Population-Specific Concerns The Prevalence of and Attitudes Toward Oligomenorrhea and Amenorrhea in Division I Female Athletes

Karen Myrick, DNP, APRN, FNP-BC, Richard Feinn, PhD, and Meaghan Harkins, MS, BSN, RN • Quinnipiac University

Research has demonstrated that amenor- hormone and follicle-stimulating hormone rhea and oligomenorrhea may be common shut down stimulation to the ovary, ceasing occurrences among female athletes.1 Due production of estradiol.2 to normalization of menstrual dysfunction The effect of oral contraceptives on the within the sport environment, amenorrhea menstrual cycle include ovulation inhibi- and oligomenorrhea tion, changes in cervical mucus, thinning may be underreported. of the uterine endometrium, and motility Key PointsPoints There are many underly- and secretion in the fallopian tubes, which Lean sport athletes are more likely to per- ing causes of menstrual decrease the likelihood of conception and 3 ceive missed menstrual cycles as normal. dysfunction. However, implantation. Oral contraceptives contain a a similar hypothalamic combination of estrogen and progesterone, Menstrual dysfunction is one prong of the amenorrhea profile is or progesterone only; thus, oral contracep- female athlete triad. frequently seen in ath- tives do not stop the production of estrogen. letes, and hypothalamic Menstrual dysfunction is one prong of the Menstrual dysfunction is often associated dysfunction is com- female athlete triad (triad). The triad is a with musculoskeletal and endothelial monly the root of ath- syndrome of linking low energy availability compromise. lete’s menstrual abnor- (EA) with or without disordered eating, men- malities.2 The common strual disturbances, and low bone mineral Education and awareness of the accultur- hormone pattern for density, across a continuum. The result of ation of commonality and normality of athletes shows a low to low EA often results in an energy deficiency, menstrual dysfunction in female athletes normal gonadotropin which when sustained for prolonged peri- is necessary. level and hypoestro- ods of time, translates to metabolic and genism resulting from reproductive suppression.1 The result is the disruption of the hypothalamic–pituitary– development of menstrual dysfunction and ovarian axis.2 With a decrease in the secre- musculoskeletal complications such as low tion of the gonadotropin-releasing hormone, bone mineral density, stress fractures, and the pituitary has limitations in the secretion endothelial dysfunction.4 of luteinizing hormone and follicle-stimulat- The absence of a monthly menstrual ing hormone. Suppressed levels of luteinizing cycle is one prong of the female athlete

© 2014 Human Kinetics - IJATT 19(6), pp. 41-47 http://dx.doi.org/10.1123/ijatt.2014-0016 international journal of Athletic Therapy & training November 2014  41 triad—an interwoven continuum of symptoms leading contraceptives that contain estrogen in their formula- to insufficient energy availability, amenorrhea, and tion may help to preserve bone mineral density and osteoporosis.4 According to the ACSM’s 2007 position support a menses once a month, likely due to hormone statement, the female athlete triad can occur when withdrawal during the week of the menses.3 However, an athlete consumes inadequate calories relative to it has been noted that any correction to energy balance her amount of physical activity. This in turn leads should be corrected.11 to delayed menarche (primary amenorrhea) or a Importantly, missed or irregular menstrual cycles cessation of menses (secondary amenorrhea) as the may serve as a first and obvious sign to an athlete body attempts to conserve much-needed energy. The that there is a health disturbance, and it follows that combination of menstrual dysfunction and insufficient athletes should understand the importance of reporting caloric intake can then lead to osteopenia or even this clinical symptom. However, research shows that osteoporosis. The position statement went further on irregular menses is often normalized within the sport to discuss the fact that menstrual dysfunction is “all too environment, particularly among those who experi- often characterized and unfortunately disregarded as ence it.12 Some athletes interpret missed menses as an a convenient by-product of intense physical exercise”.5 encouraging sign of fitness.13 Such misinterpretation of The National Collegiate Athletic Association (NCAA) what is essentially a diseased state can be a significant has noted that in some sports, especially those sports hindrance to the prevention of further injury, and may where weight or appearance may be a factor in eligibil- result in long-term consequences.14,15 To underscore ity or judging performance (also known as lean body this point, Ducher et al point out that symptoms of sports), student-athletes can develop misperceptions the triad often go undetected in athletes until a stress about what constitutes a healthy weight, which in turn fracture occurs.16 Notably, the longer the duration of can lead athletes into patterns of disordered eating.5 the menstrual dysfunction the larger the bone mineral Furthermore, the NCAA offers educational information deficit at non-weight-bearing sites.14 on eating disorders for athletes and members of the A recent study demonstrated that bone metabolism coaching and healthcare team through The Sport Sci- markers in females with menstrual cycle dysfunction ence Institute, but this information is not mandatory correlated; though bone reformation occurred at a learning for athletes or the care team.6 faster rate in athletes compared with controls and An athlete need not suffer from all three compo- a biomarker indicated that bone disintegrated at a nents of the triad simultaneously to be at heightened higher rate in the amenorrhea and oligomenorrhea risk for injury. Each prong represents a potential threat group than in the group of postmenopausal females to an athlete’s health. Indeed, research has shown that with osteoporosis.17 Furthermore, these values were missed menstrual cycles alone contribute to increased significantly above the recommended upper values.17 risk for musculoskeletal injury and stress fractures Most recent research has proposed what the long- among athletes.7,8 Menstrual dysfunction can also lead term consequences of the female athlete triad are. to prolonged interruptions in training.9 Further, though Delays in menarche or periods of amenorrhea during weight-bearing exercise serves a protective function in adolescence may increase risk for osteoporosis later in terms of bone health, amenorrheic athletes may not life because peak bone accrual occurs during adoles- reap the full protective benefits as compared with their cence.14 The concept that the “bone bank” is already eumenorrheic counterparts.10 Duckman et al found depleted once bone reabsorption begins to occur in the that estrogen deficiency appears to limit exercise-in- 20s was introduced.14 Peak bone mass in the femur duced bone gains.10 For example, in oligomenorrheic was found to occur during adolescence, while peak and amenorrheic athletes, the bone mineral density bone mass in the lumbar spine occurred later in life.14 was found to be lower in the femoral neck and spine Pollock et al demonstrated in a longitudinal and than those eumenorrheic athletes.10 Perhaps the most cross-sectional observational study that bone mineral disturbing implications are the potential long-term content was lost by amenorrheic athletes at a rate of and irreversible consequences of athletic amenorrhea, 5.6% per year of total body, 1.2% at lumbar spine, which include heightened long-term risk for osteopo- and 4.9% at radius.18 The long-term implication of this rosis and fracture. work is that when these athletes reach menopause, Often, athletes will be placed on an oral contra- when bone loss occurs at about 5% per year, they will ceptive to normalize their menstrual cycle. The oral already be significantly bone mineral density depleted,

42  November 2014 international journal of Athletic Therapy & training