Bone Mineral Changes and Cardiovascular Effects among Female Athletes with Chronic Menstrual Dysfunction

Differences of Bone Mineral Density by Characteristics of Sports in Amenorrheic Athletes

Hypothalamic amenorrhea leads to a hypoestrogenic state, causing decreased bone mineral density (BMD), while strong impact loading on bone has been shown to increase BMD. The purpose of this study is to compare BMD in female athletes based on menstrual status and their sports/events by impact loading characteristics. BMD at the lumbar spine was measured by dual-energy X-ray absorptiometry and hormone level. The subjects were classified into four groups and BMD and hormone levels were compared among the four groups, which were divided into amenorrheic athletes (AAs) and eumenorrheic athletes (EAs). This study recruited 410 female athletes (164 in the AAs and 246 in the EAs), 55 athletes in non-impact sports, 123 in low-impact sports, 141 in multidirectional sports, and 91 in high-impact sports. In the AAs group, BMD Z-score was lowest in low-impact sports (Z-score: -1.53 [-1.76, -1.30]), and was highest in high-impact sports (Z-score: 0.02 [-0.34, 0.38]). In multidirectional and high-impact sports, BMD Z-score in the AAs group did not show results lower than the average for non-athletes. When screening female athletes for low BMD, it is important to evaluate the risk of low BMD based on the impact loading characteristics of their sports/events, in addition to the menstrual state.

An Intervention of Four Weeks of Time-Restricted Eating (16/8) in Male Long-Distance Runners Does Not Affect Cardiometabolic Risk Factors

Timing of nutrient intake for athletes may affect exercise performance and cardiometabolic factors. Our objective was to examine the effect of time-restricted eating (TRE) on cardiometabolic health. Using a cross-over study design, 15 endurance-trained male runners were randomized to either a normal dietary pattern (ND) first (12 h eating/fasting times) followed by time-restricted eating (TRE) pattern (16 h fast; 8 h eating) or the reverse, with a 4-week washout period between interventions. Body composition, resting energy expenditure, blood pressure and serum insulin, glucose and lipids were measured using standard laboratory methods. Exercise training and dietary intake (calories and macronutrients) were similar across interventions. No significant differences were observed in resting energy expenditure, markers of insulin resistance, serum lipids or blood pressure. Body composition did change significantly (p < 0.05) with whole body fat mass (-0.8 ± 1.3 kg with TRE vs. +0.1 ± 4.3 kg with ND), leg fat mass (-0.3 ± 0.5 kg with TRE vs. +0.1 ± 0.4 kg with ND), and percent body fat (-1.0 ± 1.5% with TRE vs. +0.1 ± 1.3% with ND) declining more in the TRE intervention, with no change in fat-free mass. This study is one of a few to investigate the effects of an isocaloric 16/8 TRE eating pattern in trained endurance athletes and confirms no change in cardiometabolic risk factors. In conclusion, TRE is not detrimental to cardiometabolic health in endurance-trained male runners but could be beneficial on exercise performance by reducing fat mass.

Metabolomic patterns, redox-related genes and metals, and bone fragility endpoints in the Hortega Study

BACKGROUND

The potential joint influence of metabolites on bone fragility has been rarely evaluated. We assessed the association of plasma metabolic patterns with bone fragility endpoints (primarily, incident osteoporosis-related bone fractures, and, secondarily, bone mineral density BMD) in the Hortega Study participants. Redox balance plays a key role in bone metabolism. We also assessed differential associations in participant subgroups by redox-related metal exposure levels and candidate genetic variants.

MATERIAL AND METHODS

In 467 participants older than 50 years from the Hortega Study, a representative sample from a region in Spain, we estimated metabolic principal components (mPC) for 54 plasma metabolites from NMR-spectrometry. Metals biomarkers were measured in plasma by AAS and in urine by HPLC-ICPMS. Redox-related SNPs (N = 341) were measured by oligo-ligation assay.

RESULTS

The prospective association with incident bone fractures was inverse for mPC1 (non-essential and essential amino acids, including branched-chain, and bacterial co-metabolites, including isobutyrate, trimethylamines and phenylpropionate, versus fatty acids and VLDL) and mPC4 (HDL), but positive for mPC2 (essential amino acids, including aromatic, and bacterial co-metabolites, including isopropanol and methanol). Findings from BMD models were consistent. Participants with decreased selenium and increased antimony, arsenic and, suggestively, cadmium exposures showed higher mPC2-associated bone fractures risk. Genetic variants annotated to 19 genes, with the strongest evidence for NCF4, NOX4 and XDH, showed differential metabolic-related bone fractures risk.

CONCLUSIONS

Metabolic patterns reflecting amino acids, microbiota co-metabolism and lipid metabolism were associated with bone fragility endpoints. Carriers of redox-related variants may benefit from metabolic interventions to prevent the consequences of bone fragility depending on their antimony, arsenic, selenium, and, possibly, cadmium, exposure levels.

The Effect of Professional Sports Participation on Bone Content and Density in Elite Female Athletes

Background: The role of exercise in osteoporosis prevention has been proven. Nevertheless, there is no consensus about the types of sports, especially at professional levels. Non-impact sports such as swimming may have a negative effect or no effect. Objectives: Thus, the present study aimed to compare the effect of different sports on bone mineral content (BMC) and bone mineral density (BMD) of elite female athletes. Methods: This was a cross-sectional study consisting of 48 athletes in five groups of long-distance running, volleyball, basketball, swimming (n = 12 for each), and ten control subjects. For measuring the lumbar spine (L2 - L4) and proximal femur (femoral neck, trochanter, and Ward’s triangle), the dual-energy X-ray absorptiometry (DEXA) method was applied. Results: Indicated that the running, basketball, and volleyball groups had a significantly higher lumbar spine and proximal femur BMD than the swimming and control groups (P < 0.05). Running resulted in significantly higher lumbar spine BMC compared to volleyball, basketball, swimming, and control groups, respectively (P < 0.01), while basketball had higher proximal femur BMC than running and controls (P < 0.01). The Z-score of the lumbar spine in the running was significantly higher than in basketball, swimming, and controls (P < 0.05), while basketball had a significantly higher femur neck Z-score than volleyball, running, and controls (P < 0.001). Finally, the swimmers had significantly higher Z-scores in the lumbar and the proximal femur than non-athletes (P < 0.001). Conclusions: Although all sports are effective for improving the bone health, the swimmers had much better bone status than non-athletes, while the sports of long-distance running and basketball were more efficient than others; therefore, a combination of endurance and jumping exercises seems to be the best way to prevent osteoporosis.

Vascular Function in Norwegian Female Elite Runners: A Cross-Sectional, Controlled Study

In general, aerobic exercise has a positive impact on the vascular system, but the syndrome of relative energy-deficiency in sports (RED-S) makes this impact less clear for the athlete. The present cross-sectional controlled study aimed to investigate the vascular function in female elite long-distance runners, compared to inactive women. Sixteen female elite long-distance runners and seventeen healthy controls were recruited. Assessments of vascular function and morphology included endothelial function, evaluated by flow-mediated dilatation (FMD), vascular stiffness, evaluated with pulse wave velocity (PWV), carotid artery reactivity (CAR %), and carotid intima-media thickness (cIMT). Blood samples included hormone analyses, metabolic parameters, lipids, and biomarkers reflecting endothelial activation. RED-S risk was assessed through the low energy availability in female questionnaire (LEAF-Q), and body composition was measured by dual-energy X-ray absorptiometry (DXA). We found no significant differences in brachial FMD, PWV, CAR %, cIMT, or biomarkers reflecting endothelial activation between the two groups. Forty-four percent of the runners had a LEAF-Q score consistent with being at risk of RED-S. Runners showed significantly higher HDL-cholesterol and insulin sensitivity compared to controls. In conclusion, Norwegian female elite runners had an as good vascular function and morphology as inactive women of the same age.

Nutritional Risks among Adolescent Athletes with Disordered Eating

In their attempt to achieve the optimum weight or body shape for their activity, athletes frequently use harmful weight-control practices that may lead to the development of disordered eating or eating disorders. These practices are linked to several medical and mental consequences that may be more serious in adolescent athletes, as their bodies must meet both intensive growth demands and training requirements at the same time. Among other consequences, adolescent athletes may be at nutritional risk, due to their high nutrient needs and unhealthy eating behaviors. A literature review was conducted to examine the main nutritional risks and malnutrition issues faced by adolescent athletes that present disordered eating attitudes or eating disorders. Most studies refer to adult elite athletes, however research on adolescent athletes also indicates that the most common nutritional risks that may arise due to disordered eating include energy, macronutrient and micronutrient deficiencies, dehydration and electrolyte imbalances and changes in body composition that may lead to menstrual abnormalities, and decreased bone mass density. Educational programs and early detection of disordered eating and eating disorders are crucial to avoid the emergence and ensure timely management of nutrition-related problems in the vulnerable group of adolescent athletes.

Relative energy deficiency in sports (RED-S): elucidation of endocrine changes affecting the health of males and females

The purpose of this review is to present a different perspective of the relative energy deficiency syndrome, to improve understanding of associated endocrine alterations, and to highlight the need for further research in this area. The term "female athlete triad" was coined over 25 years ago to describe three interrelated components: disordered eating, menstrual dysfunction, and low bone mass. The syndrome's etiology is attributed to energy intake deficiency relative to energy expenditure required for health, function, and daily living. Recently, it became clear that there was a need to broaden the term, as the disorder is not an issue of only three interrelated problems but of a whole spectrum of insults resulting from low energy availability (LEA; i.e., insufficient energy availability to cover basic physiological demands) that can potentially affect any exerciser, irrespective of gender. The new model, termed relative energy deficiency in sport (RED-S), has received greater scrutiny in sports medicine due to its effects on both health and performance in athletes of both sexes. RED-S results from low-energy diets (intentional or unintentional) and/or excessive exercise. Energy deficiency reduces hypothalamic pulsatile release of gonadotropin-releasing hormone, this impairing anterior pituitary release of gonadotropins. In women, reduced FSH and LH pulsatility produces hypoestrogenism, causing functional hypothalamic amenorrhea and decreased bone mass. In men, it reduces testosterone and negatively affects bone health. Moreover, LEA alters other hormonal pathways, causing physiological consequences, such as alteration of the thyroid hormone signaling pathways, leptin levels, carbohydrate metabolism, the growth hormone/insulin-like growth factor-1 axis, and sympathetic/parasympathetic tone. This review explains and clarifies the effects of RED-S in both sexes.

Low Bone Mineral Density in Elite Female Athletes With a History of Secondary Amenorrhea in Their Teens

OBJECTIVE

To determine whether secondary amenorrhea during teenage years influences bone mineral density (BMD) in female athletes in their 20s.

DESIGN

Original research.

SETTING

Japan Institute of Sports Sciences.

PARTICIPANTS

Two hundred ten elite female athletes older than 20 years were included in the study.

MAIN OUTCOME MEASURES

Information on the participants' past (ie, during their teenage years) and current menstrual cycle, training time, history of stress fractures, and blood tests for hormones received was obtained. Bone mineral density of the lumbar spine was evaluated by dual-energy x-ray absorptiometry; low BMD was defined as a Z-score ≤-1. We investigated the correlation factors for low BMD in athletes in their 20s by univariable and multivariable logistic regression analysis.

RESULTS

A total of 39 (18.6%) female athletes had low BMD. Secondary amenorrhea in their teens [odds ratio (OR), 7.11, 95% confidence interval (CI), 2.38-21.24; P < 0.001] and present body mass index (BMI) (OR, 0.56, 95% CI, 0.42-0.73; P < 0.001) were independent correlation factors for low BMD in the multivariable logistic regression analysis. The average Z-score for those with secondary amenorrhea in their teens and 20s, secondary amenorrhea in their 20s only, and regular menstruation was -1.56 ± 1.00, -0.45 ± 1.21, and 0.82 ± 1.11 g/cm, respectively.

CONCLUSIONS

Secondary amenorrhea for at least 1 year during teenage years in female athletes and BMI at present was strongly associated with low BMD in their 20s.

Effect of transdermal estradiol therapy on bone mineral density of amenorrheic female athletes

BACKGROUND

The effects of transdermal estradiol treatment (HT) in amenorrheic athletes (AA) with low body weight (BW) and low bone mineral density (BMD) are unknown.

PURPOSE

To investigate whether HT increases BMD in AA with low BW and to compare the results with levels in AA who have recovered spontaneous menstruation (SM).

METHODS

Female athletes (n = 151) were recruited at the Japan Institute of Sports Sciences and the University of Tokyo. All participants were divided into four groups: an AA group (untreated group) (n = 36), a HT group (n = 55), a SM group (n = 21), and an eumenorrheic athletes (EA) group (n = 39). Height, body weight, blood tests, and dual-energy X-ray absorptiometry were measured at baseline and after 12 months. The HT group was treated daily for 12 months with transdermal estrogen therapy. In addition, participants received oral progestin for 7 days once every 3 months.

RESULTS

After 12 months, BMD in the AA group was significantly lower than at baseline; however, BMD in the other three groups was significantly higher than at baseline. The ratio of the change in BMD values before and after 12 months was -1.6 ± 3.2% for the AA group, 5.3 ± 8.7% for the HT group, 11.1 ± 8.9% for the SM group, and 2.3 ± 5.7% for the EA group. The rate of change in BMD values in the SM group was greater than that in the HT group.

CONCLUSION

HT increased BMD in AA with low BW, and the increase in those with SM was greater than that in those treated with HT.

Lipidomic profiles, lipid trajectories and clinical biomarkers in female elite endurance athletes

We assessed whether blood lipid metabolites and their changes associate with various cardiometabolic, endocrine, bone- and energy-related comorbidities of Relative Energy Deficiency in Sport (RED-S) in female elite endurance athletes. Thirty-eight Scandinavian female elite athletes underwent a day-long exercise test. Five blood samples were obtained during the day - at fasting state and before and after two standardized exercise tests. Clinical biomarkers were assessed at fasting state, while untargeted lipidomics was undertaken using all blood samples. Linear and logistic regression was used to assess associations between lipidomic features and clinical biomarkers. Overrepresentations of findings with P < 0.05 from these association tests were assessed using Fisher's exact tests. Self-organizing maps and a trajectory clustering algorithm were utilized to identify informative clusters in the population. Twenty associations P_FDR < 0.05 were detected between lipidomic features and clinical biomarkers. Notably, cortisol demonstrated an overrepresentation of associations with P < 0.05 compared to other traits (P_Fisher = 1.9×10^-14). Mean lipid trajectories were created for 201 named features for the cohort and subsequently by stratifying participants by their energy availability and menstrual dysfunction status. This exploratory analysis of lipid trajectories indicates that participants with menstrual dysfunction might have decreased adaptive response to exercise interventions.

The effect of hormone therapy on bone mineral density and cardiovascular factors among Iranian female athletes with amenorrhea/oligomenorrhea: A randomized clinical trial

Background: Functional hypothalamic menstrual disorder (FHMD) has a destructive effect on the athlete's bone mineral density and cardiovascular system. Utilizing hormone replacement therapy to treat FHMD in athletes is controversial. This study was conducted to examine the effect of hormone therapy on bone density and the cardiovascular system of professional female athletes with FHMD. Methods: In this study, 18 female athletes with at least a 2- year history of FHMD were recruited in a 9-month single blind randomized clinical intervention (RCT) and randomly classified into 2 groups: the oral contraceptive pills (OCP) group, who received a lowdose combined oral contraceptive (OC) containing 30 µg ethinyl estradiol and 150 µg levonorgestrel (n= 10), and the control group (n= 8). Bone mineral densitometry (BMD) and certain cardiovascular risk factors were measured before and after the 9-month trial. The Chi square test was used to compare the quantitative and qualitative results. Results: Bone mineral density did not change significantly in either group. Very low density lipoprotein (VLDL) (p= 0.035) and Apolipoprotein B (Apo B) (p= 0.04) reduced significantly in the OCP group. An increase was observed in the serum levels of Apolipoprotein A (Apo A) (p= 0.01) in the control group. Changes in the Apo B to Apo A ratio was significant in both groups (OCP group: p= 0.018, control group: p= 0.040). No significant changes were observed in the other measured factors. Conclusion: Although the administration of estrogen did not significantly increase bone mineral density, it had positive effects on the cardiovascular system and lipid profile.

Acetohydroxyacid synthase FgIlv2 and FgIlv6 are involved in BCAA biosynthesis, mycelial and conidial morphogenesis, and full virulence in Fusarium graminearum

In this study, we characterized FgIlv2 and FgIlv6, the catalytic and regulatory subunits of acetohydroxyacid synthase (AHAS) from the important wheat head scab fungus Fusarium graminearum. AHAS catalyzes the first common step in the parallel pathways toward branched-chain amino acids (BCAAs: isoleucine, leucine, valine) and is the inhibitory target of several commercialized herbicides. Both FgILV2 and FgILV6 deletion mutants were BCAA-auxotrophic and showed reduced aerial hyphal growth and red pigmentation when cultured on PDA plates. Conidial formation was completely blocked in the FgILV2 deletion mutant ΔFgIlv2-4 and significantly reduced in the FgILV6 deletion mutant ΔFgIlv6-12. The auxotrophs of ΔFgIlv2-4 and ΔFgIlv6-12 could be restored by exogenous addition of BCAAs but relied on the designated nitrogen source the medium contained. Deletion of FgILV2 or FgILV6 also leads to hypersensitivity to various cellular stresses and reduced deoxynivalenol production. ΔFgIlv2-4 lost virulence completely on flowering wheat heads, whereas ΔFgIlv6-12 could cause scab symptoms in the inoculated spikelet but lost its aggressiveness. Taken together, our study implies the potential value of antifungals targeting both FgIlv2 and FgIlv6 in F. graminearum.

Female athlete triad for the primary care pediatrician

PURPOSE OF REVIEW

Female participation in athletics has increased significantly over the past several decades. For most young women, participation in sport fosters self-confidence, positive relationships with peers, and good physical health. However, with growing female representation in athletics, the sport community has become increasingly aware of the syndrome known as 'female athlete triad,' which describes the interplay between low energy availability (LEA), menstrual disturbances, and decreased bone mineral density (BMD). This review aims to discuss the definition and prevalence of the triad and prevention, detection, and treatment strategies.

RECENT FINDINGS

Current research has elucidated the importance of identifying and treating the triad in young athletes, as adolescence is a critical time for bone development and failure to intervene can lead to long-term problems. First defined in 1992, full characterization of the triad in adolescents has been elusive because of difficulties in diagnosing low BMD in this population and reliance on self-report for menstrual disturbances and LEA. A 2007 reformulation of the triad incorporated research demonstrating that the full deleterious triad is rare and emphasized that its components exist on a spectrum. Removal of the stigma from the triad has the potential to allow earlier detection and treatment, thereby improving outcomes.

SUMMARY

The female athlete triad is a problem with important long-term consequences. Education should be geared toward athletes as well as coaches, athletic trainers, school nurses, primary care providers, and others involved in female athletics to allow early identification and intervention.

Variability in HOMA-IR, lipoprotein profile and selected hormones in young active men

Resistance to insulin actions is contributing to many metabolic disturbances. Such factors as age, sex, nutrition, body fat, and physical activity determine body insulin resistance. Present study attempted to asses insulin resistance and its metabolic effects with respect to energy intake in young, lean, and active men. A total of 87 men aged 18-23 participated in the study. Plasma levels of glucose, insulin, lipoproteins, cortisol, and TSH were determined. Insulin resistance was expressed as Homeostasis Model Assessment for Insulin Resistance (HOMA-IR) and calculated using homeostatic model. The median value of HOMA-IR (1.344) was used to divide subjects into two groups. Men did not differ in anthropometric parameters, daily physical activity, and plasma TSH and cortisol levels. However, in men with higher HOMA-IR significantly lower daily energy intake was observed concomitantly with higher TG, TC, and HDL-C concentrations in plasma versus their counterparts with lower HOMA-IR. Exclusively in subjects with higher HOMA-IR significant and positive correlation was noted between HOMA-IR and TC and LDL-C. We concluded that despite a normal body weight and physical activity, a subset of young men displayed unfavorable changes in insulin sensitivity and lipid profile, probably due to insufficient energy intake.

Female athlete triad and its components: toward improved screening and management

As female athletic participation has increased, the positive effects of exercise on health have become evident. However, with this growth in sports activity, a set of health problems unique to the female athlete has emerged. The female athlete triad as first described in 1992 by the American College of Sports Medicine consisted of disordered eating, amenorrhea, and osteoporosis; the definition was updated in 2007 to include a spectrum of dysfunction related to energy availability, menstrual function, and bone mineral density. For this review, a comprehensive search of databases-MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Scopus, from earliest inclusive dates to January 2013-was conducted by an experienced librarian with input from the authors. Controlled vocabulary supplemented with keywords such as female athlete triad, amenorrhea, oligomenorrhea, fracture, osteopenia, osteoporosis, bone disease, anorexia, bulimia, disordered eating, low energy availability was used to search for articles on female athlete triad. Articles addressing the prevalence, screening, and management of the female athlete triad were selected for inclusion in the review. This article reviews the current definitions of the triad components, epidemiology, pathophysiology, and recommended screening and management guidelines. The lack of efficacy of current screening of athletes is highlighted. Low energy availablity, from either dietary restriction or increased expenditure, plays a pivotal role in development of the triad. Athletes involved in "lean sports" (those that emphasize weight categories or aesthetics, such as ballet, gymnastics, or endurance running) are at highest risk. Treatment is centered on restoring energy availability to reverse adverse changes in the metabolic milieu. Prevention and early recognition of triad disorders are crucial to ensure timely intervention. Caregivers and physicians of female athletes must remain vigilant in education, recognition, and treatment of athletes at risk.

Effect of Exercise Program and Calcium Supplements on Low Bone Mass among Young Indian Women- A Comparative Study

Purpose

Low bone mass is a major health concern among young women nowadays due to sedentary lifestyle and lack of calcium rich food intake. Therefore there is an increase in the incidence of LBM among young university women so our main purpose of study was to compare effects of exercise program and calcium supplements on bone mass in young women.

Methods

This single blinded, cross sectional study included data collection in the form of SOS T-scores at distal radius for 104 young university women of mean age 22.3 years using Sunlight Omnisense Bone Sonometer 7000S. Of these, 62 women with low bone mass were included in a 3 month study but 60 subjects completed the study. They were randomly divided into 3 groups: exercise group (n=21), calcium supplementation group (n=21) and control group (n=20). All participants were evaluated pre and post protocol for T-score distal radius and midshaft tibia.

Results

After measuring SOS T-score of 104 subjects; we found that 60.57% had low bone mass and remaining 39.43% had normal bone mass. After 3 months, the exercise group showed significant improvement in distal radius SOS T-score (t=5.10, P<0.001), at midshaft tibia (t=3.71, P<0.001) followed by improvement in calcium group at distal radius (t=6.28, P<0.001), midshaft tibia (t=2.33, P<0.05) as compared to control group which showed a marginal increase.

Conclusions

Exercise group showed more improvement in T-scores than calcium and control group. Exercise is important modifiable factor to improve bone accretion at this age and reduce risk of developing osteoporosis related debilitating conditions later in life.