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Zhang Y, Li F, Cheng Y, Zhu J, Li Y, Zhao H, Song J, Yin J, Yang B, Kuang H. A novel way of regression of pregnant corpus luteum during parturition in mice: The ferroptosis associated with NCOA4-mediated ferritinophagy. Biochem Pharmacol 2025; 236:116910. [PMID: 40174644 DOI: 10.1016/j.bcp.2025.116910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Revised: 03/12/2025] [Accepted: 03/26/2025] [Indexed: 04/04/2025]
Abstract
Numerous studies have shown that inappropriate regression of corpus luteum would lead to adverse pregnancy outcomes during gestation. However, the detailed mechanisms and types of programmed cell death involved in the regression of pregnant corpus luteum are largely unknown. Here, we investigated whether ferroptosis and ferritinophagy were involved in luteal regression during parturition in mice and related mechanisms. The results showed that ferroptosis and ferritinophagy were both involved in luteal regression during mice peri-parturition in vivo. Erastin (ferroptosis agonist) treatment significantly accelerated luteal regression and induced premature labor in pregnant mice. PGF2α treatment induced the ferroptosis and ferritinophagy of luteal cells in vitro. Nevertheless, inhibition or promotion of ferroptosis significantly altered the states of PGF2α-induced luteal cell viability and ferroptosis. Furthermore, inhibition of autophagy (3-methyladenine co-treatment) alleviated PGF2α-induced ferritinophagy and ferroptosis of luteal cells, and knockdown of NCOA4 reduced the degradation of FTH1 and the level of ferroptosis of luteal cells induced by PGF2α. In summary, our current data demonstrated that the ferroptosis associated with NCOA4-mediated ferritinophagy was a novel way of luteal regression during peri-parturition in mice. Targeting ferroptosis in the corpus luteum may be a therapeutic strategy for preventing luteal insufficiency in the future.
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Affiliation(s)
- Yulu Zhang
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China.
| | - Fei Li
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China
| | - Yanmin Cheng
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China
| | - Jun Zhu
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China
| | - Yue Li
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China
| | - Hongru Zhao
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China
| | - Jiahao Song
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China
| | - Jiting Yin
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China
| | - Bei Yang
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China.
| | - Haibin Kuang
- Department of Physiology, School of Basic Medical Sciences, Jiangxi Medical College, Nanchang University, Jiangxi 330006, PR China.
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Salamunes ACC, Williams NI, De Souza MJ. Are menstrual disturbances associated with an energy availability threshold? A critical review of the evidence. Appl Physiol Nutr Metab 2024; 49:584-598. [PMID: 38194640 DOI: 10.1139/apnm-2023-0418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Exercising women have a high prevalence of menstrual disturbances. In 2003, it was suggested that disruption in luteinizing hormone (LH) pulsatility occurs below a threshold of energy availability (EA) of 30 kcal/kg lean body mass (LBM)/day. This paper is a critical review of the evidence regarding the theory that disruptions to the reproductive axis and menstrual disturbances occur below the proposed threshold. Short-term laboratory studies demonstrated that 4-5 days of an EA below 30 kcal/kg LBM/day, induced with or without exercise, decreased serum triiodothyronine and LH pulse frequency, and increased LH pulse amplitude in sedentary, regularly menstruating women. Fewer studies have investigated downstream ovarian effects after long-term exposure to low EA. The Sargent Camp Study was the first randomized trial that induced luteal phase defects, delayed menses, and anovulation by causing weight loss (-4 ± 0.3 kg) with an abrupt increase in exercise volume for two menstrual cycles. The BioEnergetics Study was a randomized controlled trial that induced varying levels of energy deficits by manipulating energy intake and expenditure for three menstrual cycles. LH pulse frequency and triiodothyronine decreased, and 57% of women developed luteal phase defects, anovulation, and/or oligomenorrhea. An EA below 30 kcal/kg fat free mass/day increased the chance of experiencing a menstrual disturbance by 50%. However, menstrual disturbances were observed above and below that EA threshold, and changes in LH pulse frequency predicted only luteal phase defects, not oligomenorrhea or anovulation. The proposed EA threshold is not a cut-off below which menstrual disturbances occur, but represents an increased risk of experiencing menstrual disturbances.
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Affiliation(s)
- Ana Carla C Salamunes
- Women's Health and Exercise Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA 16802, USA
| | - Nancy I Williams
- Women's Health and Exercise Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA 16802, USA
| | - Mary Jane De Souza
- Women's Health and Exercise Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA 16802, USA
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Collins LC, Gatta LA, Dotters-Katz SK, Kuller JA, Schust DJ. Luteal Phase Defects and Progesterone Supplementation. Obstet Gynecol Surv 2024; 79:122-128. [PMID: 38377455 DOI: 10.1097/ogx.0000000000001242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Importance Luteal phase defects (LPDs), or an insufficiency of progesterone production during the luteal phase of the menstrual cycle, have been identified as a potential cause of recurrent pregnancy loss (RPL), but its exact contribution to RPL is not well-defined. In addition, the role of exogenous progesterone supplementation during pregnancy remains controversial. Objective The goal of this review is to provide an updated, evidence-based summary of LPD, including prevalence and potential pathophysiologic mechanisms, and to explore the current controversies regarding progesterone supplementation for management and treatment of RPL. Evidence Acquisition A literature review identified relevant research using a PubMed search, Cochrane summaries, review articles, textbook chapters, databases, and society guidelines. Results Endogenous progesterone plays a crucial role in the first trimester of pregnancy, and therefore, insufficiency may contribute to RPL. However, the precise relationship between LPD and RPL remains unclear. Luteal phase defect is primarily a clinical diagnosis based on a luteal phase less than 10 days. Although there may be a possibility of incorporating a combined clinical and biochemical approach in defining LPD, the current lack of validated diagnostic criteria creates a challenge for its routine incorporation in the workup of infertility. Moreover, no treatment modality has demonstrated efficacy in improving fertility outcomes for LPD patients, including progesterone supplementation, whose inconsistent data do not sufficiently support its routine use, despite its minimal risk. It is imperative that women diagnosed with LPD should be worked up for other potential conditions that may contribute to a shortened luteal phase. Future work needs to focus on identifying a reproducible diagnostic test for LPD to guide treatment. Conclusions and Relevance Currently, the perceived relationship between LPD and RPL is challenged by conflicting data. Therefore, patients with an abnormal luteal phase should undergo a thorough workup to address any other potential etiologies. Although supplemental progesterone is commonly utilized for treatment of LPD and RPL, inconsistent supporting data call for exogenous hormone therapy to be only used in a research setting or after a thorough discussion of its shortcomings.
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Affiliation(s)
- Lucas C Collins
- Medical Student (MS2), Duke University School of Medicine, 201 Trent Drive, Durham, NC
| | - Luke A Gatta
- Assistant Professor, Obstetrics and Gynecology, Maternal-Fetal Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | | | | | - Danny J Schust
- Professor, Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, Duke University School of Medicine, Durham, NC
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Stefaniak M, Dmoch-Gajzlerska E, Jankowska K, Rogowski A, Kajdy A, Maksym RB. Progesterone and Its Metabolites Play a Beneficial Role in Affect Regulation in the Female Brain. Pharmaceuticals (Basel) 2023; 16:ph16040520. [PMID: 37111278 PMCID: PMC10143192 DOI: 10.3390/ph16040520] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Premenstrual dysphoric disorder is a female affective disorder that is defined by mood symptoms. The condition is linked to unstable progesterone concentrations. Progestin supplementation is given in cases of threatened or recurrent miscarriage and for luteal phase support. Progesterone is essential for implantation, immune tolerance, and modulation of uterine contractility. For a long time, the administration of progestins was associated with an unfavorable impact on mood, leading to negative affect, and, therefore, was contraindicated in existing mood disorders. Establishing the role of the natural progesterone derivative allopregnanolone in advances in the treatment of postpartum depression has shed new light on the general pathophysiology of mood disorders. Allopregnanolone directly interacts with gamma-aminobutyric acid type A (GABA-A) receptors even at nanomolar concentrations and induces significant anti-depressant, anti-stress, sedative, and anxiolytic effects. Postpartum depression is caused by a rapid drop in hormones and can be instantly reversed by the administration of allopregnanolone. Premenstrual dysphoric disorder can also be considered to result from insufficient neuroactive steroid action due to low progesterone derivative concentration, unstable hormone levels, or decreased receptor sensitivity. The decrease in progesterone levels in perimenopause is also associated with affective symptoms and an exacerbation of some psychosomatic syndromes. Bioidentical progesterone supplementation encounters several obstacles, including limited absorption, first-pass effect, and rapid metabolism. Hence, non-bioidentical progestins with better bioavailability were widely applied. The paradoxical, unfavorable effect of progestins on mood can be explained by the fact that progestins suppress ovulation and disturb the endocrine function of the ovary in the luteal phase. Moreover, their distinct chemical structure prevents their metabolism to neuroactive, mood-improving derivatives. A new understanding of progesterone-related mood disorders can translate the study results from case series and observational studies to cohort studies, clinical trials, and novel, effective treatment protocols being developed.
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Affiliation(s)
- Małgorzata Stefaniak
- Department of Obstetrics and Gynecology Didactics, Medical University of Warsaw, ul. Litewska 14/16, 00-575 Warsaw, Poland
| | - Ewa Dmoch-Gajzlerska
- Department of Obstetrics and Gynecology Didactics, Medical University of Warsaw, ul. Litewska 14/16, 00-575 Warsaw, Poland
| | - Katarzyna Jankowska
- Department of Endocrinology, Centre of Postgraduate Medical Education, ul. Cegłowska 80, 01-809 Warsaw, Poland
| | - Artur Rogowski
- Department of Minimally Invasive and Endoscopic Gynecology, Military Institute of Medicine, ul. Zegrzyńska 8, 05-119 Legionowo, Poland
| | - Anna Kajdy
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, ul. Żelazna 90, 02-004 Warszawa, Poland
| | - Radosław B. Maksym
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, ul. Żelazna 90, 02-004 Warszawa, Poland
- Correspondence:
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Bethea CL, Cameron JL. Neuro-pharmacological reinstatement of ovulation and associated neurobiology in a macaque model of functional hypothalamic amenorrhoea. Hum Reprod 2021; 36:175-188. [PMID: 33319240 DOI: 10.1093/humrep/deaa296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 09/23/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the underlying neuropathology in a cynomolgus macaque model of functional hypothalamic amenorrhoea (FHA) and can it be normalized to restore ovulation? SUMMARY ANSWER Anovulatory monkeys exhibited increased hypothalamic norepinephrine (NE), kisspeptin and gonadotropin-releasing hormone (GnRH) in the early follicular phase, but administration of the NE reuptake inhibitor (NRI), reboxetine (REB), restored ovulation during stress and normalized NE, kisspeptin and GnRH. WHAT IS KNOWN ALREADY Female cynomolgus macaques, like women, show individual reproductive sensitivity to modest psychosocial and metabolic stress. During stress, resilient females ovulate through two menstrual cycles whereas stress-sensitive (SS) macaques immediately cease ovulation. On Day 5 of a non-stressed menstrual cycle, resilient macaques have less NE synthesizing enzyme [dopamine β-hydroxylase (DBH)], kisspeptin and GnRH innervation of the medial basal hypothalamus but more endogenous serotonin than SS macaques. Stress increased DBH/NE, kisspeptin and GnRH but did not alter serotonin. STUDY DESIGN, SIZE, DURATION In a longitudinal design, 27 adult (7-13 years) female cynomolgus macaques (Macaca fascicularis) with three different levels of sensitivity to stress were monitored with daily vaginal swabs and frequent serum progesterone (P) measurements. Three 90-day experimental periods called 'Cycle Sets' were monitored. A Cycle Set consisted of one ovulatory menstrual cycle without stress, and two cycles, or 60 days, with modest stress. Each Cycle Set was followed by a rest period. During a Cycle Set, individuals were either untreated (placebo) or administered escitalopram (CIT) or REB. Ultimately, half of each sensitivity group was euthanized during stress with CIT or REB treatment and the hypothalamus was obtained. Neurobiological endpoints were compared between CIT and REB treatment groups in stress resilient and SS monkeys. PARTICIPANTS/MATERIALS, SETTING, METHODS The monkeys were housed at the University of Pittsburgh primate facility for the duration of the experiments. Upon euthanasia, their brains and serum samples were shipped to the Oregon National Primate Research Center. The hypothalamus was examined with immunohistochemistry for the expression of DBH (a marker for NE axons), kisspeptin and GnRH. P was measured in the serum samples by radioimmunoassay. MAIN RESULTS AND THE ROLE OF CHANCE Daily administration of REB restored ovulation in 9 of 10 SS animals during stress. Of note, REB significantly increased P secretion during stress in the most sensitive group (P = 0.032), which indicates ovulation. CIT lacked efficacy. REB significantly reduced DBH/NE, kisspeptin and GnRH axon density in the hypothalamus relative to CIT treatment (P = 0.003. 0.018 and 0.0001, respectively) on Day 5 of the menstrual cycle in resilient and sensitive groups. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION The US FDA has not approved REB for human use, although it is used in Europe for the treatment of depression/anxiety as EdronaxTR. Whether REB could be useful for the treatment of FHA in women has not been determined. WIDER IMPLICATIONS FOR THE FINDINGS The use of an NRI to treat FHA is a novel approach and the potential reinstatement of ovulation could be straightforward compared to current treatment protocols. The underlying neurobiology provides a compelling case for treating the origin of the pathology, i.e. elevated NE, rather than circumventing the hypothalamus altogether with gonadotropins, which have associated risks such as hyperstimulation syndrome or multiple births. STUDY FUNDING/COMPETING INTEREST(S) Portions of this study were supported by NIH grant HD062864 to C.L.B., NIH grant HD62618 to J.L.C. and C.L.B. and 1P51 OD011092 for the operation of the Oregon National Primate Research Center. There were no competing interests.
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Affiliation(s)
- Cynthia L Bethea
- Division of Reproductive Sciences, Oregon National Primate Research Center, Beaverton, OR 97006, USA.,Division of Neuroscience, Oregon National Primate Research Center, Beaverton, OR 97006, USA.,Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR 97201, USA
| | - Judy L Cameron
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15261, USA
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Diagnosis and treatment of luteal phase deficiency: a committee opinion. Fertil Steril 2021; 115:1416-1423. [PMID: 33827766 DOI: 10.1016/j.fertnstert.2021.02.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 11/21/2022]
Abstract
Luteal phase deficiency (LPD) is a clinical diagnosis associated with an abnormal luteal phase length of ≤10 days. Potential etiologies of LPD include inadequate progesterone duration, inadequate progesterone levels, or endometrial progesterone resistance. LPD has not only been described in association with medical conditions but also in fertile, normally menstruating women. Although progesterone is important for the process of implantation and early embryonic development, LPD has not been proven to be an independent entity causing infertility or recurrent pregnancy loss. Controversy exists regarding the multiple proposed measures for diagnosing LPD and, assuming it can be diagnosed accurately, whether treatment improves outcomes. This document replaces the document entitled "Current clinical irrelevance of luteal phase deficiency: a committee opinion," last published in 2015 (Fertil Steril 2015;103:e27-e32).
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chen J, Qiu Q, Lohstroh PN, Overstreet JW, Lasley BL. Hormonal Characteristics in the Early Luteal Phase of Conceptive and Nonconceptive Menstrual Cycles. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/107155760301000106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | - James W. Overstreet
- Center for Health and the Environment, University of California, Davis, Davis, California; Division of Maternal-Fetal medicine, Department of Obstetrics and Gynecology, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Bill L. Lasley
- Center for Health and the Environment, University of California, Davis, Davis, California; Division of Maternal-Fetal medicine, Department of Obstetrics and Gynecology, University of Ottawa/The Ottawa Hospital, Ottawa, Ontario, Canada; Center for Health and the Environment, University of California at Davis, One Shields Avenue, Davis, CA 95616-8739
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8
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Current clinical irrelevance of luteal phase deficiency: a committee opinion. Fertil Steril 2015; 103:e27-32. [DOI: 10.1016/j.fertnstert.2014.12.128] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 12/31/2014] [Indexed: 11/29/2022]
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The clinical relevance of luteal phase deficiency: a committee opinion. Fertil Steril 2012; 98:1112-7. [DOI: 10.1016/j.fertnstert.2012.06.050] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 11/15/2022]
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10
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Jones HW. Luteal-phase defect: the role of Georgeanna Seegar Jones. Fertil Steril 2007; 90:e5-7. [PMID: 18001720 DOI: 10.1016/j.fertnstert.2007.08.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 08/14/2007] [Accepted: 08/14/2007] [Indexed: 11/17/2022]
Abstract
The study and treatment of luteal phase defect since the late 1940s, particularly the work of Georgeanna Seegar Jones, are summarized.
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Affiliation(s)
- Howard W Jones
- Eastern Virginia Medical School, Norfolk, Virginia 23513, USA.
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11
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Abbott DH, Foong SC, Barnett DK, Dumesic DA. Nonhuman primates contribute unique understanding to anovulatory infertility in women. ILAR J 2004; 45:116-31. [PMID: 15111731 DOI: 10.1093/ilar.45.2.116] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Anovulatory infertility affects a large proportion of reproductive-aged women. Major improvements in successful clinical treatment of this prevalent disorder in women's health have been made possible because of biomedical research employing nonhuman primates. Experiments on female rhesus monkeys were the first to demonstrate that the key hypothalamic neurotransmitter, gonadotropin-releasing hormone, involved in stimulating pituitary gonadotropin synthesis, storage, and release was bioactive only when released in approximately hourly bursts. This breakthrough in understanding gonadotropin regulation enabled identification of hypogonadotropic, apparently normogonadotropic, and hypergonadotropic forms of anovulatory infertility, and development of appropriate stimulatory or inhibitory gonadotropin therapies. Treatments to overcome anovulatory infertility represent one of the major advances in clinical reproductive endocrinology during the last 25 yr. The future promise of nonhuman primate models for human ovulatory dysfunction, however, may be based on an increased understanding of molecular and physiological mechanisms responsible for fetal programming of adult metabolic and reproductive defects and for obesity-related, hyperinsulinemic impairment of oocyte development.
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Affiliation(s)
- David H Abbott
- Department of Obstetrics and Gynecology, and UW-Madison National Primate Research Center, University of Wisconsin, Madison, USA
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Williams NI, Bullen BA, McArthur JW, Skrinar GS, Turnbull BA. Effects of short-term strenuous endurance exercise upon corpus luteum function. Med Sci Sports Exerc 1999; 31:949-58. [PMID: 10416555 DOI: 10.1097/00005768-199907000-00006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The present study tested whether short-term, abruptly initiated training can cause corpus luteum dysfunction when exercise is limited to either the follicular or luteal phase of the cycle. METHODS Reproductive hormone excretion and menstrual characteristics were studied in sedentary women who exercised only during the follicular (N = 5) or the luteal (N = 4) phase. Six women served as controls, three of whom exercised at a low volume and three who remained sedentary. Weekly progressive increments in exercise volume continued until either ovulation (follicular group) or menses (luteal group) occurred. Physical activity and nutrient intake were closely monitored with the intent to maintain body weight. RESULTS No luteal phase disturbances occurred in any of the control subjects, whereas 40% of follicular and 50% of luteal exercisers experienced luteal defects. The proportion of menstrual cycles disrupted was not different between luteal and follicular exercisers (50% vs 30%, respectively) but was significantly greater than the proportion of cycles disrupted in control subjects (P < 0.05). CONCLUSIONS These results suggest that exposure to abrupt onset of training can alter luteal function, regardless of the menstrual cycle phase in which exercise occurs. This study also demonstrates that a relatively low volume of exercise suffices to induce mild disturbances in luteal function.
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Affiliation(s)
- N I Williams
- Department of Health Sciences, Sargent College, Boston University, MA, USA.
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