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Abstract
Background: Low Energy Availability (LEA) occurs when a female athlete’s dietary energy intake does not adequately support physiological functions after considering the energy used during exercise. It leads to various physiological problems that affect many systems. Among these, a major concerning disorder is reduced gonadotropin-releasing hormone (GnRH) pulsatility. This results in menstrual issues, from oligomenorrhea to functional hypothalamic amenorrhea, and forms part of the frameworks of the Female Athlete Triad.
Despite the increasing awareness of LEA, there is a paucity of data from Indian female athletic populations. Cultural factors, stigma around menstruation, and limited nutritional awareness may compound the risk.
Objective: This study aims to investigate the proportion of LEA and its relation to menstrual problems among Indian female athletes.
Methods: We conducted a cross-sectional study with 60 female athletes aged 18 to 25 years among university collegiate students in Bangalore. The Low Energy Availability in Females Questionnaire (LEAF-Q) assessed LEA, while structured interviews gathered menstrual history.
Results: We identified LEA in 45% (27 out of 60) of the participants. Athletes with LEA experienced menstrual disturbances (70.4%) significantly more often than those without LEA (26.7%) (p < 0.01).
Conclusion: The study concludes that LEA is a significant and changeable risk factor for menstrual dysfunction in female athletes. Regular screening and nutritional education are crucial for early detection and intervention to improve their health status, quality of life and sports performance. Identifying and addressing this issue early is vital for ensuring the long-term health and performance of this vulnerable group.
Keywords: oligomenorrhea, gonadotropin-releasing hormone, Female Athlete Triad, anthropometric, hypothalamic amenorrhea
Introduction
Low Energy Availability (LEA) occurs when a female athlete’s dietary energy intake does not adequately support physiological functions after considering the energy used during exercise [1]. It leads to various physiological problems that affect many systems. Among these, a major concerning disorder is reduced gonadotropin-releasing hormone (GnRH) pulsatility [2]. This results in menstrual issues, from oligomenorrhea to functional hypothalamic amenorrhea, and forms part of the frameworks of the Female Athlete Triad [3]. Despite the increasing awareness of LEA, there is a paucity of data from Indian female athletic populations. Cultural factors, stigma around menstruation, and limited nutritional awareness may compound the risk.
Material and Methods
Study Design and Setting: A cross-sectional study was conducted across university affiliated sports institutes in Bengaluru, India. This study is part of a larger study which was conducted by us on university collegiate athletes.
Sample Size Calculation: The sample size was calculated based on an earlier study which reported a 55% prevalence of menstrual dysfunction among athletes with LEA [4]. Assuming a confidence level of 95% and 80% power to detect a difference of 30% in menstrual abnormalities between LEA and non-LEA groups, the minimum sample size was estimated to be 52. To account for potential dropouts or incomplete data, 60 participants were included.
Participants
Female athletes aged 18–25 years, training ≥5 hours/week for ≥1 year and willing to provide written consent were included. Those with diagnosed endocrine disorders, on hormonal contraceptives, pregnancy, or with chronic illnesses were excluded.
Data Collection Tools
The LEAF-Q, a validated and standardized questionnaire, was used to assess LEA. This was filled in the presence of investigators in confidentiality. A detailed menstrual history and anthropometric measurements (height, weight, BMI) were recorded.
Statistical Analysis
Data were analyzed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize participant characteristics. The Chi-square test was applied to evaluate the association between Low Energy Availability (LEA) and menstrual irregularities. A p-value less than 0.05 was considered statistically significant.
Results
Demographics: The mean age of participants was 20.8 ± 1.9 years, average training duration was 8.6 ± 2.3 hours/week, and mean BMI was 21.2 ± 2.4 kg/m². (Table 1)
Out if the total participants, 45% of participants were identified as LEA-positive using the LEAF-Q. A total of 27 athletes were reported to be affected by LEA. Of the LEA-positive athletes, 70.4% had menstrual irregularities including amenorrhea and/or oligomenorrhea, compared to 26.7% in the LEA-negative group (p < 0.001). (Table 2)
Discussion
This study highlights that Low Energy Availability (LEA) is common among young female athletes, with 45% identified as at risk, and shows a strong link between LEA and menstrual problems. Nearly 70.4% of those with LEA reported menstrual disturbances, compared to only 26.7% in the group without LEA - a statistically significant difference. These results align with previous studies regarding the Female Athlete Triad, which emphasize energy imbalance as a significant factor in reproductive issues [1].
LEA negatively affects reproductive health mainly by impacting the hypothalamic-pituitary-gonadal (HPG) axis. When energy availability drops below a critical level (around 30 kcal/ kg FFM/day), it causes disruptions in GnRH pulsatility. This leads to reduced luteinizing hormone (LH) and follicle-stimulating hormone (FSH) secretion, ultimately resulting in functional hypothalamic amenorrhea [2]. This adaptive response prioritizes metabolic and survival functions over reproduction, when energy is insufficient.
Studies by De Souza et al. and others have confirmed the neuroendocrine effects of LEA and its strong connection to menstrual dysfunction [3]. Our findings show similar trends, with nearly half of the athletes at risk for LEA experiencing menstrual issues.
Using the LEAF-Q was crucial for screening LEA. This tool is validated for athletic populations and demonstrates high sensitivity and specificity for identifying at-risk athletes [4]. Its use in our study offered an effective, non-invasive method for risk stratification in a real-world setting- a particularly fitting approach for low-resource environments.
Interestingly, it was noted that a significant number of athletes in our study viewed irregular menstruation as unalarming or, even a positive result of training. This indicates a lack of understanding about menstrual health, similar to findings in other studies, and underscores the need to include menstrual education in sports science programs [5].
Comparisons with global data indicate that LEA prevalence varies with sport type and training intensity. Aesthetic and endurance sports typically show higher rates, particularly when leanness is emphasized [6]. While our sample included a mix of sports, further research could examine sport-specific risk profiles. LEA and related menstrual dysfunctions indicate broader physiological issues. Chronic LEA can lead to dysfunctions such as reduced bone mineral density, weakened immune response, gastrointestinal problems, and mental health effects [1]. Low estrogen levels from hypoestrogenism may also increase lifetime risk of osteoporosis and heart disease [7].
Despite these insights, some limitations are worth mentioning. The cross-sectional design of the study means that causal relationships cannot be established, and self-reported data on diet and menstruation can be influenced by recall bias. While the LEAF-Q is a validated tool, it cannot replace biochemical or calorimetric assessments, which may provide more accurate diagnosis.
Still, this data is important for highlighting the prevalence of LEA and its effects on Indian female athletes. It emphasizes the need for regular screening using reliable tools like the LEAF-Q, educational initiatives for athletes and coaches about proper nutrition and menstrual health, and involvement of multidisciplinary support teams, including sports nutritionists and endocrinologists, in athletic programs.
Conclusion
The study concludes that LEA is a significant and changeable risk factor for menstrual dysfunction in female athletes. Identifying and addressing this issue early is vital for ensuring the long-term health and performance of this vulnerable group.
References
- Mountjoy M, Sundgot-Borgen J, Burke L, et al. (2018) The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). Br J Sports Med 52(11): 687-697.
- Loucks AB, Thuma JR (2003) Luteinizing hormone pulsatility is disrupted at a threshold of energy availability in regularly menstruating women. J Clin Endocrinol Metab 88(1): 297-311.
- De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, et al. (2014) Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play. Br J Sports Med 48(4): 289.
- Melin A, Tornberg ÅB, Skouby S, et al. (2014) The LEAF Questionnaire is a valid tool for screening female athletes at risk for the Female Athlete Triad. J Sports Sci 32(2): 121–129.
- Logue DM, Madigan SM, Delahunt E, et al. (2018) Low energy availability in athletes: A review of prevalence, dietary patterns, physiological health, and sports performance. Sports Med 48(1): 73-96.
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- Nattiv A, Loucks AB, Manore MM, et al. (2007) American College of Sports Medicine position stand: The female athlete triad. Med Sci Sports Exerc 39(10): 1867-1882.
