
menstrual periods). In one study, girls who ate pri-
marily protein foods were shown to reach menarche
sooner, and girls who eat primarily carbohydrates
reached menarche later. However, in other studies of
all the dietary variables analyzed, only energy intake
was related to age at menarche. In a longitudinal
study, girls who consumed more (energy-adjusted)
animal protein and less vegetable protein at ages
3–5 years had an earlier menarche, and girls aged
1–2 years with higher dietary fat intakes and girls
aged 6–8 years with higher animal protein intakes
became adolescents with earlier peak growth. Con-
trolling for body size, girls who consumed more
calories and animal protein 2 years before peak
growth had a higher peak growth velocity. These
findings may have implications regarding adult
diseases whose risks are associated with adolescent
growth and development factors.
Body Weight and the Menstrual Cycle
0003 It is well established that starvation and emaciation
are almost invariably associated with amenorrhea
(lack of menstrual periods), the most profound
disturbance of the menstrual cycle. The work of
Frisch in the USA identified the link between body
composition and ovulation in the human female.
She suggested that fat must comprise at least 22%
of body weight for the maintenance of ovulatory
cycles and also observed that in normal postpubertal
women, fat is about 28% of body weight. It is
well recognized that the relationship is to the fat
content of the body rather than absolute body weight.
Trained athletes of average or above average body
weight may have a very low body fat content and
may be oligo- or amenorrheic. Frisch observed
that amongst trained athletes who became fit after a
normal menarche, 60% continued regular cycles, but
40% had irregular cycles and presumably associated
subfertility.
0004 Eating disorders such as anorexia nervosa and
bulimia nervosa are also causes of oligo- or amenor-
rhea. In anorexia nervosa, amenorrhea and failure to
maintain a body weight within 15% of that expected
are both diagnostic criteria. However, many women
engage in pathologic dieting behaviors without meet-
ing the current diagnostic criteria for anorexia or
bulimia nervosa. Clinical eating disorders are only
the most extreme form of pathologic eating attitudes
and behaviors that are present in many young
women. Specific food choices and nutrient intakes
may be associated with altered gonadal hormone
status of these dieters.
0005 Extreme weight loss is not a prerequisite for men-
strual cycle disturbances because dieting can induce
missed cycles before substantial weight loss occurs.
Even a very short-term (i.e., 4-day) acute energy
shortage can interfere with luteinizing hormone
pulsatility and thereby affect cycle function. In
humans, dieting with minor or moderate weight loss
has been shown to cause menstrual cycle disturbances
or may be a risk factor for the development of repro-
ductive dysfunction in normal weight healthy
women. Cognitive factors may also be associated
with the stability of the menstrual cycle. One such
factor is cognitive dietary restraint, the perception
that food intake is constantly being limited in an
effort to control body weight. Menstrual differences
between women with high and low restraint scores
were detected in a number of studies. One study
found that women with high restraint scores had
significantly shorter cycle lengths, shorter luteal-
phase lengths, and lower mean luteal-phase proges-
terone concentrations. In a group of women with
a wide range of physical activity levels who were
initially confirmed to ovulate normally, it was found
that the luteal-phase length was shorter, without
alteration of cycle length, in women with high re-
straint scores.
0006Cycle disturbances are associated with obesity as
well as with energy shortages. A high prevalence of
obesity among amenorrheic women was reported
many years ago, and anovulatory cycles appear to
be more common in obese women. Weight loss in
obese women results in improved ovulation and
pregnancy rates. It has been suggested that high
androstenedione concentrations observed in obese
women may activate the conversion of estradiol to
estrone in adipose tissue. Estrone in turn may
trigger higher luteinizing hormone concentrations,
leading to ovarian hyperstimulation, thus increasing
testosterone concentrations, resulting in anovulatory
cycles.
0007The Nurses Health Study in the USA has also
produced some interesting information about the
relative risk of menstrual cycle irregularity not only
in the underweight but also in the overweight
woman. For women with a body mass index (BMI)
below 20, at the age of 18 years, ovulatory infertility
was found with a relative risk of about 1.2 compared
to women with a BMI of 20–25. Interestingly,
however, the relative risk of ovulatory infertility
was 1.5 in those with a BMI of 28 and more than 2
in the obese group with a BMI above 30. About half
of the risk is associated with polycystic ovarian
syndrome, in which ovulatory infertility and obesity
coexist, but there is still a doubling in relative risk of
ovulatory infertility in women with a BMI above 30
who do not have ultrasonically detectable polycystic
ovaries.
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