The paper by Hagmar et al. (3) in this issue of Medicine & Science in Sports & Exercise ® describes a condition in which hyperandrogenism led to menstrual dysfunction in female Olympic athletes. The investigators used a gynecological examination including ultrasonography to determine that the most common cause of menstrual dysfunction in this group of elite women athletes was polycystic ovary syndrome (PCOS). This study supports earlier studies by this same investigative group indicating that the role of hyperandrogenism in menstrual dysfunction extends to many active women (4,5). In an interesting twist, the greater hyperandrogenism in these athletes may confer an athletic advantage (4) because the combination of hyperandrogenism and exercise may help athletic women with PCOS maintain their lean phenotype. The data of Hagmar et al. suggest that reproductive dysfunction in female athletes is more often associated with PCOS than with hypothalamic inhibition. Most importantly, their paper suggests that PCOS can be missed during the evaluation of athletes with irregular menstrual cycles. The missed diagnosis of PCOS in an athlete, or in any woman, can have dangerous consequences.
Polycystic ovary syndrome is the most common reproductive endocrinopathy in young women (1), affecting 6%-10% of women of reproductive age (6). The morbidity associated with PCOS is significant and extends well beyond menstrual disturbances and reproduction, making proper diagnosis essential. The reproductive consequences are well known and include irregular menses, infertility, and recurrent pregnancy loss. Recently, it has become apparent that insulin resistance is associated with PCOS and that women with PCOS are at increased risk for diabetes. One-third of nondiabetic women with PCOS develop the metabolic syndrome by 49 yr, although most of these women develop this before they reach the age of 40 yr (2). The androgen excess seen in PCOS can also cause acne and hirsutism. In addition, PCOS is associated with increased risk of endometrial cancer, cardiovascular disease, and poor lipid profiles.
Because there is no definitive test for exercise related menstrual disturbances, this diagnosis is one of exclusion. The accuracy of the diagnosis depends on the extent of the evaluation. Unfortunately, this diagnosis may be made prematurely in athletes; the evaluation rarely includes the use of ultrasound, which can reveal the classic polycystic-appearing ovaries. In addition, the classic signs and symptoms of PCOS may be masked by the decreased hypothalamic drive associated with exercise. The decreased follicle-stimulating hormone and luteinizing hormone production that is seen in some athletes with a component of chronic energy deficiency can mask the presentation of PCOS in women with both PCOS and exercise-related menstrual disturbances.
Clinicians may mistakenly assume that if the athlete is normal weight or slightly underweight she does not have PCOS because obesity or overweight is common in women with the syndrome. However, only about 50% of women with PCOS are obese, and the condition is underdiagnosed in women with low or normal body mass index. In the study of Hagmar et al. published here, women with and without PCOS have similar body mass index and percent body fat.
The misdiagnosis of PCOS in athletes may lead to behavior that will worsen the disease or delay treatment. Weight gain is detrimental in women with PCOS, and attempts to limit exercise or increase energy availability may worsen the symptoms and the progression of the disease. Further, failure to diagnose insulin resistance will likely delay appropriate treatment with insulin-sensitizing agents.
We should focus on making accurate diagnosis in athletic women with menstrual dysfunction. In addition to PCOS, other common reasons for menstrual disturbances in young women are thyroid disease, elevated prolactin, and anatomic causes such as polyps and fibroids. Endometrial cancer is uncommon in young women but can also lead to menstrual disturbances. The current study demonstrates that we have been remiss in giving these women adequate medical care. Appropriate evaluation of menstrual irregularity in female athletes should include an evaluation of androgen levels and an ultrasound of the ovaries.
1. Barontini M, Garcia-Rudaz MC, Veldhuis JD. Mechanisms of hypothalamic-pituitary-gonadal disruption in polycystic ovarian syndrome. Arch Med Res
2. Ehrmann DA, Liljenquist DR, Kasza K, Azziz R, Legro RS, Ghazzi MN. Prevalence and predictors of the metabolic syndrome in women with polycystic ovary syndrome. J Clin Endocrinol Metab
3. Hagmar M, Berglund B, Brismar K, Hirschberg AL. Hyperandrogenism may explain reproductive dysfunction in Olympic athletes. Med Sci Sports Exerc
4. Rickenlund A, Carlstrom K, Ekblom B, Brismar TB, von Schoultz B, Hirschberg AL. Hyperandrogenicity is an alternative mechanism underlying oligomenorrhea or amenorrhea in female athletes and may improve physical performance. Fertil Steril
5. Rickenlund A, Thoren M, Carlstrom K, von Schoultz B, Hirschberg AL. Diurnal profiles of testosterone and pituitary hormones suggest different mechanisms for menstrual disturbances in endurance athletes. J Clin Endocrinol Metab
6. Tsilchorozidou T, Overton C, Conway GS. The pathophysiology of polycystic ovary syndrome. Clin Endocrinol