Abstract
Physicians commonly recommend estrogen replacement as treatment for exercise-associated amenorrhoea. While the evidence shows that the basis of the amenorrhoea is estrogen deficiency, it is not clear that it is the only factor in the development of lowered bone density found in oligo-amenorrhoeic female athletes. Nutritional factors, significant in the development of the reproductive dysfunction, could also contribute to bone loss. No randomised, controlled studies of estrogen replacement in athletes have been published. However, one non-randomised study of a small group of athletes does suggest that there are significant gains in bone density to be made by the initiation of estrogen therapy. More research is clearly needed.
Similar content being viewed by others
References
Speroff L, Redwine DB. Exercise and menstrual dysfunction. Phys Sportsmed 1981; 8: 42–52
Haberland CA, Seddick D, Marcus R, et al. Aphysician survey of therapy for exercise-associated amenorrhea: a brief report. Clin J Sport Med 1995; 5: 246–50
Loucks AB, Verdun M, Health EM. Low energy availability, not stress of exercise alters LH pulsatility in exercising women. J Appl Physiol 1998; 84: 37–46
Warren MP, Perlroth NE. The effect of intense exercise on the female reproductive system. J Endocrinol 2001; 170: 3–11
Baer JT. Endocrine parameters in amenorrheic and eumenorheic adolescent female runners. Int J Sports Med 1993; 14: 191–5
Laughlin GA, Yen SS. Nutritional and endocrine-metabolic aberrations in amenorrheic athletes. J Clin Endocrinol Metab 1996; 81: 4301–9
Baker ER, Mathur RS, Kirk RF, et al. Female runners and secondary amenorrhea: correlation with age, parity, mileage and plasma hormones and sex-hormone-binding globulin. Fertil Steril 1981; 36: 183–7
Schwartz B, Cumming DC, Riordan E, et al. Exercise associated amenorrhea: a distinct entity? Am J Obstet Gynecol 1981; 114: 662–70
Loucks AB, Mortola JF, Girton L, et al. Alterations in the hypothalamic-pituitary-ovarian and the hypothalamic-pituitary-adrenal axes. J Clin Endocrinol Metab 1989; 68: 402–11
Villaneuva AL, Schlosser C, Hopper B, et al. Increased cortisol production in women runners. J Clin Endocrinol Metab 1986; 63: 133–6
Ding JH, Sheckter CB, Drinkwater BL, et al. High serum cortisol levels in exercise-associated amenorrhea. Ann Intern Med 1988; 108: 530–4
De Souza MJ, Maguire MS, Maresh CM, et al. Adrenal activation and the prolactin response to exercise in eumenorrheic and amenorrheic runners. J Appl Physiol 1991; 70: 2378–87
Jahreis G, Kauf E, Frohner G, et al. Influence of intensive exercise on insulin-like growth factor I, thyroid and steroid hormones in female gymnasts. Growth Regul 1991; 1: 95–9
Lindholm C, Hirschberg AL, Carlstrom K, et al. Altered adrenal steroid metabolism underlying hypercortisolismin female endurance athletes. Fertil Steril 1995; 63: 1190–4
Lloyd T, Buchanan JR, Bitzer S, et al. Interrelationships of diet, athletic activity, menstrual status, and bone density in collegiate women. Am J Clin Nutr 1987; 46: 681–4
Frusztajer NT, Dhuper S, Warren MP, et al. Nutrition and the incidence of stress fractures in ballet dancers. Am J Clin Nutr 1999; 51: 779–83
Cumming DC, Wheeler GD, Harber VJ. Physical activity, nutrition, and reproduction. Ann N Y Acad Sci 1994; 709: 55–76
Cumming DC, Rebar RW. Lack of consistency in the indirect methods of estimating body fat. Fertil Steril 1984; 41: 739–42
Frisch RE, Snow R, Gerard EL, et al. Magnetic resonance imaging of body fat of athletes compared with controls, and the oxidative metabolism of estradiol. Metab Clin Exp 1992; 41: 191–3
Frisch RE, Snow RC, Johnson LA, et al. Magnetic resonance imaging of overall and regional body fat, estrogen metabolism, and ovulation of athletes compared to controls. J Clin Endocrinol Metab 1993; 77: 471–7
Judd SJ. Disturbance of the reproductive axis induced by negative energy balance. Reprod Fertil Dev 1998; 10: 65–72
Lane JM, Russell L, Khan SN. Osteoporosis. Clin Orthop 2000; 372: 139–50
McClung MR. Clinical risk factors and evaluation of the risk of osteoporosis in clinical practice. Ann Med Interne (Paris) 2000; 151: 392–8
Dwyer JT. Health aspects of vegetarian diets. Am J Clin Nutr 1988; 48 Suppl.: 712–38
Sahota O, Hosking DJ. The contribution of nutritional factors to osteopenia in the elderly. Curr Opin Clin Nutr Metab Care 2001; 4: 15–20
Manelli F, Giustina A. Glucocorticoid-induced osteoporosis. Trends Endocrinol Metab 2000; 11: 79–85
Rubin CT, McLeod KJ, Lanyon LE. Prevention of osteoporosis by pulsed electromagnetic fields. J Bone Joint Surg Am 1989; 71: 411–7
Hetland ML, Haarbo J, Christiansen C. Body composition and serum lipids in female runners: influence of exercise level and menstrual bleeding pattern. Eur J Clin Invest 1995; 25: 553–8
Friday KE, Drinkwater BL, Bruemmer B, et al. Elevated plasma low-density lipoprotein and high-density lipoprotein cholesterol levels in amenorrheic athletes: effects of endogenous hormone status and nutrient intake. J Clin Endocrinol Metab 1993; 77: 1605–9
Lamon-Fava S, Fisher EC, Nelson ME, et al. Effect of exercise and menstrual cycle status on plasma lipids, low density lipoprotein particle size, and apolipoproteins. J Clin Endocrinol Metab 1989; 68: 17–21
Marcus R, Cann C, Madvig P, et al. Menstrual function and bone mass in elite women distance runners: endocrine and metabolic features. Ann Intern Med 1985; 102: 158–63
Harber VJ, Webber CE, Sutton JR, et al. The effect of amenorrhea on calcaneal bone density and total bone turnover in runners. Int J Sports Med 1991; 12: 505–8
Louis O, Demeirleir K, Kalender W, et al. Low vertebral bone density values in young non-elite female runners. Int J Sports Med 1991; 12: 214–7
Warren MP, Brooks-Gunn J, Fox RP, et al. Lack of bone accretion and amenorrhea: evidence for a relative osteopenia in weight-bearing bones. J Clin Endocrinol Metab 1991; 72: 847–53
Myburgh KH, Bachrach LK, Lewis B, et al. Low bone mineral density at axial and appendicular sites in amenorrheic athletes. Med Sci Sports Exerc 1993; 25: 1197–202
Okano H, Mizunuma H, Soda M, et al. Effects of exercise and amenorrhea on bone mineral density in teenage runners. Endocr J 1995; 42: 271–6
Moen SM, Sanborn CF, DiMarco NM, et al. Lumbar bone mineral density in adolescent female runners. J Sports Med Phys Fitness 1998; 38: 234–9
Armamento-Villareal R, Villareal DT, Avioli LV, et al. Estrogen status and heredity are major determinants of premenopausal bone mass. J Clin Invest 1992; 90: 2464–71
Baer JT, Taper LJ, Gwazdauskas FG, et al. Diet, hormonal, and metabolic factors affecting bone mineral density in adolescent amenorrheic and eumenorrheic female runners. J Sports Med Phys Fitness 1992; 32: 51–8
Robinson TL, Snow-Harter C, Taaffe DR, et al. Gymnasts exhibit higher bone mass than runners despite similar prevalence of amenorrhea and oligomenorrhea. J Bone Miner Res 1995; 10: 26–35
De Souza MJ, Miller BE, Sequenzia LC, et al. Bone health is not affected by luteal phase abnormalities and decreased ovarian progesterone production in female runners. J Clin Endocrinol Metab 1997; 82: 2867–76
Hetland ML, Haarbo J, Christiansen C, et al. Running induces menstrual disturbances but bone mass is unaffected, except in amenorrheic women. Am J Med 1993; 95: 53–60
Prior JC, Vigna YM, Schechter MT, et al. Spinal bone loss and ovulatory disturbances. N Engl J Med 1990; 323: 1221–7
Winters KM, Adams WC, Meredith CN, et al. Bone density and cyclic ovarian function in trained runners and active controls. Med Sci Sports Exerc 1996; 28 (7): 776–85
Fisher EC, Nelson ME, Frontera WR, et al. Bone mineral content and levels of gonadotropins and estrogens in amenorrheic running women. J Clin Endocrinol Metab 1986; 62: 1232–6
Nelson ME, Fisher EC, Catsos PD, et al. Diet and bone status in amenorrheic runners. Am J Clin Nutr 1986; 43: 910–6
Snead DB, Stubbs CC, Weltman JY, et al. Dietary patterns, eating behaviors, and bone mineral density in women runners. Am J Clin Nutr 1992; 56: 705–11
Wilmore JH, Wambsgans KC, Brenner M, et al. Is there energy conservation in amenorrheic compared with eumenorrheic distance runners? J Appl Physiol 1992; 72: 15–22
Rebar RW, Cumming DC. Reproductive function in women athletes. JAMA 1981; 246 (14): 1590
Schachter M, Shoham Z. Amenorrhea during the reproductive years — is it safe? Fertil Steril 1994; 62 (1): 1–16
Chen EC, Brzyski RG. Exercise and reproductive dysfunction. Fertil Steril 1999; 71 (1): 1–6
Dueck CA, Matt KS, Manore MM, et al. Treatment of athletic amenorrhea with a diet and training intervention program. Int J Sport Nutr 1996; 6: 24–40
Drinkwater BL, Nilson K, Ott S, et al. Bone mineral density after resumption of menses in amenorrheic athletes. JAMA 1986; 256: 380–2
Jonnavithula S, Warren MP, Fox RP, et al. Bone density is compromised in amenorrheic women despite return of menses: a 2-year study. Obstet Gynecol 1993; 81: 669–74
Burkman RT, Collins JA, Greene RA. Current perspectives on benefits and risks of hormone replacement therapy. Am J Obstet Gynecol 2001 Aug; 185 (2 Suppl.): S13–23
Metka M, Holzer G, Heytmanek G, et al. Hypergonadotropic hypogonadic amenorrhea (World Health Organization III) and osteoporosis. Fertil Steril 1992; 57 (1): 37–41
Mora S, Weber G, Guarneri MP, et al. Effect of estrogen replacement therapy on bone mineral content in girls with Turner syndrome. Obstet Gynecol 1992; 79: 747–51
Kreipe RE, Hicks DG, Rosier RN, et al. Preliminary findings on the effects of sex hormones on bone metabolism in anorexia nervosa. J Adolesc Health 1993; 14: 319–24
Haenggi W, Casez JP, Birkhaeuser MH, et al. Bone mineral density in young women with long-standing amenorrhea: limited effect of hormone replacement therapy with ethinylestradiol and desogestrel. Osteoporos Int 1994; 4: 99–103
Klibanski A, Biller BM, Schoenfeld DA, et al. The effects of estrogen administration on trabecular bone loss in young women with anorexia nervosa. J Clin Endocrinol Metab 1995; 80: 898–904
Seeman E, Szmukler GI, Formica C, et al. Osteoporosis in anorexia nervosa: the influence of peak bone density, bone loss, oral contraceptive use, and exercise. J Bone Miner Res 1992; 7: 1467–74
Hergenroeder AC, Smith EO, Shypallo R, et al. Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone, or placebo over 12 months. Am J Obstet Gynecol 1997; 176: 1017–25
Cumming DC. Exercise-associated amenorrhea, low bone density, and estrogen replacement therapy. Arch Intern Med 1996; 156: 2193–5
De Cree C, Lewin R, Ostyn M. Suitability of cyproterone acetate in the treatment of osteoporosis associated with athletic amenorrhea. Int J Sports Med 1988; 9: 187–92
Gibson JH, Mitchell A, Reeve J, et al. Treatment of reduced bone mineral density in athletic amenorrhea: a pilot study. Osteoporos Int 1999; 10: 284–9
Prior JC, Vigna YM, Barr SI, et al. Cyclic medroxyprogesterone treatment increases bone density: a controlled trial in active women with menstrual cycle disturbances. Am J Med 1994; 96: 521–30
Acknowledgments
The authors have no conflicts of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Cumming, D.C., Cumming, C.E. Estrogen Replacement Therapy and Female Athletes. Sports Med 31, 1025–1031 (2001). https://doi.org/10.2165/00007256-200131150-00001
Published:
Issue Date:
DOI: https://doi.org/10.2165/00007256-200131150-00001