Women have become increasingly physically active in recent decades. While exercise provides substantial health benefits, intensive exercise is also associated with a unique set of risks for the female athlete. Hypothalamic dysfunction associated with strenuous exercise, and the resulting disturbance of GnRH pulsatility, can result in delayed menarche and disruption of menstrual cyclicity. Specific mechanisms triggering reproductive dysfunction may vary across athletic disciplines. An energy drain incurred by women whose energy expenditure exceeds dietary energy intake appears to be the primary factor effecting GnRH suppression in athletes engaged in sports emphasizing leanness; nutritional restriction may be an important causal factor in the hypoestrogenism observed in these athletes. A distinct hormonal profile characterized by hyperandrogenism rather than hypoestrogenism is associated with athletes engaged in sports emphasizing strength over leanness. Complications associated with suppression of GnRH include infertility and compromised bone density. Failure to attain peak bone mass and bone loss predispose hypoestrogenic athletes to osteopenia and osteoporosis. Metabolic aberrations associated with nutritional insult may be the primary factors effecting low bone density in hypoestrogenic athletes, thus diagnosis should include careful screening for abnormal eating behavior. Increasing caloric intake to offset high energy demand may be sufficient to reverse menstrual dysfunction and stimulate bone accretion. Treatment with exogenous estrogen may help to curb further bone loss in the hypoestrogenic amenorrheic athlete, but may not be sufficient to stimulate bone growth. Treatment aimed at correcting metabolic abnormalities may in fact prove more effective than that aimed at correcting estrogen deficiencies.
HOW DOES SPORT AFFECT FERTILITY?
CJ DeGuara: Today we are discussing an interesting subject; I’d like to start by getting a general overview for our readers about athletics and fertility; how do the two work together, what are some of the common issues especially with high-performance athletics?
Dr. Vasiliki Moragianni: This is indeed a very interesting subject, as it affects many individuals. Sports relates to fertility either through a hormonal or a mechanical pathway. By hormonal, I refer to the changes in hormones resulting from strenuous exercising. By mechanical, I refer to direct trauma to the body that can affect fertility.
CJ DeGuara: Let’s focus first on hormonal as I believe these would be easier to correct?
Dr. Vasiliki Moragianni: It depends. Exercising can have effects on both the male and female reproductive systems. In terms of women, intense exercising that leads to a reduction of body fat in exchange for muscle mass can lead to menstrual irregularities, problems with ovulation, and even cessation of menses, and thus infertility. Furthermore, in men or women using anabolic steroids or performance-enhancing agents, the reproductive system can “shut down” temporarily or in some cases irreversibly.
ATHLETICS AND FEMALE FERTILITY: WHAT YOU NEED TO KNOW
CJ DeGuara: Wow, ok so as to focus a little; let’s learn a little more about women and hormone-related instances of infertility or sub-fertility. Are there situations where the damage cannot be reversed?
Dr. Vasiliki Moragianni: In general, a healthy balance of fat and muscle tissue is required to maintain a healthy reproductive system. Fat is an important source of estrogen and by severe drops in fat tissue, estrogen levels can drop as well. As a result, we get manifestations similar to the typical “female athlete triad”. This includes (a) disordered eating, (b) menstrual dysfunction, and (c) decreased bone density.
CJ DeGuara: Is this also harmful to an athlete’s long-term health and ability to perform in athletics or is the consideration only as it pertains to fertility? I ask because I understand that for some individuals the drive to excel in athletic endeavors is extremely high so it is important that we fully understand the situation.
Dr. Vasiliki Moragianni: Absolutely, and this is what makes this even harder for individuals to deal with. Eating disorders, as well as poor bone and overall health, are long-term consequences that can sometimes remain irreversible.
CJ DeGuara: In your experience, can athletic excellence exist alongside healthy reproductive health or is this somewhat of a trade top performing athletes find themselves having to make?
Dr. Vasiliki Moragianni: It definitely requires an overall change in the culture of athletics in general. As with everything else in life, a healthy balance needs to be maintained at all times. High-performance athletes should be followed closely by trained specialists in the medical field who are attuned to these issues so they can prevent them or detect them early enough when they can still be reversed.
CJ DeGuara: In short then, it is important to have more awareness; in some cases though if I am understanding correctly an athlete may have to make a decision with regards to their priorities in this regard?
Dr. Vasiliki Moragianni: Health should always be the first priority; therefore, athletes, as well as their coaches and teams, should only focus on that.
CJ DeGuara: Understood and agreed. So how would one go about identifying these issues? I am guessing catching this early is extremely important to the long-term reproductive health of the athlete; what should they be asking?
Dr. Vasiliki Moragianni: In terms of reproductive health, asking about frequency and pattern of menstrual cycles is a great place to start.
CJ DeGuara: How early on in an athlete’s life can the potential for harm to the reproductive system begin? I know for example gymnastics is an extremely competitive sport started at a young age, in some cases prior to a menstrual period may have begun.
Dr. Vasiliki Moragianni: Extreme physical activity can lead to irregularities (or cessation) of menses once the menstrual cycle has begun or to delayed puberty (i.e. menses starting much later than anticipated). Both of these circumstances warrant further testing and evaluation by a physician.
CJ DeGuara: So, in effect, we need to be keeping an eye on this as early as puberty? If that is the case, I want to make sure we are not scaring people unnecessarily, how prevalent is this problem and what can be done once an issue is diagnosed? Would the athlete have to cease or pull back on their training?
Dr. Vasiliki Moragianni: We definitely do not need to alarm athletes or cause unnecessary anxiety. As long as they maintain a healthy balance of exercise and diet, they should address any health issues as and if they arise. These issues certainly do not affect all athletes and once diagnosed can, in the majority of cases, be reversed.
CJ DeGuara: I am assuming mechanical issues are less common in women?
Dr. Vasiliki Moragianni: That is correct. However, for both men and women, head trauma can also affect the reproductive system. The hormones that “speak” to ovaries and testes are secreted in the brain and therefore any injury to that area can disrupt the communication.
CJ DeGuara: Ok, so how does that impact female reproduction?
Dr. Vasiliki Moragianni: It depends on the severity of the injury, it can be temporary or irreversible. It can lead to changes in menstrual pattern, cessation of menses, and infertility.
CJ DeGuara: Wow ok, so any injury to the head; which of course should always be checked may also impact fertility. Is there any way to test for this?
Dr. Vasiliki Moragianni: Any head injury could affect the reproductive system but of course not all of them do. It depends on the area of the brain that is affected and the severity of the injury. The main “symptom” that would warrant further evaluation would be menstrual irregularity.
CJ DeGuara: So, if we had to summarize on the female fertility side one of the most prominent indicators is irregular menstrual activity and in younger females delayed puberty?
Dr. Vasiliki Moragianni: Exactly.
CJ DeGuara: Also, things to watch out for are extremely low body fat and any disordered eating patterns that could impact fertility. Are there any supplements or ways to reduce the likelihood of these issues apart from of course adjusting the training regimen?
Dr. Vasiliki Moragianni: There are no supplements that can help. Avoiding performance-enhancing supplements and especially anabolic steroids is very important as well!