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REVIEW Impact of the Menstrual Cycle on Determinants of Energy Balance: a Putative Role in Weight Loss Attempts

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REVIEW Impact of the Menstrual Cycle on Determinants of Energy Balance: a Putative Role in Weight Loss Attempts International Journal of Obesity (2007) 31, 1777–1785 & 2007 Nature Publishing Group All rights reserved 0307-0565/07 $30.00 www.nature.com/ijo REVIEW Impact of the menstrual cycle on determinants of energy balance: a putative role in weight loss attempts L Davidsen, B Vistisen and A Astrup Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, Frederiksberg, Denmark Women’s weight and body composition is significantly influenced by the female sex-steroid hormones. Levels of these hormones fluctuate in a defined manner throughout the menstrual cycle and interact to modulate energy homeostasis. This paper reviews the scientific literature on the relationship between hormonal changes across the menstrual cycle and components of energy balance, with the aim of clarifying whether this influences weight loss in women. In the luteal phase of the menstrual cycle it appears that women’s energy intake and energy expenditure are increased and they experience more frequent cravings for foods, particularly those high in carbohydrate and fat, than during the follicular phase. This suggests that the potential of the underlying physiology related to each phase of the menstrual cycle may be worth considering as an element in strategies to optimize weight loss. Studies are needed to assess the weight loss outcome of tailoring dietary recommendations and the degree of energy restriction to each menstrual phase throughout a weight management program, taking these preliminary findings into account. International Journal of Obesity (2007) 31, 1777–1785; doi:10.1038/sj.ijo.0803699; published online 7 August 2007 Keywords: menstrual cycle; weight loss attempts; energy intake; energy expenditure; food cravings; mood Introduction Weight loss strategies include eating fewer calories, eating less fat or carbohydrate, exercising more, skipping meals, Around the world obesity is becoming an increasing problem attending weight loss programs, taking diet pills or diuretics and it is accompanied by major health consequences for the and even fasting for more than 24 h.1 Americans spend more individual and society. This has prompted more people to than $33 billion on weight loss products and services every attempt to prevent weight gain, or to lose weight, by altering year.1 However, despite the numerous strategies used, the dietary habits, eating behavior and physical activity. The prevalence of obesity is still increasing. More than 30% of National Health Interview Survey conducted in 1998, which Americans are now obese,3 and increasing prevalences are included 32 440 Americans, showed that 24% of the male reported from most other parts of the world.4–7 For those and 38% of the female population were trying to lose who achieve weight loss, scientific evidence indicates that weight.1 The percentage of the population attempting to lose only 23% of the initial weight loss is sustained 5 years after weight rose as body mass index (BMI) increased. In men the completing a structured weight loss program.8 number trying to lose weight climbed from 6% in the normal When commencing with a diet, cosmetic factors are weight population (BMIo25) to 50% in the obese popula- clearly important motivational factors especially for women, tion (BMIX30). For women the comparable estimates were who appear more motivated to diet because of dissatisfaction 24 and 58%, respectively. In a Danish study interviews with with their body appearance than men.1 Nevertheless, 1200 men and women revealed that approximately half of women may have more difficulty in losing weight, and this population had attempted to lose weight.2 Also here the generally lose less weight than men during weight manage- prevalence of trying to lose weight increased with BMI. ment programs.9,10 This may partly be due to gender differences in energy metabolism and in appetite control brought about by secretion of reproductive hormones. In Correspondence: L Davidsen, Department of Human Nutrition, Faculty of Life women these hormones control the menstrual cycle and Sciences, University of Copenhagen, Rolighedsvej 30, DK-1958, Frederiks- coordinate changes in energy intake (EI), expenditure and berg, Denmark. storage, while preparing the body for pregnancy every E-mail: [email protected] 11 Received 26 September 2006; revised 29 May 2007; accepted 4 June 2007; month. As reproduction is a primary biological function, published online 7 August 2007 these hormones may be such strong mediators of eating Menstrual cycle and energy balance L Davidsen et al 1778 behavior that they influence the outcome of a weight loss the release of LH and FSH from the anterior pituitary, which attempt. The menstrual cycle should therefore be taken into in turn stimulate release of estrogens and progesterone from consideration as a factor in the physiology of energy balance the ovaries.22 in premenopausal women. This paper reviews the literature In the early follicular phase follicular enlargement begins on appetite, cravings, pattern of food intake, energy and is characterized by high circulating levels of FSH, which metabolism and mood across the menstrual cycle. An in- stimulate follicular growth. Levels of plasma LH, estradiol depth understanding of any mechanisms that change and progesterone are low in this phase. Plasma FSH induces a determinants of energy balance during the course of the rise in the concentration of estradiol, which starts in the mid menstrual cycle could provide helpful tools for the preven- follicular phase and continues until the late follicular phase, tion and treatment of obesity. The potential of the when it finally peaks. This event triggers the mid cycle LH physiology related to each phase of the menstrual cycle to surge, which lasts for 40–48 h and induces ovulation. optimize weight loss outcome is discussed. Consequently, the level of plasma estradiol decreases, though it remains slightly elevated throughout the luteal phase.20 When ovulation has occurred progesterone is secreted and Hormonal changes during the menstrual cycle its concentration increases until it reaches its peak in the mid luteal phase, and LH and FSH return to their previous levels. The menstrual cycle is coordinated by the hypothalamic – If the ovum is not fertilized the plasma concentrations of pituitary – gonadal (HPG) axis and is influenced by estradiol and progesterone drop at the end of the luteal physiological and pathological changes that occur through- phase, which initiates menstruation and thereby a new out life.12 The menarche (the first menstruation) is often menstrual cycle.23 The cyclic changes in hormones and body considered the central event of female puberty, as it signals temperature are illustrated in Figure 1. the commencement of fertility. The average age for menarche is between 12 and 13.5 years.13 It seems to occur most frequently when a young woman reaches around 17% Energy intake body fat.14 However, it may not be the amount of body fat per se that affects the timing of menarche. Height, weight It has been observed in animal studies that EI is reduced at 15 and skinfold thickness all appear to play a role. Race and the time of ovulation, when plasma estrogen levels peak, and socioeconomic status have also been suggested to influence that EI is increased after ovulation, when plasma progester- menarcheal age.15,16 The menstrual cycle continues until the onset of menopause around the age of 5017 when the ovaries stop producing estrogens. The reproductive system then Luteinizing hormone 18 gradually shuts down. Follicle stimulating hormone In the majority of women the menstrual cycle averages 28 days, where the day of onset of menstruation is generally referred to as day 1.19 The cycle can be divided into four phases: menstruation or early follicular phase (days 1–4), late follicular phase (days 5–11), periovulation (days 12–15) and the luteal Oestrogen phase (days 16–28).19 The culmination of the follicular phase occurs when ovulation takes place around day 14 or 15. After ovulation the luteal phase begins and lasts about 14 days until the onset of the next menstruation.20 However, when studying Progesterone energy balance across the menstrual cycle it is often divided into two phases separated by menstruation, with a pre- and 19 37°C postmenstrual phase, which is also the case for several of the Temperature studies included in this review. 36°C The predominant hormones that regulate the menstrual Ovulation cycle are gonadotropin-releasing hormone (GnRH), follicle- Follicular phase Luteal phase stimulating hormone (FSH), luteinizing hormone (LH), Menses progesterone and estrogen.20 There are three major forms of estrogen: estradiol, estrone and estriol. Estradiol is the day 1 day 14 day 28 most potent of these.21 Hormones are secreted at various sites. GnRH is secreted by Figure 1 The menstrual cycle: changes in hormones and in body temperature. Modified from Wikipedia.org. This Wikipedia and Wikimedia the hypothalamus, the gonadotropins FSH and LH are Commons image is from the user Chris 73 and is freely available at http:// secreted by the anterior pituitary gland and estrogens and commons.wikimedia.org/wiki/Image:MenstrualCycle.png under the creative progesterone are secreted from the ovaries. GnRH stimulates commons cc-by-sa 2.5 license. International Journal of Obesity Menstrual cycle and energy balance L Davidsen et al 1779 one is elevated.24–30 Consequently, it has been hypothesized luteal phase, where women’s EI is increased, are somewhat that estrogens reduce appetite and EI and are thus reciprocal higher compared to levels in the early follicular phase, in to a possible appetite-stimulating effect of progesterone in which EI appears to be lower. This suggests that it is perhaps animals. In humans, a review has summarized EI in relation not estrogen per se that mediates EI but that it might also be to menstrual cycle phases in 30 studies, which included a affected by progesterone. A certain increase in progesterone, total of 37 groups of women.31 Twenty-seven of the groups as occurs in the luteal phase, may somehow interact with demonstrated significantly higher EI in the luteal phase than estrogen and thus antagonize the metabolic effects of in the follicular phase.
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