Sports Medicine Handbook - NCAA

66
Menstrual-Cycle
Dysfunction
January 1986 • Revised June 2002
The NCAA Committee on
Competitive Safeguards and Medical
Aspects of Sports acknowledges the
significant input of Dr. Anne Loucks,
Ohio University, in the revision of
this guideline.
In 80 percent of college-age women,
the length of the menstrual cycle
ranges from 23 to 35 days.
Oligomenorrhea refers to a menstrual
cycle that occurs inconsistently,
irregularly and at longer intervals.
Amenorrhea is the cessation of the
menstrual cycle with ovulation
occurring infrequently or not at all.
A serious medical problem of amenorrhea
is the lower level of circulating
estrogen (hypoestrogenism), and
its potential health consequences.
The prevalence of menstrual-cycle
irregularities found in surveys
depends on the definition of menstrual
function used, but has been
reported to be as high as 44 percent
in athletic women. Research suggests
that failure to increase dietary
energy intake in compensation for
the expenditure of energy during
exercise can disrupt the hypothalamic-pituitary-ovarian
(HPO) axis.
Exercise training appears to have no
suppressive effect on the HPO axis
beyond the impact of its strain on
energy availability.
There are several important reasons
to discuss the treatment of menstrual-cycle
irregularities. One reason is
infertility; fortunately, the long-term
effects of menstrual cycle dysfunc-
GUIDELINE 2k
tion appear to be reversible. Another
medical consequence is skeletal
demineralization, which occurs in
hypoestrogenic women. Skeletal
demineralization was first observed
in amenorrheic athletes in 1984.
Initially, the lumbar spine appeared
to be the primary site where skeletal
demineralization occurs, but new
techniques for measuring bone mineral
density show that demineralization
occurs throughout the skeleton.
Some women with menstrual disturbances
involved in high-impact
activities, such as gymnastics and
figure skating, display less demineralization
than women runners.
Despite resumption of normal menses,
the loss of bone mass during
prolonged hypoestrogenemia is not
completely reversible. Therefore,
young women with low levels of circulating
estrogen, due to menstrual
irregularities, are at risk for low peak
bone mass which may increase the
potential for osteoporotic fractures
later in life. An increased incidence
of stress fractures also has been
observed in the long bones and feet
of women with menstrual irregularities.
The treatment goal for women with
menstrual irregularities is the reestablishment
of an appropriate hormonal
environment for the maintenance
of bone health. This can be
achieved by the re-establishment of
a regular menstrual cycle or by hormone
replacement therapy, although
neither change has been shown to
result in complete recovery of the
lost bone mass. Additional research
is necessary to develop a specific
prognosis for exercise-induced menstrual
dysfunction.
All student-athletes with menstrual
irregularities should be seen by a
physician. General guidelines
include:
1. Full medical evaluation, including
an endocrine work-up and bone mineral
density test;
2. Nutritional counseling with specific
emphasis on:
a. Total caloric intake versus
energy expenditure.
b. Calcium intake of 1,200 to
1,500 milligrams a day; and
3. Routine monitoring of the diet,
menstrual function, weight-training
schedule and exercise habits.
If this treatment scheme does not
result in regular menstrual cycles,
estrogen-progesterone supplementation
should be considered. This
should be coupled with appropriate
counseling on hormone replacement
and review of family history.
Hormone-replacement therapy is
thought to be important for amenorrheic
women and oligomenorrheic
women whose hormonal profile
reveals an estrogen deficiency.
The relationship between amenorrhea,
osteoporosis and disordered