disorders of the menstrual cycle in elite female ice hockey players and figure skaters
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Disorders of the Menstrual Cyclein Elite Female Ice Hockey Playersand Figure SkatersE. Egan, T. Reilly, G. Whyte, M. Giacomoni & N.T. Cable
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To cite this article: E. Egan, T. Reilly, G. Whyte, M. Giacomoni & N.T. Cable (2003):Disorders of the Menstrual Cycle in Elite Female Ice Hockey Players and Figure Skaters,Biological Rhythm Research, 34:3, 251-264
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Disorders of the Menstrual Cycle in Elite Female IceHockey Players and Figure Skaters
E. Egan1, T. Reilly1, G. Whyte2, M. Giacomoni3 and N.T. Cable1
1Research Institute for Sport and Exercise Sciences, Liverpool John MooresUniversity, Liverpool, U.K.; 2British Olympic Medical Centre, Middlesex, U.K.;3Laboratoire Ergonomine Sportive et Performance, Université de Toulon-Var,Toulon, France
Abstract
The purpose of this study was to assess and compare the incidence of delayed menar-che and menstrual dysfunction among elite ice hockey players and figure skaters.Forty-three ice hockey players (23.5 ± 4.8 years, 68.2 ± 1.2kg, 1.68 ± 0.01m) and39 figure skaters (17.5 ± 3.4 years, 53.7 ± 5.8kg, 1.64 ± 0.05m) completed a self-administered questionnaire on their menstrual status and history, training regimensand lifestyle. Age at menarche did not differ significantly between ice hockey players(13.3 ± 1.3 years) and figure skaters (13.7 ± 1.4 years). Menarche was unrelated tonationality, vigorous training premenarche or age at which the athlete began her sport,but was correlated with the age at menarche of the athletes’ mothers (r = 0.39, p <0.05). Hormonal contraceptives were used by 35% of ice hockey players and 15% ofthe figure skaters. Amenorrhea and oligomenorrhea were experienced by 7.1% and38.7% of postmenarcheal, ice hockey players and figure skaters respectively not usinghormonal contraceptives. Menstrual dysfunction was associated with both age andage at menarche in the ice hockey players only. Training factors, and psychologicalpressure were perceived by the athletes to contribute to menstrual dysfunction. Agreater training volume, younger age at commencing sport, lower body mass, greatersubjective body image pressure and younger biological and gynaecological age werereported among the figure skaters, and were proposed to explain the higher incidenceof menstrual dysfunction among the figure skaters compared with the ice hockeyplayers. Figure skaters appear at increased risk of amenorrhea and oligomenorrheacompared with ice hockey players, which may be linked to training and physical char-acteristics of the sports.
Keywords: Menarche, menstrual dysfunction, amenorrhea, oligomenorrhea, training,winter sports.
Address correspondence to: Elizabeth Egan, Postgraduate researcher, Research Institute for Sports andExercise Sciences, Liverpool John Moores University, 15-21 Webster Street, Liverpool John Moores UnivL3 2ET, U.K. Tel.: +44 (0)151 231 4341; Fax: +44 (0)151 231 4353; E-mail: [email protected]
Biological Rhythm Research 0165-0424/3403-251$16.002003, Vol. 34 No. 3. pp. 251–264 © Swets & Zeitlinger
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Introduction
The female reproductive years are characterised by cyclical circamenstrual rhythmsresulting in periodic ovulation and menstruation. These processes are controlledintrinsically by negative and positive endocrine feedback loops between the hypo-thalamus, pituitary and ovaries (the hypothalamic-pituitary-ovarian axis). As well asthe traditional reproductive hormones, (gonadotrophin releasing hormone, folliclestimulating hormone, luteinising hormone, oestrogen and progestrone), hormonessuch as melatonin, which control other chronobiological processes, have been pro-posed to be involved in the female reproductive cycle, affecting gonadal growth andfunction (Jafarey et al., 1970). Indeed, the menstrual cycle has previously been pro-posed to coincide with the 28 day cycle of the moon though this is now consideredto be unlikely (Birch, 2000; Reilly, 2000). Many factors appear to control and disruptnormal cyclical menstruation and this disruption and sometimes complete absence ofnormal menstrual function appears pronounced in athletes.
Consequences of disruption to menstrual function include decreased physical per-formance and physical and mental morbidity. The effects of mineral density loss andmicro-architectural deterioration of bone, on resultant injury and future health cannotbe ignored. Other consequences of prolonged hypoestrogenemia include infertility,decreased muscle recovery rates and a risk of premature cardiovascular disease (Hochet al., 2002). Delayed menarche may have similar consequences (Warren, 2002).
Many athletes appear to be susceptible to menstrual disturbances but athletes incertain endurance and aesthetic sports appear to be at an added risk of delayed menar-che (Ross, 1976; Malina, 1979) and menstrual dysfunction (Webb, 1979; Sanborn,1987). Body composition (Feicht, 1978), training volume and intensity (Frisch &McArthur, 1974), menstrual history (Baker et al., 1981), diet (Hill et al., 1980) andstress (Sanders & Bruce, 1999) have all been associated with menstrual dysfunction.These factors, together with age of participants, performance measures and the physical demands of the sport, may explain the sports-specific nature of menstrualdysfunction.
Menstrual dysfunction has often been reported in endurance athletes (Dale et al.,1979; Ronkainen et al., 1984), gymnasts (Robinson et al., 1994), and ballet dancers(Buchanan et al., 1992), with some menstrual disruption also reported in ball gameplayers (Güler & Hasçelik, 1993), and swimmers (Sanborn, 1982). However, the lit-erature on winter sports is limited and the incidence of menstrual dysfunction amongfigure skaters and ice hockey players is unknown. Nevertheless, figure skaters do seemto experience delayed menarche (Ross et al., 1976; Vadocz et al., 2002).
Factors specific to these sports such as training and competing in cooler climatesand in the winter and in countries with altered light-dark cycles may place addedstress on the body and affect melatonin production. Exposure to chemical fumes fromice rinks may also be a risk factor. Figure skaters may be at an added risk because ofthe subjective nature of performance assesment in their event, because they specialiseearly and because they compete in high level of competition at an early age.
This study aimed to examine the existence and sports-specific nature of delayedmenarche and menstrual dysfunction in two winter sports events, namely ice hockey
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and figure skating, sports which differ greatly in their physiological requirements,training regimens, and performance measures.
Materials and Methods
Subjects
Any athlete who was preparing for the 2002 Winter Olympic Games was consideredelite and thus eligible to participate in this study. Written informed consent to par-ticipate was received from 43 ice hockey players (23.5 ± 4.8 years; 68.2 ± 1.2kg; 1.68± 0.01m) and 39 figure skaters (17.5 ± 3.4 years; 53.7 ± 5.8kg; 1.64 ± 0.05m).
Questionnaire
A questionnaire designed to be self-administered was developed and received ethicalapproval from the institution’s Human Ethics Committee. The questionnaire waspiloted for ease of understanding and accuracy among a sample of active universitystudents and adjustments were made accordingly. The questionnaire was distributedvia e-mail to the relevant national governing bodies, with three national ice hockeyteams (Sweden, USA and Canada) and figure skaters from six nations (Finland,Britain, Slovakia, Slovenia, Canada, Switzerland and the Netherlands) completing thequestionnaire in the months immediately prior to and after the 2002 Winter OlympicGames.
The athletes were asked to record their height (cm), mass (kg), body fat (%), ifknown, and date of birth. Typical training weeks were outlined including informationon intensity, frequency, duration and timing of training sessions. Location of trainingduring the winter and summer seasons was also recorded.
Athletes were asked to report the age (in years and months) at which they firstmenstruated (menarche), and to detail their sports participation prior to this event.The athletes were asked how many children they had and if they had ever been diag-nosed with any gynaecological dysfunction. Questions on past and present oral con-traceptive use were also included. Athletes indicated if they considered themselves tohave regular or irregular menstrual cycles, and if they have ever experienced men-strual dysfunction. Amenorrhea was defined as three or less menstruations per yearand oligomenorrhea as cycles of between 45 and 90 days. The term ‘minor menstrualdysfunction’ was used, for the purposes of analysis to describe collectively (i) fre-quently long cycles (cycles of between 35 and 45 days), (ii) frequently short cycles(cycles less than 21 days) and (iii) intermenstrual bleeding (small amounts of bloodloss between ‘real’ periods). The athletes were asked to report the age of menarcheof their female relatives (mother, sisters) if known and if they suffered any form ofmenstrual dysfunction.
Frequency of smoking and alcohol use, frequency and type of medication andoccurrence of sleep disturbances were reported. Athletes reported past and presentvegetarianism, described their typical dietary patterns and indicated the degree towhich they controlled their diet with respect to type of food and caloric intake. An
Disorders of the Menstrual Cycle 253
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open-ended question assessing the role of body image and pressures to maintain alow body weight in their sport was also included.
Statistical analysis
Results are expressed as mean ± SD. Statistical analysis was carried out using SPSSversion 11. Independent samples t-tests and one-way ANOVAs were used to analysegroup differences between sets of parametric data and Mann-Whitney and Kruskal-Wallis tests were applied to non-parametric data. When significance was found, aTukey post-hoc test was performed. A Spearman’s non-parametric two-tailed corre-lation was applied to correlate the data. Statistical significance was accepted at a confidence level of P < 0.05 (*) and P < 0.001 (**).
Results
Selected anthropometric characteristics and training data for the study groups areshown in Table 1. The ice hockey players were older, taller, weighed more and had agreater BMI than the figure skaters. Body fat data were only available for a smallnumber of athletes and were discarded due to the varying measurement techniquesused.
The ice hockey players had more years experience than the figure skaters and 22(51%) of them had previously competed at an Olympic Games (prior to 2002); bycontrast, none of the figure skaters had competed in a precious Olympic Games. Allathletes had competed at an international level and had been training for the 2002Olympic Games. All the ice hockey players were on teams which had qualified for
254 E. Egan et al.
Table 1. Characteristics of ice hockey players and figure skaters (mean ± SD).
Ice FigureHockey Skating
AntropometryAge (years)** 23.5 ± 4.8 17.5 ± 3.4Mass (kg)** 68.2 ± 1.2 53.7 ± 5.8Height (m)* 1.68 ± 0.01 1.64 ± 0.05BMI (kg·m-2)** 24.1 ± 0.4 19.9 ± 1.3
TrainingTraining sessions/week (no.)** 8.1 ± 1.8 13.8 ± 4.0Experience (years)* 15.1 ± 5.2 12.2 ± 3.5Age started sport (years)** 8.2 ± 3.1 5.3 ± 1.2Duration of competition season (months) 6.5 ± 1.0 6.1 ± 1.3
**denotes statistical significance at the 0.001 significance level and *denotes significance atthe 0.05 significance level.
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the 2002 Games, and 3 (8%) of the figure skaters had competed in the 2002 Games.Figure skaters participated in a greater number of training sessions per week. For theice hockey players, the competitive season lasted marginally longer than for figureskating, consisting of approximately 50 games in its 6-month duration, compared with5–13 competitions for the figure skaters. Nine of the hockey players played othersports, seven in other team sports such as football and softball. One of the figureskaters also participated in football. Half the ice hockey players (n = 22) and 72% of the figure skaters participated in some form of psychological training and/or relaxation sessions.
All ice hockey players and 37 (95%) of the figure skaters reported having reachedmenarche. The two figure skaters who had not reached menarche were aged 12.2 and13.4 years. In those who had reached menarche, age was reported to the nearest monthby 28%, in whole years by 64% and was not reported by 9% of the athletes. No indi-cation of the confidence of recall of these results was given.
Mean age at menarche for the ice hockey players was 13.3 ± 1.3 years and rangedfrom 9.5 to 15 years. Age at menarche was slightly, and not significantly, older in thefigure skaters (13.7 ± 1.4 years) and ranged from 11 to 19 years. Median and modalvalues for the ice hockey players were 13.0 and 14.0 years respectively and 13.0 and13.0 years for the figure skaters. A graphical representation of the distribution of ageat menarche for both sports is given in Figure 1. Fifteen percent of the ice hockeyplayers and 18% of the figure skaters did not reach menarche until after their fifteenthbirthday. One figure skater was 19 years old at menarche.
Participation in vigorous prepubertal training did not delay menarche in either of the sports. Nationality or level of competition prior to menarche was not associ-ated with age at menarche (P > 0.05). One factor which was associated with age at menarche, however, was the age at menarche of the athletes’ mother (r = 0.39, P < 0.05).
Disorders of the Menstrual Cycle 255
Figure Skating
Ice Hockey
Figure 1. Box plot of menarcheal ages of the athletes showing maximum and minimumvalues, interquartile ranges and median value.
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The ice hockey players participated in a total of 17 different sports covering abroad variety of skills and physical requirements prior to menarche. Fourteen hascompeted at a national or international level. The figure skaters, on the other hand,specialised much earlier. Only three athletes trained for sports other than figureskating before menarche (one in apparatus gymnastics and two in football). Thirteen skaters had competed at an international level at their chosen sport prior tomenarche.
Fifteen (34.9%) of the ice hockey players and six (15.4%) of the figure skaterswere using hormonal contraceptives. The ice hockey players all used either phasic orcombined type pills while half the figure skaters on hormonal contraceptives used‘progesterone-only’ pills or injections. Ten athletes used hormonal contraceptives forregulating of the cycle, indicating the extent to which pill use may mask the true inci-dence of menstrual dysfunction. A further eight (18.6%) ice hockey players and 3(7.7%) figure skaters had previously used oral contraceptives for a duration ofbetween 2 and 96 months.
Five ice hockey players considered themselves to have irregular cycles, one hadregular cycles which lasted less than 21 days and the remainder of the athletesreported usual regular cycle length of between 21 and 35 days. Fourteen of the figureskaters reported irregular cycles, one had regular cycles of greater than 35 days, onehad no cycle because of the use of progesterone injection and two had not yet reachedmenarche. The remaining 21 skaters reported usual regular cycles of between 21 and35 days.
One of the ice hockey players suffered an underlying gynaecological dysfunction(hirsutism and polycystic ovary syndrome) and experienced seven years amenorrheaprior to taking the pill. Two more of the pill users previously had amenorrhea and onehad oligomenorrhea. Contraceptive pill use had resulted in regular, though artificial,‘menstruation’ in all. One athlete also had oligomenorrhea prior to having a child.Two (4.7%) ice hockey players reported experiencing oligomenorrhea on an ‘often’basis. Minor menstrual disturbances such as cycles outside the ‘normal’ 21–35 dayrange and intermenstrual bleeding, were ‘rarely’ or ‘sometimes’ experienced by 24 ofthe athletes (57.1%). Ten (23.8%) of the athletes reported never experiencing anyform of menstrual dysfunction.
Of the 37 post-menarcheal figure skaters, three experienced amenorrhea and eightexperienced oligomenorrhea, none of whom were using oral contraceptives. Anotherskater experienced amenorrhea and one had oligomenorrhea because of the contra-ceptive progesterone injection they had received. One athlete also reported regularlyexperiencing short cycles. Minor irregularities were experienced rarely or sometimesby 13 athletes, one of whom was using oral contraceptives.
Excluding the hormonal contraceptive users and those who have not yet reached menarche, 7.1% of the ice hockey players experienced oligomenorrhea,71.5% experienced minor menstrual dysfunction and 21.4% never experienced any form of menstrual dysfunction. In comparison 38.7% of the figure skaters experienced amenorrhea and oligomenorrhea, 38.7% experienced other minor menstrual irregularities and the remaining 22.6% never experienced menstrual dysfunction.
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In those not using oral contraceptives, no significant relationship was foundbetween BMI, body mass, age, gynaecological age, number of years experience attheir sport or age at which they began their sport and the severity of menstrual dys-function (P-values > 0.05). Trends can, however, be seen between the severity of men-strual dysfunction and age and gynaecological age but only in the ice hockey players(Fig. 2). There is also a significant relationship between the number of training ses-sions the athletes participate in and the severity of menstrual dysfunction (P < 0.05).
The athletes were asked to consider a list of factors associated with menstrual dys-function and to indicate which ones they attributed to their own menstrual dysfunc-
Disorders of the Menstrual Cycle 257
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Amen. Oligo. Other None
Tra
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Figure 2. Age and gynaecological age and number of training sessions per week (mean +SD), for ice hockey players and figure skaters grouped according to severity of menstrual dys-function. The groups are 1) amenorrhea (amen.) 2) oligomenorrheic (oligo.), 3) athletes withminor menstrual dysfunction such as frequently long or short cycles or intermenstrual bleed-ing (other) and 4) athletes who never experience any form of menstrual dysfunction (none).Open bars (�) represent the figure skaters and closed bars (�) represent the ice hockey players.
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tion. A breakdown of the results is given in Table 2. Factors relating to training(increased training volume and increased training intensity), were most often reportedby the ice hockey players. Fifty-two percent of the athletes who experienced men-strual dysfunction attributed their menstrual dysfunction to at least one trainingrelated factor, 35% indicated some form of psychological stress and 16% associatedmenstrual dysfunction with an eating/weight related factor. In contrast, the figureskaters were more likely to associate pressure from competition, family, friends, workor study and dietary factors with their menstrual dysfunction. At least one pressure-related factor was reported by 28%, an eating-related factor by 28% and a training-related factor by 12% of the figure skaters. Menstrual dysfunction was reported to bemore common during the summer in this group.
The athletes’ subjective view of how much they controlled their diet is given inFigure 3. A larger percentage of the athletes appear to be moderately or less control-ling for calorie intake than for type of food. Altogether, 68% of the ice hockey playersand 63% of the figure skaters controlled their diet only ‘moderately’ or ‘not at all’with respect to calorie intake. Conversely 68% of the ice hockey players and 51% ofthe figure skaters reported ‘often’ or ‘always’ controlling their diet with respect totype of food. There were no evident differences in subjective control of energy intakeor food type between the two sports.
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Table 2. Factors associated by the athletes with menstrual dysfunction.
Ice Hockey Figure Skating
Factor No. % No. %
Increased training volume 14 45.1 2 8.0Increased training intensity 12 38.7 1 4.0Increased pressure from competition 6 19.4 4 18.0Increased pressure from work/studies 5 16.1 5 20.0Increased pressure from family/friends 3 9.7 2 8.0Changes in body composition 3 9.7 2 8.0Increased competition frequency 2 6.5 0Changes in dietary pattern 2 6.5 3 12.0Caloric restriction 2 6.5 3 12.0Long haul flights 2 6.5 1 4.0Injury 1 3.2 1 4.0Rapid weight loss 1 3.2 2 8.0A particular time of year 1 3.2 4 18.0Sleep deprivation 1 3.2 0New female company 1 3.2 0Gynaecological dysfunction 1 3.2 0Genetic 0 1 4.0
No. indicates the number of athletes indicating each response and % is calculated as percentof those who experience menstrual dysfunction (n = 31).
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The athletes’ perceptions of the role of body image in their sport and perceivedpressure to maintain lean physiques show a stark contrast between the two sports.Many of the ice hockey players believed that body image was not important and thatthe emphasis was on functional body strength, with one of the athletes under somepressure to gain weight. Full clothing worn in competition meant that their body wasnot constantly on show. The following are some typical responses from the ice hockeyplayers:
‘I have to be fit and filled with energy to make results, it’s important to eat well’
‘No, not as important as in other sports because when we are competing and in the public eye, we havefull hockey equipment on so people can’t really see our body composition.’
‘Not a huge role but still very present. Pressure to be in best shape possible — emphasis on lean bodyweight — some competition among athletes. Focus on being fit — caution about body image.’
While 11 of the ice hockey players reported that body image played no part intheir sport, all the figure skaters reported that body image and/or low body weightplayed some role in their sport, particularly in relation to performing jumps, becauseof the costumes worn in competition, in response to monthly weight control prac-tices, and because low body weight was perceived to look better from a competitiveperspective. Some of the athletes reported no pressure from coaches, federation orfellow skaters while others reported immense pressure from coaches to lose and/ormaintain very low body weights and that they constantly needed to diet. Commentsranged from:
‘Yes it is important, no pressure’
to
‘Yes, there is a lot of pressure because body image does play a big role. My coach once told me to losesome weight because I had/have too big a tummy’
and
‘Long lean physiques is important. Coaches constantly remind students that they need to lose weight. Otherathletes comment on competitors weight/fatness. Disordered eating is common.’
Disorders of the Menstrual Cycle 259
Typeoffood
Calorieintake
IH
FS
Not at all
Moderately
Often
Always
0% 20% 40% 60% 80% 100%
IH
FS
Figure 3. Percentages of athletes controlling their diet with respect to calorie intake and typeof food. FS = figure skating, IH = ice hockey.
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Discussion
The key to determining those factors which predispose an athlete to menstrual dys-function may lie in a close examination of the characteristics of sports in which thereis a high incidence of menstrual dysfunction. Figure skating and ice hockey are twosports which differ greatly in their physical demands, performance outcomes andtraining requirements and subsequently as shown in this study, their association withmenstrual dysfunction.
Previous research has indicated age at menarche to be sports specific (Ross et al.,1976; Malina et al., 1979). While ice hockey players on average reached menarcheapproximately 4 months before their ice skating counterparts, this trend was not sig-nificant. Previous studies examining age at menarche in figure skaters reported meanages at menarche ranging from 12.4 years (Ziegler et al., 1998) to 14 years (Ross etal., 1976). In the study by Zeigler and colleagues (1998), 23% of the sample had notyet reached menarche which may have some effect on underestimation of the groupmean. Since both the athletes in the present study who had not reached menarchewere younger than the group mean age at menarche, this was not expected to havean effect on the overall age at menarche. Another explanation for the discrepanciesin reported mean age at menarche is the level at which the athletes compete, withelite international athletes reaching menarche later than athletes participating at alower level. This factor may indicate that delayed menarche enhances performance ormay be that those who reach the highest level in their sport trained vigorously priorto menarche and that this delayed their menarche. All the figure skaters in the presentsample competed at a national or international level, and had aspirations to competeat the Winter Olympic Games, though only three participated in the 2002 OlympicGames. In contrast, all the ice hockey players were on national squads which hadqualified for the Games, though the data were not available to calculate the exact per-centage of the group that competed in Salt Lake City. There are no previous data onage at menarche in ice hockey players with which the current observations can becompared. Premenarcheal training, level of competition prior to menarche and nation-ality appeared to have no effect on the age at menarche. When the volume of pre-menarcheal training was considered (reported number of sessions per week), therewas a significant correlation, suggesting that there is some link between premenar-cheal training and age at menarche. It is, however, very difficult to quantify preme-narcheal training and thus to analyse the true relationship between training and thetiming of menarche, if indeed there is one. There appears to be a familial resemblancein age at menarche (Malina et al., 1994). Age at menarche was significantly corre-lated with age at menarche of the athletes’ mothers in the current samples, thoughsome of the strength of this correlation may be due to the athlete, and not the motherherself reporting the age, the age being reported in years rather than months, and thelength of recall associated with mothers’, compared with athletes’ age at menarche.Familial resemblance has previously been found between university level athletes andtheir mothers (Malina et al., 1994). It is also difficult to say if this is a genetic factoror if it is because their mothers were also athletes. We have not details on the activ-ity level of their mothers.
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Fifteen percent of ice hockey players and 18% of figure skaters were 15 years oldor more when they reached menarche. These values compare with group values of16.4% and 17.9% found in national (Malina et al., 1978) and Olympic (Malina et al.,1979) athletes, respectively. A breakdown of these results, however, shows that 5–6%of athletes in ball sports reached menarche after 15 years, while the proportion offigure skaters and gymnasts reaching menarche at or after their 15th birthday wasmuch higher (44–54%).
The incidence of menstrual dysfunction in figure skaters is similar to that foundin gymnasts (Robinson et al., 1994). Slemenda and Johnston (1993) have previouslyfound disruption to menstrual patterns in 40% of their sample examining bone healthin figure skaters. The incidence of menstrual dysfunction in ice hockey players islower than that found in elite and/or Olympic volleyball, basketball players or athletes in other ball games (Malina et al., 1978; Ronakainen et al., 1984; Güler &Hasçelik, 1993), suggesting that certain factors within certain types of sports mayaffect menstrual dysfunction and how it compares with similar sports. A number ofcharacteristic differences between the two elite winter sports groups were evident.These include age, mass, BMI, number of training sessions per week, age at entry inchosen sport, attitudes towards body image, and slight difference in age at menarche.
Body mass, body fat, weight loss and nutritional factors have previously been asso-ciated with menstrual dysfunction. The suggestion that a critical percent body fat isnecessary to commence and maintain menstruation (Frisch & McArthur, 1974) hasbeen discredited (Sanborn et al., 1987). Unfortunately body fat estimates were onlyavailable for a small number of this group. Neither body mass index nor body mass,however, seemed to affect menstrual function. Factors which appeared to affect men-strual function were age and gynaecological age. The first few years of menstruationhave been associated with irregular cycles in non-athletic populations, and youngerathletes have previously been shown to have increased susceptibility to menstrual dys-function (Harlow & Emphross, 1995). Athletes most often reported that increasedtraining volume and intensity and increased pressure caused their menstrual dys-function. This observation is in agreement with other research (Loucks, 1990).
Body image concerns do not appear pronounced in ice hockey, due in part to thefact that full clothing is worn by the athletes in competition. The figure skaters aresubjected to pressure from adjudicators, coaches, and fellow athletes. Their physiqueis constantly visible in training and in competition, and how they look is an impor-tant part of competition outcomes. In spite of this, there was no reported differencein the percentage of athletes who often or always controlled their calorie intakebetween the two groups. One of the reported difficulties in diagnosing disorderedeating is a denial by the athlete themselves of such practices. The possible associa-tion between body image concerns, disordered eating and menstrual dysfunction mayhelp explain the high incidence of amenorrhea and oligomenorrhea among the figureskaters.
In addition to being more susceptible to menstrual dysfunction, the figure skaterswere also less likely than the ice hockey players to use hormonal contraceptives andhalf of those who did, used progesterone-only pills or injections. The associationbetween hypoestrogenemic states and diminished bone health (Miller & Klibanski,
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1999), suggests that figure skaters would be at a higher risk of osteopenia and boneinjury, both because of menstrual dysfunction and their choice of hormonal contra-ceptives.
As with all studies of this nature, there is a likelihood that athletes with menstrualdysfunction are more likely to respond. This was largely avoided among the hockeyplayers since the questionnaire was distributed to, and returned by, a large proportionof the Swedish and American squads and thus results for these teams at least are rep-resentative of elite Olympic level ice hockey teams. Another limitation of question-naire type analysis of menstrual dysfunction is that subtle changes in luteal function are not identified and thus the true incidence of menstrual disturbances isunderestimated.
Conclusions
Elite figure skaters reported a higher incidence of menstrual dysfunction, a greater age at menarche and a lower incidence of oral contraceptive use, than eliteice hockey players. Characteristic differences between the two groups — such as age,weight, BMI, degree of specialisation before puberty, number of training sessions perweek, and pressure to maintain low body mass — may explain to some extent thesedifferences.
Acknowledgements
The authors thank the International Olympic Committee’s Medical Commission inassociation with Pfizer for funding this research, the subjects for their participationand all those who helped to distribute the questionnaire including Murray Costello atthe International Ice Hockey Federation and Sharon Gill at the International SkatingUnion.
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