The Female Athlete Triad

Q&A for Session #2
The Female Athlete, Sex Hormones and Nutrition
Sports Nutrition Symposium 4.0
Monday January 17th, 2022 @ 7 pm CST

Stacy T Sims, MSc, PhD

Female athletes have long been on the backfoot of equality, with the shamedly lack of research which consider how sex hormones might affect nutritional needs and status. The aim of this presentation is to highlight the broader effect of estrogen and progesterone, how these two hormones interact; and the implications of using existing guidelines for nutrition, supplementation, and concussion recovery.

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  •  Re the progesterone phase, I get the higher need for leucine, but why the need for lysine?
    • Lysine is also used in endometrial lining; fuleing shift in exercise - higher lysine use in exercise.

  • Progesterone(?), so it increases sodium excretion, but not sweat rate? Or?
    • Sweat rate is delayed in leutial phase and has nothing to do with progesterone effect more had to do with estrogen effect. When women do start to sweat since the onset is delayed they produce more sweat because they intrinsicly stored more heat. Has to do with estrogen and changes in vasodilation (not progesterone).

  • How strong is the evidence? I see a reductionistic/mechanistic perspective on hormones? But is this really as clear as you stated?
    • It is - When looking at the metabolism and estrogen and progesterone influences, evidence is there. Go into fertility, diabetic, and endocrinology literature. Look for ISSN position stand coming out soon!

  • How does being on an OC or IUD impact the changes in fuel utilization for women that were described earlier? Does that all change or are they the same?
    • On IUD is the same because that does not down regulate your natural menstrual cycle- you ovulate 6 months after implantation. Oral contraceptive it depends on what kind you are on- each component of the pill (estrogen and progesterone amount) changes how you process carbohydrates and protein metabolism.

  • How can individuals know their estrogen/progesterone ratio?
    • Go to GP and ask to get tested- want to specifically ask for the ratio.

  • How does that change in iron supplementation recommendation by menstrual phase for women in pregnancy?
    • Pregnancy is completely different- have a higher amount of estrogen, progesterone, and oxytocin. Higher amounts of inflammation as well. Iron supp in pregnancy is every other day because it's the most beneficial way of absorbing iron. Too much in gut will not absorb. During pregnancy: status quo is every other day.

  • Why do endurance athletes tend to have lower hemoglobin levels? What is the science behind it?
    • Most of time low hemoglobin is due to female endurance athletes being in low energy state which leads to endocrine disruption. When they are on the low end of iron that is really too low for them. Metabolic shift of iron metabolism for endurance athletes is because they don't have enough fuel to support the endocrine system.

  • To clarify a point on creatine, it is correct that women have 70-80% stores of creatine?
    • Correct

  • For women on BC, does this affect when you should supplement with Creatine?
    • Steady state hormone profile on OC so it is different. Taking 3-5 g per day of creatine while on OC is the best so you don't have a hormonal shift in endogenous responses.

  • Like iron, is there a downside to supplementing with 3-5 grams of creatine per day during the follicular phase or would it be ok to encourage 3-5 grams of supplementation per day, every day in women even though the need increases during the luteal phase?
    • If you forget to start/stop, then use creatine throughout. Creatine is beneficial during luteal. Iron isn't abosrbed in luteal but is in follicular phase.

  • What are the best types of iron and creatine? Also can Vit D supplementation help with heavy bleeding?
    • Vit D supplementation doesn't have anything to do with heavy bleeding. Fixes are IUD with progestin, progestin and mini pill, and anticoagulants used at onset of bleeding. Vitamin D being low will affect iron absorotion (low vitamin D increases inflammation which upregulates hepcidin). Monohydrate for creatine. Ferrous fumarate or glycanate for iron.

  • How can you time FE/Creatine supplementation for women who do not have regular cycles?
    • If you are treacking and are irregular with cycle then start with iron every other day. Take for 14 days, then take creatine until next bleed.

  • How important is it to follow these supplementations if you are not an athlete, but still train for fun a few days a week?
    • Use iron supplement if you have an iron deficiency. Whether you are an athlete or not you can use 3-5 g of creatine.Women who used creatine got out of depressive episodes faster than on SSRIs since it is so important for brain health.

  • What about iron and creatine for post menopausal women?
    • Yes - the thing is that the first two years after onset, may find to be deficient due to systemic inflammation 4-5 years prior to and lasts for two years after onset. No inflammatory responses so women can get overloaded if they continue to supplement with iron. Creatine they can continue taking.

  • Regarding master’s female athletes please discuss hormone replacement. Patches vs pills. Both estrogen and testosterone; can both be replaced.
    • This is a whole other presentation - It's not hormone replacing; there's a difference. Hormones taken have different impacts. Slow down body fat gain and lean mass loss, but dont do much for bone density or to change body composition with training. What you should use - find someone/GP who specializes in hormones and menopasue.

  • For creatine supplementation: can the dose be used each day throughout the month or strategically used during phases of the cycle?
    • Both- for general health to improve creatine stores for overall energy the 3-5 g per day works. If you are looking to strategically for training blocks then dose two times of 5 g per day for acute load and drop back down to 3-5 g per day.

  • What about an oral progesteron versus an IUD? any difference in the effects? And does this added progesterone effect estrogen in any way?
    • Mini pill (progesterone only) has less systemic effects than IUD because IUD is localized and really effects endothelial lining. Oral progesterone effects autonomic nervous system- direct effect on heart rate variability, respiratory rate, and increases core temperature.

  • Are the iron supplementation recommendations the same as described (every other day from first day of period to ovulation)if someone is diagnosed with low ferratin/low iron levels?
    • Yes- it's the amount you take that differs.

  • What health/performance implications are present if an athlete stays on her OC straight through and never gets a bleed?
    • This is still being researched. Endocrinologists say it mimics a womans cycle. Implications on performance: there are negative indicators with regard to aerobic capacity and developing strength. Lots of things to consider especially with the formulation. Your body needs a break. Long term affect from health standpoint, there is none. Athletic standpoint, it is long overdue for literature.

  • Should women completely avoid iron supplementation in the luteal phase? Is there a small amount of absorption happening, or is it truely not bioavailable at this time?
    • You can but it is not that effective. If looking at cost of supplementation, then work with GP to make sure its working for you.

  • If an athlete experiences dehydration and constipation during their menstrual cycle are there any recommendations to combat this?
    • Putting a little bit of salt in the water you drink (1/16 tsp salt in 16 oz water). You will absorb more of the water.

  • For weight specific sports, what effect would the phases have on implementing a water load/cut?
    • Estrogen elevation elevates water storage. Increasing crucerferous veggies or taking DIM as a supplement will mitigate estrogen effects- will reduce bloating. Can also increase magnesium and omega 3 which will counter prostaglandins that also increase water retention.

  • Is there evidence to support that increasing protein during the luteal phase helps support growth/maintenance of muscle tissue in relation to the catabolic effects of progesterone?
    • There is and has to do with timing. Progesterone is catabolic and amino acids used during exercise so need to time protein post exercise for Muscle protein synthesis. If delaying, not as much of benefit as it does when dosing around training.

  • What about menopausal women using pellet hormones? Are you seeing issues with higher BG levels?
    • She hasn't looked into this, unsure. Depends on how your body responds to the formulation. Pros and cons for all.

  • What is the reasoning for taking iron supplements every other day? What would be the downside of taking it every day--does this cause less absorption/ upregulate hepcidin?
    • Every other day shows better iron absorption because you have less hepcidin response, every day shows too much iron and can't absorb it.

  • Is there a reference guide of practitioners with expertise in female specified hormone therapy? Ie board certification
    • Endocrinologists that specialize in menopause. Look for board certified or fertility endocrinologists.

  • What about the Depo shot (depo-provera) for birth control? Does the female still have the hormonal cycle similar to the IUD?
    • You do with Depo. It is progestin only. With Depo and implant, efficacy declines after a year so you can start tracking ovulation then too.

  • Would women with anemia or diagnosed iron deficiency follow the same every other day supplementation?
    • yes- how much you take changes.