Estrogen Replacement Improves Verbal Memory and Executive Control in Oligomenorrheic/Amenorrheic Athletes in a Randomized Controlled Trial

Case report: Neuropsychological assessment in a patient with 4H leukodystrophy

Objective: POLR3-HLD or 4H leukodystrophy is an autosomal recessive disorder characterized by hypomyelination, hypodontia, and hypogonadotropic hypogonadism, and caused by variants in POLR3A, POLR3B, POLR1C, or POLR3K genes. Neurological and non-neurological clinical features and disease severity vary. While previous studies reference variable cognition, this is the first report of 4H detailing a comprehensive neuropsychological assessment. Method: The current study presents a 20-year-old, English-speaking, right-handed, non-Hispanic White female with 12 years of education with genetically confirmed 4H POLR3B-related leukodystrophy without hormonal replacement treatment. Results: At age 4, developmental delays, ataxia, hearing loss, and abnormal dentition were present. Imaging, endocrinology, and neurologic examinations revealed hypomyelination, reduced cerebellar volume, delayed bone age density, osteopenia, and evidence of adrenarche without signs of true puberty. Neuropsychological assessment at age 20 revealed global cognitive impairment with intellectual, attention, verbal memory retrieval, construction, executive (e.g. processing speed, sustained attention) and math computation deficits, along with behavioral dysregulation. Conclusion: We present the first detailed neuropsychological assessment of a patient with 4H leukodystrophy. The neuropsychological assessment revealed cognitive and behavioral dysexecutive deficits aligning with hypomyelination observed on imaging. Further longitudinal studies are needed to shed light on the neurobehavioral presentation associated with this disorder to assist care providers, patients, and their families.

S, Williams AM, Lubas M, Brinkman TM, Chemaitilly W, Robison LL, Hudson MM, Krull KR, Delaney A. Hypogonadism and neurocognitive outcomes among childhood cancer survivors

OBJECTIVE

Childhood cancer survivors are at risk for hypogonadism. The impact of hypogonadism on neurocognitive impairment and emotional distress in the non-cancer population has been shown; however, the relationship among the childhood cancer survivor population is unknown. We aimed to evaluate the contribution of hypogonadism to neurocognitive impairment and emotional distress among survivors.

DESIGN

Cross-sectional study using retrospective cohort.

METHODS

In total, 3628 survivors who completed standard neurocognitive tests (six domains: processing speed, memory, executive function, attention, academics, and global cognition) and self-reported emotional distress were included in our study. Participants were stratified by sex and gonadal status. Outcomes were compared between hypogonadal and eugonadal groups by multivariable analysis, adjusting for established predictors, and mediation analyses to determine the direct/indirect effects of hypogonadism on outcomes.

RESULTS

The hypogonadal group exhibited a higher prevalence of neurocognitive impairment across domains, but no difference in emotional distress. Hypogonadal females exhibited higher relative risk (1.7, 95% CI, 1.2-2.5) for impaired visual processing speed, compared to eugonadal females after adjusting for cancer-related variables. In mediation models, hypogonadism had a significant direct (P < .01) and indirect (from P < .01) impact on impairment in visual processing speed among females. Males demonstrated direct (P = .03) and indirect (P = .04) impact of hypogonadism on motor processing speed.

CONCLUSION

Processing speed may be the most vulnerable neurocognitive domain associated with hypogonadism in survivors, while other domains were mainly impacted by cancer-related variables. Our findings support the need for further evaluation of the impact of sex hormone replacement therapy on neurocognitive function.

[Endocrine and psychosomatic disorders in patients with amenorrhea]

The article presents data on the relationship of pathogenetic mechanisms for the development of menstrual disorders of functional and organic origin in connection with mental disturbances from the point of view of the psychosomatic concept. According to the latter, functional disorders of the menstrual cycle are considered as psychosomatic, in which gynecological pathology develops as a result of psychopathological illness. A striking example of such a disorder is functional hypothalamic amenorrhea. At the same time, endocrinopathies, such as polycystic ovary syndrome and premature ovarian insufficiency, can also be considered in the paradigm of psychosomatic illnesses of ovarian function due to the high prevalence of anxiety and depressive disorders in this cohort of patients. This review highlights the importance of interdisciplinary collaboration between a gynecologist and a psychiatrist for the most effective reproductive rehabilitation of patients with amenorrhea. Literature search was carried out in national (eLibrary, CyberLeninka.ru) and international (PubMed, Cochrane Library) databases in Russian and English. The priority was free access to the full text of articles. The choice of sources was prioritized for the period from 2018 to 2023.However, taking into account the insufficient knowledge of the chosen topic, the choice of sources dates back to 1985.

Physiological biomarker monitoring during arduous military training: Maintaining readiness and performance

OBJECTIVES

Physiological and psychological stressors can degrade soldiers' readiness and performance during military training and operational environments. Integrative and holistic assessments of biomarkers across diverse human performance optimization domains during multistressor training can be leveraged to provide actionable insight to military leadership regarding service member health and readiness.

DESIGN/METHOD

A broad categorization of biomarkers, to include biochemical measures, bone and body composition, psychometric assessments, movement screening, and physiological load can be incorporated into robust analytical pipelines for understanding the complex factors that impact military human performance.

RESULTS

In this perspective commentary we overview the rationale, selection, and methodologies for monitoring biomarker domains that are relevant to military research and specifically highlight methods that have been incorporated in a research program funded by the Office of Naval Research, Code 34 Biological and Physiological Monitoring and Modeling of Warfighter Performance.

CONCLUSIONS

The integration of screening and continuous monitoring methodologies via robust analytical approaches will provide novel insight for military leaders regarding health, performance, and readiness outcomes during multistressor military training.

Participation in varsity sports, dance, and Greek life associated with menstrual disturbance in a national sample of female college students

Objective: The objective of this study was to identify university-sponsored activities associated with increased odds of menstrual disturbance among female college students. Participants: The sample included 3,277 female-identifying students at 12 colleges and universities participating in the Healthy Bodies Study during the 2013-2014 and 2014-2015 academic years. Methods: Crude and adjusted logistic regression models were run to report odds of any menstrual disturbance and amenorrhea (AMN) for participants in sports, dance, and Greek Life. Survey weights were used to account for response bias. Results: In the adjusted models, participation in varsity sport (OR = 1.82, CI 1.37, 2.37), dance (OR = 1.68, CI 1.37, 2.05) and Greek life (OR= 2.12, CI 0.13,0.18) was significantly associated with increased odds of menstrual disturbance, compared to non-participants. Conclusions: Findings suggest additional need for prevention and intervention programming against menstrual disturbance in varsity sports, dance, and Greek life activities.

The female athlete triad: review of current literature

PURPOSE OF REVIEW

Adolescence and young adulthood are a critical period in the life of women for optimizing long-term bone health. Young athletes lead a demanding lifestyle with increased dietary requirements to meet the robust demands of energy expenditure to maintain a state of energy balance. During a time of fast paced changes and unpredictable societal demands on young athletes, it is important to review the severe consequences of energy deficiency and options for adequate management.

RECENT FINDINGS

This review focuses on hormonal adaptations that occur in energy deficient female athletes that lead to menstrual irregularities and impaired bone health, increasing the risk for stress and other fractures. We also describe management strategies to mitigate the consequences of limited energy availability on bone and other outcomes.

SUMMARY

These strategies should help guide the management of young female athletes to prevent irreversible changes to their bone health. Identifying current knowledge should help increase awareness among medical providers, which can then be communicated to the sports community, parents, and athletes.

Functional hypothalamic amenorrhea: Impact on bone and neuropsychiatric outcomes

Functional hypothalamic amenorrhea is a state of reversible hypogonadism common in adolescents and young women that can be triggered by energy deficit or emotional stress or a combination of these factors. Energy deficit may be a consequence of (i) reduced caloric intake, as seen in patients with eating disorders, such as anorexia nervosa, or (ii) excessive exercise, when caloric intake is insufficient to meet the needs of energy expenditure. In these conditions of energy deficit, suppression of the hypothalamic secretion of gonadotrophin-releasing hormone (with resulting hypoestrogenism) as well as other changes in hypothalamic-pituitary function may occur as an adaptive response to limited energy availability. Many of these adaptive changes, however, are deleterious to reproductive, skeletal, and neuropsychiatric health. Particularly, normoestrogenemia is critical for normal bone accrual during adolescence, and hypoestrogenemia during this time may lead to deficits in peak bone mass acquisition with longstanding effects on skeletal health. The adolescent years are also a time of neurological changes that impact cognitive function, and anxiety and depression present more frequently during this time. Normal estrogen status is essential for optimal cognitive function (particularly verbal memory and executive function) and may impact emotion and mood. Early recognition of women at high risk of developing hypothalamic amenorrhea and its timely management with a multidisciplinary team are crucial to prevent the severe and long-term effects of this condition.

The Path Towards Progress: A Critical Review to Advance the Science of the Female and Male Athlete Triad and Relative Energy Deficiency in Sport

Energy status plays a key role in the health of athletes and exercising individuals. Energy deficiency/low energy availability (EA), referring to a state in which insufficient energy intake and/or excessive exercise energy expenditure has resulted in compensatory metabolic adaptations to conserve fuel, can affect numerous physiological systems in women and men. The Female Athlete Triad, Male Athlete Triad, and Relative Energy Deficiency in Sport (RED-S) models conceptualize the effects of energy deficiency in athletes, and each model has strengths and limitations. For instance, the Female Athlete Triad model depicts relationships between low EA, reproductive, and bone health, underpinning decades of experimental evidence, but may be perceived as limited in scope, while the more recent RED-S model proposes a wider range of potential health effects of low EA, though many model components require more robust scientific justification. This critical review summarizes current evidence regarding the effects of energy deficiency on athlete health by addressing the quality of the underlying science, the strengths and limitations of each model, and highlighting areas where future research is needed to advance the field. With the health and wellness of athletes and exercising individuals as the overarching priority, we conclude with specific steps that will help focus future research on the Female and Male Athlete Triad and RED-S, and encourage all researchers, clinicians, and practitioners to collaborate to support the common goal of promoting the highest quality science and evidence-based medicine in pursuit of the advancement of athletes' health, well-being, and performance.

Functional Hypothalamic Amenorrhea: A Stress-Based Disease

The aim of the study is to present the problem of functional hypothalamic amenorrhea, taking into account any disease and treatment, diagnosis, and consequences of this disease. We searched PubMed (MEDLINE) and included 38 original and review articles concerning functional hypothalamic amenorrhea. Functional hypothalamic amenorrhea is the most common cause of secondary amenorrhea in women of childbearing age. It is a reversible disorder caused by stress related to weight loss, excessive exercise and/or traumatic mental experiences. The basis of functional hypothalamic amenorrhea is hormonal, based on impaired pulsatile GnRH secretion in the hypothalamus, then decreased secretion of gonadotropins, and, consequently, impaired hormonal function of the ovaries. This disorder leads to hypoestrogenism, manifested by a disturbance of the menstrual cycle in the form of amenorrhea, leading to anovulation. Prolonged state of hypoestrogenism can be very detrimental to general health, leading to many harmful short- and long-term consequences. Treatment of functional hypothalamic amenorrhea should be started as soon as possible, and it should primarily involve lifestyle modification. Only then should pharmacological treatment be applied. Importantly, treatment is most often long-term, but it results in recovery for the majority of patients. Effective therapy, based on multidirectional action, can protect patients from numerous negative impacts on fertility, cardiovascular system and bone health, as well as reducing mental morbidity.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part II: Diagnosis, Treatment, and Return-To-Play

ABSTRACT

The Male Athlete Triad is a medical syndrome most common in adolescent and young adult male athletes in sports that emphasize a lean physique, especially endurance and weight-class athletes. The 3 interrelated conditions of the Male Athlete Triad occur on spectrums of energy deficiency/low energy availability (EA), suppression of the hypothalamic-pituitary-gonadal axis, and impaired bone health, ranging from optimal health to clinically relevant outcomes of energy deficiency/low EA with or without disordered eating or eating disorder, functional hypogonadotropic hypogonadism, and osteoporosis or low bone mineral density with or without bone stress injury (BSI). Because of the importance of bone mass acquisition and health concerns in adolescence, screening is recommended during this time period in the at-risk male athlete. Diagnosis of the Male Athlete Triad is best accomplished by a multidisciplinary medical team. Clearance and return-to-play guidelines are recommended to optimize prevention and treatment. Evidence-based risk assessment protocols for the male athlete at risk for the Male Athlete Triad have been shown to be predictive for BSI and impaired bone health and should be encouraged. Improving energetic status through optimal fueling is the mainstay of treatment. A Roundtable on the Male Athlete Triad was convened by the Female and Male Athlete Triad Coalition in conjunction with the 64th Annual Meeting of the American College of Sports Medicine in Denver, Colorado, in May of 2017. In this second article, the latest clinical research to support current models of screening, diagnosis, and management for at-risk male athlete is reviewed with evidence-based recommendations.

The Specificities of Elite Female Athletes: A Multidisciplinary Approach

Female athletes have garnered considerable attention in the last few years as more and more women participate in sports events. However, despite the well-known repercussions of female sex hormones, few studies have investigated the specificities of elite female athletes. In this review, we present the current but still limited data on how normal menstrual phases, altered menstrual phases, and hormonal contraception affect both physical and cognitive performances in these elite athletes. To examine the implicated mechanisms, as well as the potential performances and health risks in this population, we then take a broader multidisciplinary approach and report on the causal/reciprocal relationships between hormonal status and mental and physical health in young (18-40 years) healthy females, both trained and untrained. We thus cover the research on both physiological and psychological variables, as well as on the Athlete Biological Passport used for anti-doping purposes. We consider the fairly frequent discrepancies and summarize the current knowledge in this new field of interest. Last, we conclude with some practical guidelines for eliciting improvements in physical and cognitive performance while minimizing the health risks for female athletes.

Effects of Hormonal Contraception Use on Cognitive Functions in Patients With Bulimia Nervosa

Background: Growing evidences indicate that sex hormones have an effect on cognitive functions, and that Bulimia Nervosa (BN) is associated with cognitive impairment. The aim of this study was to determine the effect of hormonal contraception (HC) use on four cognitive functions that are impaired in patients with BN. Methods: This retrospective exploratory study included 103 women with a diagnosis of BN based on the DSM-5 criteria. Their age ranged from 15 to 45 years, and 46.6% were taking HC (oral, transdermal, or intrauterine). Cognition was assessed with the d2 test (attention), Iowa gambling task (IGT; decision making), Brixton spatial anticipation test (set shifting), and Rey-Osterrieth complex figure test (central coherence). Data were analyzed with logistic regression models to estimate the adjusted odds ratios (OR) and 95% confidence intervals (CI) of HC effect on the neuropsychological test scores. Results: In the multivariate model, HC use was significantly associated with better scores for two d2 test indices: F-score [OR = 0.98, 95% CI = (0.95; 0.99)] and final total score ratio [OR = 0.87, 95% CI = (0.77; 0.99)]. HC was also associated with a better understanding of the IGT explicit rules. No difference between the two groups (HC and non-HC use) was detected for set shifting and central coherence. Conclusions: This exploratory study suggests that HC could have effects on the sustained attention and concentration in women with BN. More studies are needed to confirm these results.

Sex Hormones as Cognitive Enhancers?

Understanding the differences in the way women and men think has made headway thanks to experiments showing how sex hormones influence cognitive capacities. Masculine and feminine sex hormones (androgens and estrogens, respectively) affect cognition in different ways and may account for some of the gender differences in cognitive abilities, allowing men and women to perform better in certain cognitive tests. In this opinion article, we discuss studies addressing differences in cognitive functions between males and females and the underlying neural substrates, as well as the effects of sex hormone supplementation. Even though some studies on patients receiving exogenous sex hormones showed gender differences that emerge at group levels on a few cognitive tasks, it is not yet clear whether these differences can be partially attributed to hormonal causes. Supplementation of female estrogen can enhance verbal skills, whereas masculine androgen can increase performance in mathematical and visuospatial tasks. Studies of the administration of exogenous sex hormones have allowed further insight into the use of sex hormones as possible cognitive enhancers.

Estrogen administration improves the trajectory of eating disorder pathology in oligo-amenorrheic athletes: A randomized controlled trial

OBJECTIVE

Estrogen replacement prevents worsening body dissatisfaction with weight gain in adolescents with anorexia nervosa. However, the impact of estrogen administration on eating disorder (ED) pathology in normal-weight young women with exercise-induced amenorrhea is unknown. We hypothesized that (1) normal-weight oligo-amenorrheic athletes (OA) would show greater ED pathology than eumenorrheic athletes (EA) and non-athletes (NA), and (2) 12 months of estrogen replacement would improve those symptoms.

TRIAL DESIGN

Randomized trial.

METHODS

One hundred seventeen OA, 50 EA, and 41 NA completed the Eating Disorder Inventory-2 (EDI-2) for measures of Drive for Thinness (DT) and Body Dissatisfaction (BD) and the Three-Factor Eating Questionnaire-R18 (TFEQ-R18). OA were then randomized to receive 100 mcg transdermal 17β-estradiol with cyclic progesterone (PATCH), an oral contraceptive pill (30 mcg ethinyl estradiol + 0.15 mg desogestrel) (PILL), or no estrogen (E-) for 12 months. Data are reported for the subset that completed questionnaires at 0 and 12 months between 11/2009 and 10/2016.

RESULTS

OA showed higher EDI-2 DT and TFEQ-R18 Cognitive Restraint scores than EA and NA and higher EDI-2 BD scores than EA. Over 12 months, the E+ group (PATCH+PILL), compared to E-, showed improved trajectories for EDI-2 DT and BD scores. In 3-group comparisons, PATCH outperformed E- for decreases in EDI-2 DT and BD, and the PILL for TFEQ-R18 Uncontrolled Eating.

CONCLUSION

In OA, 12 months of estrogen replacement improves ED pathology trajectories, emphasizing the broad importance of normalizing estrogen levels.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT00946192.