Topic: Effects of menstrual cycle phase on rehabilitation and recovery
Annotated Bibliography
Adachi, N., Nawata, K., Maeta, M. et al. Relationship of the menstrual cycle phase to anterior cruciate ligament injuries in teenaged female athletes. Arch Orthop Trauma Surg 128, 473–478 (2008). https://doi.org/10.1007/s00402-007-0461-1
Study performed to see if ACL injuries occurred randomly or if it is linked to a specific phase of the menstrual cycle and if pre-menstrual and menstrual dysfunction also has an influence.
Statistical significance was found between the phase of the menstrual cycle and the time of ACL injury.
More injuries were observed in the ovulatory phase than was expected, likely due to mid cycle surge of estrogen.
Subjective level of activity and perimenstrual symptoms do not seem to have an effect on the risk of non-contact ACL injuries.
Literature is conflicting when looking at specific cycles but if you break it down to preovulatory and postovulatory results would be consistent.
High risk interval of non-contact ACL injury is in the preovulatory phase.
Berger GK, Rockov ZA, Byrne C, Trentacosta NE, Stone MA. The role of relaxin in anterior cruciate ligament injuries: a systematic review. Eur J Orthop Surg Traumatol. 2023;33(8):3319-3326. doi:10.1007/s00590-023-03618-7
Relaxin levels may be correlated with increased ACL injury.
Relaxin has been shown to be associated with increased risk of shoulder instability, but it is suspected that high relaxin levels coupled with high estrogen levels have a intensifying effect.
It has also been associated with impaired tendon healing as it is involved in collagen remodeling.
Compared to male ACL harvest female ACLs have increased relaxin binding activity.
Screening for injury prophylaxis = SRC greater than 6.0 pg/mL are 4x mire at risk. Sensitivity 71% and specificity 52%
Oral contraceptives have been found to reduce SRCs
The article mentions a study on rats that were exposed to OCPs with higher progesterone to estrogen ratio resulted in increased ACL strength.
Cano Sokoloff N, Misra M, Ackerman KE. Exercise, Training, and the Hypothalamic-Pituitary-Gonadal Axis in Men and Women. Front Horm Res. 2016;47:27-43. doi:10.1159/000445154
Estradiol fluctuates throughout the menstrual cycle; it increases during follicular phase, peaks right before ovulation and the plummets.
Estradiol appears to have a protective role concerning muscles during exercise acting as a possible antioxidant, membrane stabilizer among phospholipids, and estrogen receptor substrate effecting downstream gene regulation.
Low energy availability as seen in the female athlete triad can suppress the HPG axis leading to amenorrhea affecting estradiol and other hormones important for bone metabolism have a negative impact on bone mineral density.
De Souza MJ, Koltun KJ, Williams NI. The Role of Energy Availability in Reproductive Function in the Female Athlete Triad and Extension of its Effects to Men: An Initial Working Model of a Similar Syndrome in Male Athletes. Sports Med. 2019;49(Suppl 2):125-137. doi:10.1007/s40279-019-01217-3
Female athlete triad is associate with poor bone health, low energy availability, disordered eating, and menstrual dysfunction.
Many athletes who report eating disorders also report that they eat in a manner to gain/build muscle.
The hypothalamic pituitary gonadal axis appears to recovery more quickly in men than women.
De Souza MJ, Mallinson RJ, Strock NCA, et al. Randomised controlled trial of the effects of increased energy intake on menstrual recovery in exercising women with menstrual disturbances: the ‘REFUEL’ study. Hum Reprod. 2021;36(8):2285-2297. doi:10.1093/humrep/deab149
Investigating the effects of increasing food intake to reverse oligomenorrhea and amenorrhea in exercising women.
Not much information from this one is applicable!
Dos Santos Andrade M, Mascarin NC, Foster R, de Jármy di Bella ZI, Vancini RL, Barbosa de Lira CA. Is muscular strength balance influenced by menstrual cycle in female soccer players?. J Sports Med Phys Fitness. 2017;57(6):859-864. doi:10.23736/S0022-4707.16.06290-3
Purpose was to examine the effects of the menstrual cycle on ACL neuromuscular and biomechanical injury risk during dynamic tasks to determine if there is a link to a particular phase. Male control group
Hamstring –to-quadricep torque strength balance ratio correlates to increased incidence of LE injury. Typical H/Q balance ration ranges from 50-80% depending on knee angle and angular speed.
Non-dominant peak H/Q torque strength balance ratio was lower than dominant in the follicular phase than the luteal whereas the male control group demonstrated no differences.
This strength imbalance during the follicular phase promotes instability of the knee predisposing females to knee injury.
Study limitations: follow up was not performed after study to verify incidences of knee injury
Dos’Santos T, Stebbings GK, Morse C, Shashidharan M, Daniels KAJ, Sanderson A. Effects of the menstrual cycle phase on anterior cruciate ligament neuromuscular and biomechanical injury risk surrogates in eumenorrheic and naturally menstruating women: A systematic review. PLoS One. 2023;18(1):e0280800. Published 2023 Jan 26. doi:10.1371/journal.pone.0280800
No significant difference in ACL injury was reported in four studies during different phase of the menstrual cycle.
Evidence in two studies showed the luteal phase may predispose women to an increased risk of non-contact ACL injury.
Knee laxity was found across the menstrual cycle phases in three studies
Two studies determined knee laxity was associated with changes in joint loading.
It was determined that the study (7 studies total) quality and quality of evidence from these studies were low therefore it is inconclusive whether different phases of the menstrual cycle contribute to ACL injury risk.
Gray AM, Gugala Z, Baillargeon JG. Effects of Oral Contraceptive Use on Anterior Cruciate Ligament Injury Epidemiology. Med Sci Sports Exerc. 2016;48(4):648-654. doi:10.1249/MSS.0000000000000806
ACL injury in children 12 and under is rare.
Females ages 15-20 years of age have the highest number of ACL injuries and girls 11-20 y.o. have the highest percentage of injuries that eventually result in surgical reconstruction.
15-19 y.o females who underwent ACL repair were 1.22 times more likely to not use oral contraceptives
Women in their follicular phase and ovulatory phases sustained injury at 1.35 times more.
Oral contraceptive used seemed to have 18% fewer injuries than nonusers in the age range of 15-19.
This evidence suggests that hormones do play a role in injury.
Onset of puberty: rise in estrogen levels, neuromuscular system lag, rapid limb growth, muscle inadequacy, incoordination when all combined may contribute to increased injury risk.
Gilmer G, Oliver GD. Preliminary Evaluation of Knee Kinetics in Female Athletes on Hormonal Contraceptives. Int J Sports Med. 2020;41(2):113-118. doi:10.1055/a-1034-7901
Purpose of study was to evaluate the differences in vertical ground reaction force and knee valgus force between female athletes who do and do not use hormonal contraceptives.
No significant difference was found when looking at pre-ovulatory or mid-luteal phase.
Knee valgus force was slightly higher in the mid-luteal phase, but the results were not significant.
This study looked at a small population and participants on oral contraceptives were on various types.
Hackney AC, Kallman AL, Ağgön E. Female sex hormones and the recovery from exercise: Menstrual cycle phase affects responses. Biomed Hum Kinet. 2019;11(1):87-89. doi:10.2478/bhk-2019-0011
Purpose was to examine muscle damage/inflammation during recovery during the mid-follicular phase or trained females.
Creatine Kinase levels were greater in the 24 hour and 72 hour mark in the mid-follicular and mid-luteal phase.
Interleukin-6 levels were significantly greater immediately post exercise, 24-hours and 72 hours during the mid-follicular phase than the mid-luteal phase.
These findings suggest that female sex hormone changes affect physiologic responses during extended recovery from intense exercise in eumenorrheic women.
Herzberg SD, Motu’apuaka ML, Lambert W, Fu R, Brady J, Guise JM. The Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis. Orthop J Sports Med. 2017;5(7):2325967117718781. Published 2017 Jul 21. doi:10.1177/2325967117718781
Article looked at 5 studies concerning the menstrual cycles, 7 on hormonal contraceptives and ACL injury, 13 on the menstrual cycle and ligament laxity
4/5 (poor- fair quality) studies looking at women not taking oral contraceptives found that the luteal phase was less associated with ACL injuries.
The two largest and high-quality studies found that oral contraceptives may be protective against ACL injury.
Significantly increased ligament laxity was noted during the ovulatory phase compared to the follicular phase in 6/12 studies.
One of the challenges/limitations is the accurate assessment of the menstrual cycle and hormone levels.
Hohmann E, Bryant AL, Livingstone E, Reaburn P, Tetsworth K, Imhoff A. Tibial acceleration profiles during the menstrual cycle in female athletes. Arch Orthop Trauma Surg. 2015;135(10):1419-1427. doi:10.1007/s00402-015-2283-x
Purpose was to investigate if endogenous estrogen had adverse effects on lower limb biomechanics given higher rates of ACL injury at different phase of the menstrual cycle
Significant differences were found for time to peak tibial acceleration between menstruation and follicular, menstruation and ovulation, menstruation and luteal phase, and follicular phase and ovulation.
Study suggests that estrogen level fluctuations influence tibial acceleration during different phases of the menstrual cycle
Therefore, the female musculoskeletal system needs to constantly adjust to various levels of hormones using neuromuscular strategies to minimize injury risk.
Khowailed IA, Petrofsky J, Lohman E, Daher N, Mohamed O. 17β-Estradiol Induced Effects on Anterior Cruciate Ligament Laxness and Neuromuscular Activation Patterns in Female Runners. J Womens Health (Larchmt). 2015;24(8):670-680. doi:10.1089/jwh.2014.5184
Increased KJL in response to peak estradiol in ovulatory phase – associated with increased pre- activation of hamstring before foot contact
Follicular phase – noted decreased hamstring activation with weight acceptance during running
Decreased ratio of medial lateral quad recruitment was associated with decreased quad:hamstring co-contraction ratio during follicular phase
Significant increase in 17 beta estradiol during ovulation
Significant increase in anterior tib translation during ovulatory phase
Martínez-Fortuny N, Alonso-Calvete A, Da Cuña-Carrera I, Abalo-Núñez R. Menstrual Cycle and Sport Injuries: A Systematic Review. International Journal of Environmental Research and Public Health. 2023; 20(4):3264. https://doi.org/10.3390/ijerph20043264
Peak estradiol levels are associated with increased laxity, muscle strength, and poor neuromuscular control therefore the ovulatory phase is associated with increased injury.
There have been some discrepancies in the research due to establishing the phases of the menstrual cycle as studies have used self- reported cycle length.
Increased ligament laxity noted in the ovulatory phase however it appears other hormones may contribute to laxity such as relaxin which appears during the follicular and luteal phases of the menstrual cycle.
During the ovulatory phase an increase in strength is attributed to estradiol as estrogen improves the quality of binding between myosin and actin filaments.
Estrogen and progesterone levels during follicular and ovulatory phase may have a negative effect on neuromuscular control via impact to the central nervous system.
Peinado AB, Alfaro-Magallanes VM, Romero-Parra N, Barba-Moreno L, Rael B, Maestre-Cascales C, Rojo-Tirado MA, Castro EA, Benito PJ, Ortega-Santos CP, et al. Methodological Approach of the Iron and Muscular Damage: Female Metabolism and Menstrual Cycle during Exercise Project (IronFEMME Study). International Journal of Environmental Research and Public Health. 2021; 18(2):735. https://doi.org/10.3390/ijerph18020735
Purpose is to examine the influence of sex hormones environment on the iron homeostasis and exercise induced muscle damage while considering the differing reproductive status present throughout the lifespan of a female athlete.
Looking to clarify sex hormone influence on the physiology of females
Variability of hormones for one female can be high for the same female between different menstrual cycles.
Seems study was conducted but statistical analysis is not complete.
Looked at hormone levels, genetic testing, serum iron levels.
Two studies: endurance and resistance outlined in detail with measures specified.
Sims ST, Ware L, Capodilupo ER. Patterns of endogenous and exogenous ovarian hormone modulation on recovery metrics across the menstrual cycle. BMJ Open Sport Exerc Med. 2021;7(3):e001047. Published 2021 Jul 19. doi:10.1136/bmjsem-2021-001047
Findings conclude that patterning of the ANS from ovarian hormones is significantly different between naturally cycling women and women on birth control.
Progestin only birth control exhibits similar patterns to natural menstruation in regard to cardiovascular strain and recovery.
Exogenous hormones are found to impact day to day recovery to increased cardiovascular strain as compared to menstrual cycles.
Exogenous hormones were found to reduce adaptation to stress across pill phases.
Lower recovery and higher strain are associated with the luteal phase of the natural menstrual cycle because progesterone has a stimulatory effect on the ANS.
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