A perspective on current research investigating the effects of hormonal contraceptives on determinants of female athlete performance

Hormonal contraceptives are used by approximately half of female athletes and may affect athletic performance as a result of their action on the endogenous hormonal milieu. In athletes, hormonal contraceptive use appears to have little effect on body composition, however further studies are needed assessing progestin-only contraceptives as they may have a negative effect in the general population. The type of progestin contained within the contraceptive may influence the anabolic response of muscle to loading although this relationship is complex as it may be due to either direct or indirect effects of exogenous hormones on protein synthesis and satellite cell proliferation. The altered hormonal milieu in hormonal contraceptive users has predominately been shown to have no effect on muscle strength and whilst maximal oxygen uptake is sometimes reduced, this does not translate into measures of performance. The majority of previous research has used cross-sectional designs and/or grouped together different types and brands of hormonal contraceptives and little research has been conducted on progestin-only contraceptives in athletes. Future research should use prospective, randomised-controlled designs to assess the effects of all types of hormonal contraceptives on athletic performance in females

A narrative review on female physique athletes: the physiological and psychological implications of weight management practices

Physique competitions are events in which aesthetic appearance and posing ability are valued above physical performance. Female physique athletes are required to possess high lean body mass and extremely low fat mass in competition. As such, extended periods of reduced energy intake and intensive training regimens are used with acute weight loss practices at the end of the precompetition phase. This represents an increased risk for chronic low energy availability and associated symptoms of relative energy deficiency in sport, compromising both psychological and physiological health. Available literature suggests that a large proportion of female physique athletes report menstrual irregularities (e.g., amenorrhea and oligomenorrhea), which are unlikely to normalize immediately postcompetition. Furthermore, the tendency to reduce intakes of numerous essential micronutrients is prominent among those using restrictive eating patterns. Following competition, reduced resting metabolic rate, and hyperphagia, is also a concern for these female athletes, which can result in frequent weight cycling, distorted body image, and disordered eating/eating disorders. Overall, female physique athletes are an understudied population, and the need for more robust studies to detect low energy availability and associated health effects is warranted. This narrative review aims to define the natural female physique athlete, explore some of the physiological and psychological implications of weight management practices experienced by female physique athletes, and propose future research directions

Parathyroid hormone secretion is controlled by both ionised calcium and phosphate during exercise and recovery in men

The mechanism by which PTH is controlled during and after exercise is poorly understood due to insufficient temporal frequency of measurements. Objective: To examine the temporal pattern of PTH, PO4, ACa and Ca2+ during and after exercise. Design and setting: A laboratory-based study with a cross-over design, comparing 30 min of running at 55%, 65% and 75%VO2max, followed by 2.5-h of recovery. Blood was obtained at baseline, after 2.5, 5, 7.5, 10, 15, 20, 25 and 30 min of exercise and after 2.5, 5, 7.5, 10, 15, 20, 25, 30, 60, 90 and 150 min of recovery. Participants: Ten men (age 23±1 y, height 1.82±0.07 m, body mass 77.0±7.5 kg) participated. Main Outcome Measures: PTH, PO4, ACa and Ca2+ Results: Independent of intensity, PTH concentrations decreased with the onset of exercise (-21 to -33%; P≤0.001), increased thereafter and were higher than baseline by the end of exercise at 75%VO2max (+52%; P≤0.001). PTH peaked transiently after 5–7.5 min of recovery (+73 to +110%; P≤0.001). PO4 followed a similar temporal pattern to PTH and Ca2+ followed a similar but inverse pattern to PTH. PTH was negatively correlated with Ca2+ across all intensities (r=-0.739 to -0.790; P≤0.001). When PTH was increasing, the strongest cross-correlation was with Ca2+ at 0 lags (3.5 min) (r=-0.902 to -0.950); during recovery, the strongest cross-correlation was with PO4 at 0 lags (8 min) (r=0.987 to 0.995). Conclusions: PTH secretion during exercise and recovery is controlled by a combination of changes in Ca2+ and PO4 in men

The effects of oral contraceptives on exercise performance in women: a systematic review and meta-analysis

Background: Oral contraceptive pills (OCPs) are double agents, which downregulate endogenous concentrations of oestradiol and progesterone whilst simultaneously providing daily supplementation of exogenous oestrogen and progestin during the OCP-taking days. This altered hormonal milieu differs significantly from that of eumenorrheic women and might impact exercise performance, due to changes in ovarian hormone-mediated physiological processes. Objective: To explore the effects of OCPs on exercise performance in women and to provide evidence-based performance recommendations to users. Methods: This review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A between-group analysis was performed, wherein performance of OCP users was compared with naturally menstruating women, and a within-group analysis was conducted, wherein performance during OCP consumption was compared with OCP withdrawal. For the between-group analysis, women were phase matched in two ways: (1) OCP withdrawal versus the early follicular phase of the menstrual cycle and (2) OCP consumption versus all phases of the menstrual cycle except for the early follicular phase. Study quality was assessed using a modified Downs and Black Checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation working group. All meta-analyses were conducted within a Bayesian framework to facilitate probabilistic interpretations. Results: 42 studies and 590 participants were included. Most studies (83%) were graded as moderate, low or very low quality, with 17% achieving high quality. For the between-group meta-analysis comparing OCP users with naturally menstruating women, posterior estimates of the pooled effect were used to calculate the probability of at least a small effect (d ≥ 0.2). Across the two between-group comparison methods, the probability of a small effect on performance favouring habitual OCP users was effectually zero (p < 0.001). In contrast, the probability of a small effect on performance favouring naturally menstruating women was moderate under comparison method (1) (d ≥ 0.2; p = 0.40) and small under comparison method (2) (d ≥ 0.2; p = 0.19). Relatively large between-study variance was identified for both between-group comparisons (0.5 = 0.16 [95% credible interval (CrI) 0.01-0.44] and 0.5 = 0.22 [95% CrI 0.06-0.45]). For the within-group analysis comparing OCP consumption with withdrawal, posterior estimates of the pooled effect size identified almost zero probability of a small effect on performance in either direction (d ≥ 0.2; p ≤ 0.001). Conclusions: OCP use might result in slightly inferior exercise performance on average when compared to naturally menstruating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and variable across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle

Perceptions of Current Issues in Female Sport Nutrition From Elite Athletes, Practitioners, and Researchers

In response to the ongoing sex data gap, the present study provides a qualitative exploration of females’ nutritional experiences in elite sporting environments. Semistructured interviews were conducted with multiple participant groups (n = 18), including athletes (n = 7), practitioners (n = 6), and researchers (n = 5) across differing disciplines within professional sporting organiza-tions and/or national governing bodies. Combined content and thematic analysis provided an insight into the specific factors influencing current sport nutrition practices. A common theme highlighted among all participant groups was the paradoxical struggle between adequate fueling for training and competition demands, and the fear this may impact body mass and body composition goals. This tension was identified as being rooted within athletes’ perceptions of body image and driven by other participant groups and wider societal ideals. Each participant group also highlighted influences on cravings and approaches to food and dietary supplementation, centered around individual perceptions and challenges driven by symptomology associated with the female menstrual cycle and contraceptive use. To address these challenges, all participant groups called for more research to inform future change and continuing education pathways. In summary, this study contributes to providing a more complete understanding of elite female athlete sport nutrition experiences than currently exists. Multiple perspectives highlight the complexity of providing sport nutrition support to elite female athlete populations and directs future research, and practice, to reconsider one-size-fits-all approaches and acknowledge unique individual contexts which may influence these areas

Where do you go when your periods go?: A case-study examining secondary amenorrhea in a professional internationally-capped female soccer player through the lens of the sport nutritionist.

This case study follows a professional internationally capped female soccer player's two-year journey from eumenorrhea, through injury, to amenorrhea, and the challenges faced by the player and nutritionist. The two years are split into three sections: (1) longitudinal profiling of the player, (2) nutrition to support her return from injury, and (3) investigation into the observed secondary amenorrhea. The cause of amenorrhea was investigated through the assessment of energy availability via doubly labelled water, remote food photography, blood biomarkers and resting metabolic rate. Despite having secondary amenorrhea and anovulatory cycles, the player did not have low energy availability. This study shows the importance for practitioner's, particularly nutritionists, to not assume that all menstrual irregularities are caused by low energy availability and could be caused by a combination of factors (e.g. clinical, physiological, and psychological), which requires a multi-disciplinary investigation and intervention team. This study also showed that education needs to be provided about menstrual health to elite female soccer players as the player (i) believed that not having a period was beneficial for performance and unsure of possible health implications; (ii) was convinced that a one-day bleed indicated a regular menstrual cycle; and (iii) was reluctant to waste the practitioners time discussing menstrual issues and was nervous of finding out if she had an actual health issue. It is therefore crucial that players feel comfortable in discussing their menstrual status with practitioners to support their performance and long-term health

Reply to: Comment on: "The effects of menstrual cycle phase on exercise performance in eumenorrheic women: a systematic review and meta-analysis" and "The effects of oral contraceptives on exercise performance in women: a systematic review and meta-analysis"

This is a letter to the editor, by the authors, in response to a comment ( https://doi.org/10.1007/s40279-020-01384-8 ) on two previous articles published in Sports Medicine 50(10), https://doi.org/10.1007/s40279-020-01319-3 ; https://doi.org/10.1007/s40279-020-01317-5

Female Athlete Representation and Dietary Control Methods Among Studies Assessing Chronic Carbohydrate Approaches to Support Training

The aim of this audit was to assess the representation of female athletes, dietary control methods, and gold standard female methodology that underpins the current guidelines for chronic carbohydrate (CHO) intake strategies for athlete daily training diets. Using a standardized audit, 281 studies were identified that examined high versus moderate CHO, periodized CHO availability, and/or low CHO, high fat diets. There were 3,735 total participants across these studies with only ∼16% of participants being women. Few studies utilized a design that specifically considered females, with only 16 studies (∼6%) including a female-only cohort and six studies (∼2%) with a sex-based comparison in their statistical procedure, in comparison to the 217 studies (∼77%) including a male-only cohort. Most studies (∼72%) did not provide sufficient information to define the menstrual status of participants, and of the 18 studies that did, optimal methodology for control of ovarian hormones was only noted in one study. While ∼40% of male-only studies provided all food and beverages to participants, only ∼20% of studies with a female-specific design used this approach for dietary control. Most studies did not implement strategies to ensure compliance to dietary interventions and/or control energy intake during dietary interventions. The literature that has contributed to the current guidelines for daily CHO intake is lacking in research that is specific to, or adequately addresses, the female athlete. Redressing this imbalance is of high priority to ensure that the female athlete receives evidence-based recommendations that consider her specific needs

Normalising the conversation: a qualitative analysis of player and stakeholder perceptions of menstrual health support within elite female soccer

Purpose: This qualitative study explores player and stakeholder perceptions of menstrual health support in elite female soccer. Methods: Semi-structured interviews were conducted with 47 participants including players (n = 12), parents (n = 9), coaches (n = 9), sport scientists (n = 7), nutritionists (n = 5) and medical staff (n = 5). Results: Via thematic analysis, data demonstrate that elite female soccer players experience a range of physical and psychological symptoms primarily at the onset of and during menses (as also perceived by stakeholders), with most participants perceiving these symptoms to impact performance. Nonetheless, menstrual health support is perceived as minimal and although players have their menstrual status tracked, they report little understanding as to why or how this information is used. This confusion was also present among stakeholders, often as a result of uncertainty about the evidence supporting the need for menstrual health support. The perceived lack of support may also be reflective of a culture where conversations about the menstrual cycle are not normalised. Overall, this may result in failure to identify and treat menstrual irregularities despite non-coaching staff members perceiving them to be common amongst players. Conclusion: These data support the need for individualised support based on the lived experiences of individual players and support staff. Furthermore, our research identifies the need for organisational, stakeholder, and player centred education programmes (led by experts in female athlete health) that create an environment where players receive personalised menstrual health support

Carbohydrate fear, skinfold targets and body image issues: a qualitative analysis of player and stakeholder perceptions of the nutrition culture within elite female soccer

Purpose: This qualitative study explores player and stakeholder perceptions of the role of nutrition in supporting player development and performance in elite female soccer. Methods: Semi-structured interviews (36 ± 18 mins in length) were conducted with 47 participants, including players (n = 12), parents (n = 9), coaches (n = 9), sport scientists (n = 7), nutritionists (n = 5) and medical staff (n = 5). Via thematic analysis, data provided an insight into the nutrition culture within elite women’s soccer. Results and conclusions: Data demonstrate that considerable confusion and misconceptions exist amongst players and stakeholders regarding the theoretical underpinning and practical application of meeting energy requirements. As such, it is perceived that players ‘under-fuel’, which is likely caused by misunderstandings about the impact of carbohydrate intake on body composition, a fear of weight gain and the associated impacts upon body image. The ‘carbohydrate fear’ that is experienced by players is exacerbated by external pressures arising from social media, key stakeholders (e.g., coaches) and the skinfold culture surrounding measurement of body composition. Such cultural issues are amplified by the lack of full-time professionally accredited nutritionists overseeing the provision of nutrition support. Indeed, the infrastructure supporting the women’s game (e.g. staffing resource, on-site food provision, player education programmes, etc.) was considered incomparable to the men’s game. When taken together, our data provide a platform for which to develop organisational, stakeholder and player centred education and behaviour change interventions that strive to promote a positive performance nutrition culture within the women’s game