly strength training: 4.5 ± 1.9 h) were recruited. A one-repetition-maximum (1RM) test and strength exercise in the squat (4 × 10 repetitions, 70%1RM) was performed in the early follicular phase or pill free interval. Concentrations of oestradiol, IL-1β, IL-1ra, IL-6, IL-8, and IL-10 were assessed before (pre), directly after (post) and 24 h after (post24) strength exercise.

RESULTS

IL-1ra increased from pre to post (+ 51.1 ± 59.4%, p = 0.189) and statistically decreased from post to post24 (- 20.5 ± 13.5%, p = 0.011) only in OC. Additionally, IL-1β statistically decreased from post to post24 (- 39.6 ± 23.0%, p = 0.044) only in OC. There was an interaction effect for IL-1β (p = 0.038) and concentrations were statistically decreased at post24 in OC compared to MC (p = 0.05). IL-8 increased across both groups from post to post24 (+ 66.6 ± 96.3%, p = 0.004).

CONCLUSION

We showed a differential regulation of IL-1β and IL-1ra between OC users in the pill-free interval and naturally cycling women 24 h after strength exercise, while there was no effect on other cytokines. Whether this is associated with previously shown compromised morphological adaptations remains to be investigated.

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

Response to Mechanical Properties and Physiological Challenges of Fascia: Diagnosis and Rehabilitative Therapeutic Intervention for Myofascial System Disorders

Damage to the fascia can cause significant performance deficits in high-performance sports and recreational exercise and may contribute to the development of musculoskeletal disorders and persistent potential pain. The fascia is widely distributed from head to toe, encompassing muscles, bones, blood vessels, nerves, and internal organs and comprising various layers of different depths, indicating the complexity of its pathogenesis. It is a connective tissue composed of irregularly arranged collagen fibers, distinctly different from the regularly arranged collagen fibers found in tendons, ligaments, or periosteum, and mechanical changes in the fascia (stiffness or tension) can produce changes in its connective tissue that can cause pain. While these mechanical changes induce inflammation associated with mechanical loading, they are also affected by biochemical influences such as aging, sex hormones, and obesity. Therefore, this paper will review the current state of knowledge on the molecular level response to the mechanical properties of the fascia and its response to other physiological challenges, including mechanical changes, innervation, injury, and aging; imaging techniques available to study the fascial system; and therapeutic interventions targeting fascial tissue in sports medicine. This article aims to summarize contemporary views.

Effects of biological sex and oral contraceptive pill use on cutaneous microvascular endothelial function and nitric oxide-dependent vasodilation in humans

The purpose of this study was to evaluate in vivo endothelial function and nitric oxide (NO)-dependent vasodilation between women in either menstrual or placebo pill phases of their respective hormonal exposure [either naturally cycling (NC) or using oral contraceptive pills (OCPs)] and men. A planned subgroup analysis was then completed to assess endothelial function and NO-dependent vasodilation between NC women, women using OCP, and men. Endothelium-dependent and NO-dependent vasodilation were assessed in the cutaneous microvasculature using laser-Doppler flowmetry, a rapid local heating protocol (39°C, 0.1 °C/s), and pharmacological perfusion through intradermal microdialysis fibers. Data are represented as means ± standard deviation. Men displayed greater endothelium-dependent vasodilation (plateau, men: 71 ± 16 vs. women: 52 ± 20%CVC_max, P < 0.01), but lower NO-dependent vasodilation (men: 52 ± 11 vs. women: 63 ± 17%NO, P = 0.05) compared with all women. Subgroup analysis revealed NC women had lower endothelium-dependent vasodilation (plateau, NC women: 48 ± 21%CVC_max, P = 0.01) but similar NO-dependent vasodilation (NC women: 52 ± 14%NO, P > 0.99), compared with men. Endothelium-dependent vasodilation did not differ between women using OCP and men (P = 0.12) or NC women (P = 0.64), but NO-dependent vasodilation was significantly greater in women using OCP (74 ± 11%NO) than both NC women and men (P < 0.01 for both). This study highlights the importance of directly quantifying NO-dependent vasodilation in cutaneous microvascular studies. This study also provides important implications for experimental design and data interpretation.NEW & NOTEWORTHY This study supports differences in microvascular endothelial function and nitric oxide (NO)-dependent vasodilation between women in low hormone phases of two hormonal exposures and men. However, when separated into subgroups of hormonal exposure, women during placebo pills of oral contraceptive pill (OCP) use have greater NO-dependent vasodilation than naturally cycling women in their menstrual phase and men. These data improve knowledge of sex differences and the effect of OCP use on microvascular endothelial function.

Understanding the female athlete: molecular mechanisms underpinning menstrual phase differences in exercise metabolism

Research should equitably reflect responses in men and women. Including women in research, however, necessitates an understanding of the ovarian hormones and menstrual phase variations in both cellular and systems physiology. This review outlines recent advances in the multiplicity of ovarian hormone molecular signaling that elucidates the mechanisms for menstrual phase variability in exercise metabolism. The prominent endogenous estrogen, 17-β-estradiol (E2), molecular structure is bioactive in stabilizing plasma membranes and quenching free radicals and both E2 and progesterone (P4) promote the expression of antioxidant enzymes attenuating exercise-induced muscle damage in the late follicular (LF) and mid-luteal (ML) phases. E2 and P4 bind nuclear hormone receptors and membrane-bound receptors to regulate gene expression directly or indirectly, which importantly includes cross-regulated expression of their own receptors. Activation of membrane-bound receptors also regulates kinases causing rapid cellular responses. Careful analysis of these signaling pathways explains menstrual phase-specific differences. Namely, E2-promoted plasma glucose uptake during exercise, via GLUT4 expression and kinases, is nullified by E2-dominant suppression of gluconeogenic gene expression in LF and ML phases, ameliorated by carbohydrate ingestion. E2 signaling maximizes fat oxidation capacity in LF and ML phases, pending low-moderate exercise intensities, restricted nutrient availability, and high E2:P4 ratios. P4 increases protein catabolism during the luteal phase by indeterminate mechanisms. Satellite cell function supported by E2-targeted gene expression is countered by P4, explaining greater muscle strengthening from follicular phase-based training. In totality, this integrative review provides causative effects, supported by meta-analyses for quantitative actuality, highlighting research opportunities and evidence-based relevance for female athletes.

Microvascular endothelial function following cessation of long-term oral contraceptive pill use: A case report

NEW FINDINGS

What is the main observation in this case? The main observation of this case report is substantial improvement in cutaneous microvascular endothelial function after cessation of long-term use of a fourth-generation oral contraceptive pill. This improvement appears independent of relative changes in the contribution of nitric oxide. What insights does it reveal? Our findings suggest that cessation of long-term, fourth-generation oral contraceptive pill use improves endothelial function within 20 months of cessation.

ABSTRACT

The purpose of this case report was to evaluate in vivo endothelial function and nitric oxide (NO)-dependent vasodilatation before and after the cessation of long-term (11-12 years) fourth-generation oral contraceptive pill (OCP) use in one young, healthy and premenopausal woman. This retrospective analysis includes data from six experimental visits: three visits during months 133-144 of fourth-generation OCP use and three visits 19-22 months after OCP cessation. Endothelium-dependent and NO-dependent vasodilatation were assessed in the cutaneous microvasculature using laser-Doppler flowmetry, a rapid local heating protocol (39°C, 0.1°C/s) and pharmacological perfusion through intradermal microdialysis fibres. The participant had consistent medical history and lifestyle behaviours throughout both hormonal exposures. Data are presented as the mean (SD). Endothelium-dependent vasodilatation was 42 (10)% of site-specific maximal cutaneous vascular conductance (CVCmax ) during OCP use and 63 (10)%CVCmax after OCP cessation (49% increase). Nitric oxide-dependent vasodilatation was 70 (5)% contribution of NO during OCP use and 60 (15)%NO after OCP cessation (15% reduction). Baseline blood flow was greater after OCP cessation, but maximal blood flow was reduced. Data from this case report support a substantial increase in cutaneous microvascular endothelial function assessed via local heating after cessation of long-term use of a fourth-generation OCP, which does not appear to be attributable to increased NO bioavailability. Overall, these data suggest an improvement in endothelial and microvascular function after the cessation of long-term use of a fourth-generation OCP.

Association between Oral Contraceptive Use and the High-Sensitivity C-Reactive Protein Level in Premenopausal Korean Women

Although oral contraceptives (OCs) are widely used, few national epidemiological studies have evaluated the association between OC use and serum high-sensitivity C-reactive protein (hs-CRP) levels in Korean women. This population-based cross-sectional study was conducted with data from the 2015–2018 National Health and Nutrition Examination Survey. In the sample of 5332 premenopausal women aged ≥19 years, hs-CRP concentrations were 1.087 mg/L among OC users and 0.953 mg/L among OC non-users. After adjustment for confounders, OC users had an increased likelihood of having risky (>1.0 mg/L) hs-CRP levels (adjusted odds ratio (aOR) = 1.58; 95% confidence interval (CI), 1.25–1.98) compared with OC non-users. In addition, the aOR for high-risk (>3.0 mg/L) hs-CRP levels in OC users compared with non-users was 1.51 (95% CI, 1.06–2.16). These findings demonstrate that OC use alters the concentration of hs-CRP, a biomarker of chronic low-grade inflammation, and suggest that long-term OC use is a risk factor in the pathogenesis of inflammatory diseases, including cardiovascular diseases.

Patterns of endogenous and exogenous ovarian hormone modulation on recovery metrics across the menstrual cycle

Introduction

As the number of female athletes competing rises globally, training methodologies should reflect sex differences across critical metrics of adaptation to training. Surrogate markers of the autonomic nervous system (ANS) used for monitoring training load are heart rate variability (HRV) and resting heart rate (RHR). The aim was to investigate ovarian hormone effects on standard recovery metrics (HRV, RHR, respiratory rate (RR) and sleep duration) across a large population of female athletes.

Methods

A retrospective study analysed 362 852 days of data representing 13 535 menstrual cycles (MC) from 4594 respondents (natural MC n=3870, BC n=455, progestin-only n=269) for relationships and/or differences between endogenous and exogenous ovarian hormones on ANS.

Results

HRV and return to baseline (recovery) decreased as resting HR and RR increased (p<0.001) from the early follicular to the late luteal phase of the MC. Patterning was paradoxical across phases for users of combined hormonal contraception (BC) as compared with the patterning of the MC. HRV and recovery start elevated and drop off quickly during the withdrawal bleed, rising through the active pill weeks (p<0.001). Progestin-only users had similar patterning as the MC. The relationship between normalised recovery and previous day strain is modulated by birth control type. BC exhibited steeper declines in recovery with additional strain-normalised recovery decreases by an additional 0.0055±0.00135 (p<0.001) per unit of strain; with no significant difference between MC and progestin-only (p=0.19).

Conclusion

The patterning of ANS modulation from ovarian hormones is significantly different between naturally cycling women and those on BC, with the patterning dependent on the type of contraception used.

Temporal changes in blood oxidative stress biomarkers across the menstrual cycle and with oral contraceptive use in active women

PURPOSE

To examine the temporal changes in blood oxidative stress biomarkers in recreationally-trained women that were naturally-cycling (WomenNC) or using oral contraceptives (WomenOC) across one month.

METHODS

Blood samples were acquired at three timepoints of the menstrual cycle (1: early-follicular, 2: late-follicular and 3: mid-luteal) and oral contraceptive packet (1: InactiveOC, 2: Mid-activeOC and 3: Late-activeOC) for determination of estradiol, progesterone, oxidative stress, C-reactive protein (CRP) and other cardiometabolic biomarkers in plasma and serum.

RESULTS

There was a Group by Time effect on estradiol (p < 0.001, partial η² = 0.64) and progesterone (p < 0.001, partial η² = 0.77). Malondialdehyde, lipid hydroperoxides and CRP concentrations were higher in WomenOC during Late-activeOC compared to InactiveOC (+ 96%, + 23% and + 104%, respectively, p < 0.05). However, there were no changes in these biomarkers across the menstrual cycle in WomenNC (p > 0.05). At all timepoints (i.e., 1, 2 and 3), WomenOC had elevated lipid hydroperoxides (+ 28, + 48% and + 50%) and CRP (+ 71%, + 117% and + 130%) compared to WomenNC (p < 0.05, partial η² > 0.25). There was no Group by Time effect on non-enzymatic antioxidants or glutathione peroxidase; however, glutathione peroxidase was lower in WomenOC, i.e., main effect of group (p < 0.05, partial η² > 0.20).

CONCLUSION

These findings demonstrate that WomenOC not only have higher oxidative stress and CRP than WomenNC, but also a transient increase across one month of habitual oral contraceptive use. Since changes in oxidative stress and CRP often relate to training stress and recovery, these outcomes may have implications to workload monitoring practices in female athletes.

Evaluating the effects of oral contraceptive use on biomarkers and body composition during a competitive season in collegiate female soccer players

High training demands throughout the competitive season in female collegiate soccer players have been shown to induce changes in biomarkers indicative of stress, inflammation, and reproduction, which may be exacerbated in athletes using oral contraceptives (OCs). This study aimed to compare biomarkers and body composition between OC-using and nonusing (CON) female soccer players throughout a competitive season. Female collegiate soccer players were stratified into two groups based on their reported OC use at the start of preseason (OC: n = 6; CON: n = 17). Before the start of preseason and immediately postseason, athletes underwent a battery of performance tests. Blood draws and body composition assessments were performed before preseason, on wks 2, 4, 8, and 12 of the season, and postseason. Area-under-the-curve ratios (OC_AUC:CON_AUC) indicated the OC group were exposed to substantially higher levels of sex hormone-binding globulin (AUC_ratio = 1.4, probability = P > 0.999), total cortisol (1.7; P > 0.999), C-reactive protein (5.2; P > 0.999), leptin (1.4; P = 0.990), growth hormone (1.5; P = 0.97), but substantively lower amounts of estradiol (0.36; P < 0.001), progesterone (0.48; P = 0.008), free testosterone (0.58; P < 0.001), follicle-stimulating hormone (0.67; P < 0.001), and creatine kinase (0.33, P < 0.001) compared with the CON across the season. Both groups increased fat free mass over the season, but CON experienced a greater magnitude of increase along with decreased body fat percentage. Although similar training loads were observed between groups over the season, the elevated exposure to stress, inflammatory, and metabolic biomarkers over the competitive season in OC users may have implications on body composition, training adaptations, and recovery in female athletes.NEW & NOTEWORTHY This study highlights the influence of OC use on physiological changes that occur over a 4-mo intense, competitive season and the differential systemic exposure to biomarkers, specifically those of inflammation, stress, anabolism, and energy balance, between OC-using and nonusing soccer players. Additionally, this study provides insight into changes in body composition with prolonged training between female athletes with and without OC use.

Sex differences and considerations for female specific nutritional strategies: a narrative review

Although there is a plethora of information available regarding the impact of nutrition on exercise performance, many recommendations are based on male needs due to the dominance of male participation in the nutrition and exercise science literature. Female participation in sport and exercise is prevalent, making it vital for guidelines to address the sex-specific nutritional needs. Female hormonal levels, such as estrogen and progesterone, fluctuate throughout the mensural cycle and lifecycle requiring more attention for effective nutritional considerations. Sex-specific nutritional recommendations and guidelines for the active female and female athlete have been lacking to date and warrant further consideration. This review provides a practical overview of key physiological and nutritional considerations for the active female. Available literature regarding sex-specific nutrition and dietary supplement guidelines for women has been synthesized, offering evidenced-based practical information that can be incorporated into the daily lives of women to improve performance, body composition, and overall health.

COVID-19-Considerations for the Female Athlete

The SARS CoV-2 virus (COVID-19) caused the whole sporting calendar to be paused. As we embark on the challenge of navigating through the return to play (RTP) process, there is a necessity to consider the needs of all athletes. This commentary specifically considers recommendations and requirements for the female athlete with a physiological emphasis during and following the COVID-19 pandemic, however, it will be relevant for any similar future scenarios that may present. It is important to acknowledge that there remain many unknowns surrounding COVID-19 and the female athlete both in the short- and long-term.

Oxidative Stress Is Increased in Combined Oral Contraceptives Users and Is Positively Associated with High-Sensitivity C-Reactive Protein

Information concerning the mechanisms underlying oxidative stress and low-grade inflammation in young healthy women predisposing eventually to future diseases is scarce. We investigated the relationship of oxidative stress and high-sensitivity C-reactive protein (hsCRP) in fertile-age women by oral combined contraceptive (OC) use. Caucasian Italian healthy non-obese women (n = 290; 100 OC-users; 190 non-OC-users; mean age 23.2 ± 4.7 years) were analyzed. Blood hydroperoxides, as oxidative stress biomarkers, were assessed by Free Oxygen Radical Test (FORT). Serum hsCRP was determined by an ultra-sensitive method (hsCRP). Markedly elevated oxidative stress (≥400 FORT Units) was found in 77.0% of OC-users and 1.6% of non-OC-users, odds ratio (OR) = 209, 95% CI = 60.9–715.4, p < 0.001. Elevated hsCRP levels ≥ 2.0 mg/L, considered risky for cardiovascular diseases (CVDs), were found in 41.0% of OC-users and 9.5% of non-OC-users, OR = 6.6, 95%CI 3.5–12.4, p < 0.001. Hydroperoxides were strongly positively correlated to hsCRP in all women (r_s = 0.622, p < 0.001), in OC-users (r_s = 0.442, p < 0.001), and in non-OC-users (r_s = 0.426, p < 0.001). Women with hydroperoxides ≥ 400 FORT Units were eight times as likely to have hsCRP ≥ 2 mg/L. In non-OC-users only, hydroperoxides values were positively correlated with weight and body mass index, but negatively correlated with red meat, fish and chocolate consumption. Our research is the first finding a strong positive correlation of serum hydroperoxides with hsCRP, a marker of low-grade chronic inflammation, in young healthy women. Further research is needed to elucidate the potential role of these two biomarkers in OC-use associated side-effects, like thromboembolism and other CVDs.

Estimated Number of Lifetime Ovulatory Years and Its Determinants in Relation to Levels of Circulating Inflammatory Biomarkers

Reproductive events, such as ovulation, trigger an inflammatory cascade. Few studies have examined their long-term influence on inflammatory profiles. We included 3,393 premenopausal and 3,915 postmenopausal women with intact ovaries/uterus from the Nurses' Health studies (Nurses' Health Study (1989-1990) and Nurses' Health Study II (1996-1999)) in an analysis of the association between lifetime ovulatory years (LOY) and levels of inflammatory biomarkers. We estimated LOY as age at menopause (age at blood collection for premenopausal women) minus age at menarche, subtracting years of oral contraceptive (OC) use and 1 year per pregnancy. After adjustment for other inflammation-related factors (e.g., body mass index, exercise, diet), every 5-year increase in LOY was associated with lower C-reactive protein (CRP) levels in both premenopausal (difference = -11.5%, 95% confidence interval: -15.0, -8.0; P < 0.0001) and postmenopausal (difference = -7.2%, 95% confidence interval: -10.0, -4.3; P < 0.0001) women. Older age at menopause (P = 0.007), earlier menarche (P = 0.007), and shorter duration of OC use (P = 0.002) were associated with lower CRP levels in postmenopausal women, whereas duration of OC use was positively associated with CRP levels in premenopausal women (P < 0.0001). LOY was modestly inversely associated with interleukin 6 in postmenopausal women (P = 0.03). Notably, the associations of CRP with LOY were similar in magnitude to associations with exercise and a healthy diet, though weaker than the association with body mass index. Although many reproductive events induce acute inflammation, increased LOY was associated with lower chronic systemic inflammation even after menopause.

Muscle damage and inflammatory status biomarkers after a 3-stage trail running race

BACKGROUND

Participants in ultramarathon and multi-stage races are continuously increasing. A detailed knowledge of the time-course of the restoration in muscular, cardiac, and inflammatory biomarkers after a multi-stage race may help the design of training schedules focused to avoid adverse outcomes of repetitive high-intensity endurance exercise and athlete exhaustion. Thus, the aim of the study was to evaluate blood parameters and serum biomarkers associated to muscle damage and inflammation in athletes participating in a 3-stage competition.

METHODS

Ten runners concluded the race "Magraid" consisting of 3 stages of 22, 48 and 20 km. Before (PRE), immediately after the end of the third stage (POST) and five days after the last stage (R5d), we collected blood samples.

RESULTS

Among others, at POST mean white blood cell (+57±42%; P=0.006), blood urea nitrogen (+68±39%; P<0.001), creatinine (+17±12%, P=0.005), alanine aminotransferase (ALT, +104±69%; P=0.002), lactate dehydrogenase (LDH, +116±64%; P<0.001), creatine kinase (CK, +2044±1433%; P=0.011), CK-MBm (+1544±1007%; P=0.004), cardiac troponin I (cTnI, +85±129%; P=0.015), C-reactive protein (hsCRP, +2137±1660%; P=0.015) were higher than PRE. At R5d, ALT (+72±53%; P=0.010), LDH (+32±25%; P=0.006) and hsCRP (+252±234%; P=0.021) were still different compared with PRE.

CONCLUSIONS

A 3-stage trail running race induces an inflammatory status and muscle damage and functional consequences on some physiological systems that may not be completely recovered within a short period.

Inflammation and Oral Contraceptive Use in Female Athletes Before the Rio Olympic Games

This study investigated the association between synthetic ovarian hormone use [i.e., the oral contraceptive (OC) pill] and basal C-reactive protein (CRP), peripheral blood immune cell subsets, and circulating pro- and anti-inflammatory cytokine concentrations in elite female athletes. Elite female athletes (n = 53) selected in Rio Summer Olympic squads participated in this study; 25 were taking an OC (AthletesOC) and 28 were naturally hormonally cycling (AthletesNC). Venous blood samples were collected at rest for the determination of sex hormones, cortisol, CRP, peripheral blood mononuclear memory and naïve CD4+ T-cells, CD8+ T-cells and natural killer cells, as well as pro- and anti-inflammatory cytokine concentrations. C-reactive protein concentrations were elevated (p < 0.001) in AthletesOC (median = 2.02, IQR = 3.15) compared to AthletesNC (median = 0.57, IQR = 1.07). No differences were reported for cortisol, cytokines, or PBMC immune cell subsets, although there was a trend (p = 0.062) for higher IL-6 concentrations in AthletesNC. Female Olympians had substantially higher CRP concentrations, a marker of inflammation and tissue damage, before the Rio Olympic Games if they used an OC. Future research should examine the potential consequences for athlete performance/recovery so that, if necessary, practitioners can implement prevention programs.

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.

Inflammation, depression and cardiovascular disease in women: the role of the immune system across critical reproductive events

Women are at increased risk for developing depression and cardiovascular disease (CVD) across the lifespan and their comorbidity is associated with adverse outcomes that contribute significantly to rates of morbidity and mortality in women worldwide. Immune-system activity has been implicated in the etiology of both depression and CVD, but it is unclear how inflammation contributes to sex differences in this comorbidity. This narrative review provides an updated synthesis of research examining the association of inflammation with depression and CVD, and their comorbidity in women. Recent research provides evidence of pro-inflammatory states and sex differences associated with alterations in the hypothalamic–pituitary–adrenal axis, the renin–angiotensin–aldosterone system and the serotonin/kynurenine pathway, that likely contribute to the development of depression and CVD. Changes to inflammatory cytokines in relation to reproductive periods of hormonal fluctuation (i.e. the menstrual cycle, perinatal period and menopause) are highlighted and provide a greater understanding of the unique vulnerability women experience in developing both depressed mood and adverse cardiovascular events. Inflammatory biomarkers hold substantial promise when combined with a patient’s reproductive and mental health history to aid in the prediction, identification and treatment of the women most at risk for CVD and depression. However, more research is needed to improve our understanding of the mechanisms underlying inflammation in relation to their comorbidity, and how these findings can be translated to improve women’s health.

Changes in inflammation markers after a 10-week high-intensity combined strength and endurance training block in women: The effect of hormonal contraceptive use

OBJECTIVES

The influence of hormonal contraceptives (HC) on inflammation and body composition after high-intensity combined strength and endurance training was investigated.

DESIGN

Active healthy women formed two training groups: HC users (HCU, n = 9) and those who had never used HC (NHC, n = 9). Training included two strength training sessions and two high-intensity interval training sessions per week for 10 weeks.

METHODS

Before (PRE) and after (POST) the training intervention, high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), and interleukin-1beta (IL-1β) concentrations were measured. Dual-energy X-ray absorptiometry was used to estimate fat mass (FM), abdominal fat mass (aFM), and lean mass (LM).

RESULTS

Circulating concentrations of hs-CRP decreased significantly in the NHC from pre to post with -0.46 mg l^-1 (95% CI: -0.78, -0.14, p = 0.009, ES = 0.434), whereas a significant increase was observed in HCU from pre to post with 0.89 mg l^-1 (95% CI: 1.66, 0.12, p = 0.048, ES = 1.988) with a significant between-group difference (p = 0.015). In addition, hs-CRP concentration was significantly higher in HCU than in NHC after training (p = 0.036) at post. Lean mass increased significantly more in NHC than in HCU (p = 0.049).

CONCLUSIONS

High-intensity combined strength and endurance training can modify inflammation and body composition of women. The present study showed that inflammation, in terms of hs-CRP was higher post training in HCU than NHC, which may be associated with smaller gains in lean mass in response to training.

Nutrition for Special Populations: Young, Female, and Masters Athletes

Adolescent, female, and masters athletes have unique nutritional requirements as a consequence of undertaking daily training and competition in addition to the specific demands of age- and gender-related physiological changes. Dietary education and recommendations for these special population athletes require a focus on eating for long-term health, with special consideration given to “at-risk” dietary patterns and nutrients (e.g., sustained restricted eating, low calcium, vitamin D and/or iron intakes relative to requirements). Recent research highlighting strategies to address age-related changes in protein metabolism and the development of tools to assist in the management of Relative Energy Deficiency in Sport are of particular relevance to special population athletes. Whenever possible, special population athletes should be encouraged to meet their nutrient needs by the consumption of whole foods rather than supplements. The recommendation of dietary supplements (particularly to young athletes) overemphasizes their ability to manipulate performance in comparison with other training/dietary strategies.

The Effect of Gender and Menstrual Phase on Serum Creatine Kinase Activity and Muscle Soreness Following Downhill Running

Serum creatine kinase (CK) activity reflects muscle membrane disruption. Oestrogen has antioxidant and membrane stabilising properties, yet no study has compared the CK and muscle soreness (DOMS) response to unaccustomed exercise between genders when all menstrual phases are represented in women. Fifteen eumenorrhoeic women (early follicular, EF (n = 5); late follicular, LF (n = 5); mid-luteal, ML (n = 5) phase) and six men performed 20 min of downhill running (−10% gradient) at 9 km/h. Serum CK activity and visual analogue scale rating of perceived muscle soreness were measured before, immediately, 24-h, 48-h and 72-h after exercise. The 24-h peak CK response (relative to pre-exercise) was similar between women and men (mean change (95% confidence interval): 58.5 (25.2 to 91.7) IU/L; 68.8 (31.3 to 106.3) IU/L, respectively). However, serum CK activity was restored to pre-exercise levels quicker in women (regardless of menstrual phase) than men; after 48-h post exercise in women (16.3 (−4.4 to 37.0) IU/L; 56.3 (37.0 to 75.6) IU/L, respectively) but only after 72-h in men (14.9 (−14.8 to 44.6) IU/L). Parallel to the CK response, muscle soreness recovered by 72-h in men. Conversely, the women still reported muscle soreness at 72-h despite CK levels being restored by 48-h; delayed recovery of muscle soreness appeared mainly in EF and LF. The CK and DOMS response to downhill running is gender-specific. The CK response recovers quicker in women than men. The CK and DOMS response occur in concert in men but not in women. The DOMS response in women is prolonged and may be influenced by menstrual phase.

Oxidative Stress in Female Athletes Using Combined Oral Contraceptives

Background

Oxidative stress in female athletes is understudied. We investigated oxidative stress in sportswomen of different disciplines according to combined oral contraceptive (OC) use and lifestyle/alimentary habits.

Methods

Italian sportswomen (n = 144; mean age 23.4 ± 4.2 years; body mass index 21.2 ± 2.2 kg m⁻²; sport activity 9.2 ± 4.1 h week⁻¹) were analyzed; 48 % were volleyball players, 12.5 % soccer players, 10.4 % track-and-field sports, and followed by other disciplines’ athletes. Oxidative stress was evaluated by free oxygen radical test (FORT) assessing blood hydroperoxides and free oxygen radical defense (FORD) assay evaluating antioxidant capacity in OC users (n = 42) compared to non-OC users.

Results

Elevated oxidative stress levels (≥310 FORT units) were found in 92.9 % of OC users and in 23.5 % of non-OC users (crude OR = 42, 95 % CI 12–149, p < 0.001; adjusted OR = 60, 95 % CI 11–322, p < 0.001). Continuous values of hydroperoxides were twofold higher in OC users versus non-OC users (median 484 versus 270 FORT units, p < 0.001) and were inversely related to FORD units in OC users (p = 0.01). Hydroperoxides were not associated with weekly hours of exercise. In OC users, lifestyle/alimentary habits were not correlated to hydroperoxides. In non-OC users only, hydroperoxide values were positively correlated with weight and BMI and inversely correlated with chocolate and fish consumption.

Conclusions

The markedly elevated oxidative stress we revealed in OC-user athletes could be detrimental to physical activity and elevate cardiovascular risk (as thromboembolism). Further research is needed to extend our results, to clarify the biochemical pathways leading to increased hydroperoxides (mainly lipid peroxides) and reduced antioxidant defense, and to elucidate the potential effects on athletic performance. OC use should be considered when developing gender-focused strategies against oxidative stress.