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Cited by 127Hypothalamic control of reproductive hormonesOvarian function and disordersMenstrual Health and Disorders

Menstrual disruption with exercise is not linked to an energy availability threshold

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LIEBERMAN, JAY L., DE SOUZA, MARY JANE, WAGSTAFF, DAVID A., WILLIAMS, NANCY I.·2018·Medicine & Science in Sports & Exercise
DOI 10.1249/mss.0000000000001451PMC PMC5820163
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Abstract

INTRODUCTION: Chronic reductions in energy availability (EA) suppress reproductive function. A particular calculation of EA quantifies the dietary energy remaining after exercise for all physiological functions. Reductions in luteinizing hormone pulse frequency have been demonstrated when EA using this calculation is <30 kcal·kg·fat-free mass (ffm)·d. PURPOSE: We determined whether menstrual disturbances (MD) are induced when EA is <30 kcal·kg ffm·d. METHODS: Thirty-five sedentary, ovulatory women age 18 to 24 yr (weight, 59.0 ± 0.8 kg; body mass index, 21.8 ± 0.4 kg·m) completed a diet and exercise intervention over three menstrual cycles. Participants were randomized to groups that varied in the magnitude of negative energy balance created by the combination of exercise and energy restriction. Menstrual disturbances were determined using daily urinary estrone-1-glucuronide and pregnanediol glucuronide, midcycle luteinizing hormone, and menstrual calendars. In a secondary analysis, we calculated EA from energy balance data and tested the association of EA with MD. RESULTS: A generalized linear mixed-effects model showed that the likelihood of a MD decreased by 9% for each unit increase in EA (odds ratio, 0.91; 95% confidence interval, 0.84-0.98; P = 0.010). No specific value of EA emerged as a threshold below which MD were induced. When participants were partitioned into EA tertile groups (low EA, 23.4-34.1; n = 11; moderate EA, 34.9-40.7; n = 12, and high EA, 41.2-50.1; n = 12 [kcal·kg ffm·d]), estrone-1-glucuronide (P < 0.001), pregnanediol glucuronide (P < 0.001), and luteal phase length (P = 0.031) decreased significantly, independent of tertile. CONCLUSIONS: These findings do not support that a threshold of EA exists below which MD are induced but do suggest that MD increase linearly as EA decreases. Menstrual disturbances can likely be prevented by monitoring EA using a simplified assessment of metabolic status.

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  • More recent information has identified large differences in the EA level associated with health and performance concerns between individuals, the sexes, and among different body systems.

    “more recent information gleaned from real-life clinical observations, as well as short-term studies, 88 theoretical constructs and methodological challenges in assessment, around the frailty of a single, universal threshold, 129 have identified large differences in the EA level associated with health and performance concerns between individuals, the sexes, and among different body systems.”

    From 2023 international olympic committee's (IOC) consensus statement on relative energy deficiency in sport (REDs) (2023) · cites this paper as [88]

    The Discussion (page unavailable) reports no demonstrated EA threshold for menstrual disruption and suggests that individual sensitivity and thresholds for different reproductive responses may vary. Those differences are proposed as possibilities, not established as large differences. The paper studies active young women and does not establish differences between sexes or EA levels associated with performance concerns. (LLM, conf=0.86)

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Authors
LIEBERMAN, J. L., DE SOUZA, M. J., WAGSTAFF, D. A., & WILLIAMS, N. I.
Affiliations
Pennsylvania State University (US)
ORCID
WILLIAMS, NANCY I.
Venue
Medicine & Science in Sports & Exercise
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2018-03
Volume
50
Issue
3
Pages
551-561
ISSN
0195-9131 (ISSN-L)
DOI
10.1249/mss.0000000000001451
PMC
PMC5820163
OpenAlex
W2763241261
Cited by
127
References
5
Citations by year
2026: 14 · 2025: 15 · 2024: 16 · 2023: 21 · 2022: 9 · 2021: 18 · 2020: 14 · 2019: 12 · 2018: 6
FWCI
10.17
Type
journal article
Language
en
Open access
Locations
  • Medicine & Science in Sports & Exercise (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Center for Research Resources (M01RR010732)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD039245)
Topics
  • Health Sciences › Medicine › Reproductive Medicine › Hypothalamic control of reproductive hormones
  • Health Sciences › Medicine › Reproductive Medicine › Ovarian function and disorders
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
Keywords
energy availability, menstrual irregularity, physical activity, caloric restriction, negative energy balance, reproductive function, luteinizing hormone, pregnanediol glucuronide, luteal phase length, fat-free mass, young women
MeSH terms
Adult, Anthropometry, Basal Metabolism, Energy Intake, Diet, Energy Metabolism, Estrone, Female, Humans, Luteal Phase, Menstrual Cycle, Menstruation Disturbances, Oxygen Consumption, Pregnanediol, Exercise, Young Adult

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