Menstrual Disruption with Exercise Is Not Linked to an Energy Availability Threshold

Jay L. Lieberman, Mary Jane De Souza, David A. Wagstaff, Nancy I. Williams

Research output: Contribution to journalArticlepeer-review

75 Scopus citations


Introduction Chronic reductions in energy availability (EA) suppress reproductive function. A particular calculation of EA quantifies the dietary energy remaining after exercise for all physiological functions. Reductions in luteinizing hormone pulse frequency have been demonstrated when EA using this calculation is <30 kcal·kg -1 ·fat-free mass (ffm)·d -1. Purpose We determined whether menstrual disturbances (MD) are induced when EA is <30 kcal·kg -1 ffm·d -1. Methods Thirty-five sedentary, ovulatory women age 18 to 24 yr (weight, 59.0 ± 0.8 kg; body mass index, 21.8 ± 0.4 kg·m -2) completed a diet and exercise intervention over three menstrual cycles. Participants were randomized to groups that varied in the magnitude of negative energy balance created by the combination of exercise and energy restriction. Menstrual disturbances were determined using daily urinary estrone-1-glucuronide and pregnanediol glucuronide, midcycle luteinizing hormone, and menstrual calendars. In a secondary analysis, we calculated EA from energy balance data and tested the association of EA with MD. Results A generalized linear mixed-effects model showed that the likelihood of a MD decreased by 9% for each unit increase in EA (odds ratio, 0.91; 95% confidence interval, 0.84-0.98; P = 0.010). No specific value of EA emerged as a threshold below which MD were induced. When participants were partitioned into EA tertile groups (low EA, 23.4-34.1; n = 11; moderate EA, 34.9-40.7; n = 12, and high EA, 41.2-50.1; n = 12 [kcal·kg -1 ffm·d -1 ]), estrone-1-glucuronide (P < 0.001), pregnanediol glucuronide (P < 0.001), and luteal phase length (P = 0.031) decreased significantly, independent of tertile. Conclusions These findings do not support that a threshold of EA exists below which MD are induced but do suggest that MD increase linearly as EA decreases. Menstrual disturbances can likely be prevented by monitoring EA using a simplified assessment of metabolic status.

Original languageEnglish (US)
Pages (from-to)551-561
Number of pages11
JournalMedicine and science in sports and exercise
Issue number3
StatePublished - Mar 1 2018

All Science Journal Classification (ASJC) codes

  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation


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