Clinical tests explain blunted cortisol responsiveness but not mild hypercortisolism in amenorrheic runners

Moderate Weight Loss is associated with Reductions in LH Pulse Frequency and Increases in 24-hour Cortisol with no change in Perceived Stress in Young Ovulatory Women

OBJECTIVE

Determine the potential role of cortisol as an indicator of both metabolic and psychosocial stress and its relation to LH pulse dynamics during a three-month diet and exercise intervention causing moderate weight loss.

METHODS

Secondary analysis of a randomized, controlled trial that demonstrated the causal role of low energy availability in the disruption of the menstrual cycle. Twenty-one women aged (18-24 yrs), BMI (21.7± 1.9 kg·m^-2), completed a baseline menstrual cycle and three intervention menstrual cycles of a controlled diet and supervised exercise program. Twenty-four-hour LH pulse dynamics (q10 min) and diurnal patterns of cortisol (q60 min) as well as Perceived Stress Scale scores were determined in the early follicular phase prior to the intervention and in the post intervention cycle. Pre to post comparisons were determined with paired t-tests, and Pearson bivariate correlations assessed associations.

RESULTS

Subjects lost weight (-2.8±1.97 kg) and LH pulse frequency declined pre=0.79±0.23 pulses·hr^-1 to post=0.60±0.29 pulses·hr^-1 (p=0.014). Weight loss was associated with an increase in cortisol AUC R=-0.473, (p=0.03) and the decline in LH pulse frequency R= 0.523; (p=0.026). Increases in cortisol AUC were associated with declines in LH pulse frequency R=-0.472; (p=0.048). The morning cortisol rise AUC increased from pre=2140±878 µg·dL^-1 · day to post=2556±1067 µg·dL^-1 · day (p=0.034). Changes in PSS were not associated with changes in LH or cortisol.

CONCLUSION

The initial perturbation of LH pulsatility with moderate diet and exercise is associated with metabolically driven increases in cortisol AUC with no influence of psychological stress.

The Specificities of Elite Female Athletes: A Multidisciplinary Approach

Female athletes have garnered considerable attention in the last few years as more and more women participate in sports events. However, despite the well-known repercussions of female sex hormones, few studies have investigated the specificities of elite female athletes. In this review, we present the current but still limited data on how normal menstrual phases, altered menstrual phases, and hormonal contraception affect both physical and cognitive performances in these elite athletes. To examine the implicated mechanisms, as well as the potential performances and health risks in this population, we then take a broader multidisciplinary approach and report on the causal/reciprocal relationships between hormonal status and mental and physical health in young (18-40 years) healthy females, both trained and untrained. We thus cover the research on both physiological and psychological variables, as well as on the Athlete Biological Passport used for anti-doping purposes. We consider the fairly frequent discrepancies and summarize the current knowledge in this new field of interest. Last, we conclude with some practical guidelines for eliciting improvements in physical and cognitive performance while minimizing the health risks for female athletes.

Decreased energy availability during training overload is associated with non-functional overreaching and suppressed ovarian function in female runners

Low energy availability (EA) suppresses many physiological processes, including ovarian function in female athletes. Low EA could also predispose athletes to develop a state of overreaching. This study compared the changes in ad libitum energy intake (EI), exercise energy expenditure (ExEE), and EA among runners completing a training overload (TO) phase. We tested the hypothesis that runners becoming overreached would show decreased EA, suppressed ovarian function and plasma leptin, compared with well-adapted (WA) runners. After 1 menstrual cycle (baseline), 16 eumenorrheic runners performed 4 weeks of TO followed by a 2-week recovery (131 ± 3% and 63 ± 6% of baseline running volume, respectively). Seven-day ExEE, EI, running performance (RUN_perf) and plasma leptin concentration were assessed for each phase. Salivary estradiol concentration was measured daily. Urinary luteinizing hormone concentration tests confirmed ovulation. Nine runners adapted positively to TO (WA, ΔRUN_perf: +4 ± 2%); 7 were non-functionally overreached (NFOR; ΔRUN_perf: -9 ± 2%) as RUN_perf remained suppressed after the recovery period. WA increased EI during TO, maintaining their baseline EA despite a large increase in ExEE (ΔEA = +1.9 ± 1.3 kcal·kg fat free mass (FFM)^-1·d^-1, P = 0.17). By contrast, NFOR showed no change in EI, leading to decreased EA (ΔEA = -5.6 ± 2.1 kcal·kg FFM^-1·d^-1, P = 0.04). Plasma leptin concentration mid-cycle and luteal salivary estradiol concentration decreased in NFOR only. Contrasting with WA, NFOR failed to maintain baseline EA during TO, resulting in poor performance outcomes and suppressed ovarian function. ClinicalTrials.gov no. NCT02224976. Novelty: Runners adapting positively to training overload (TO) increased ad libitum energy intake, maintaining baseline EA and ovarian function through TO. By contrast, NFOR runners failed to increase energy intake, showing suppressed EA and ovarian function during TO.

Endocrine Effects of Relative Energy Deficiency in Sport

The term Relative Energy Deficiency in Sport was introduced by the International Olympic Committee in 2014. It refers to the potential health and performance consequences of inadequate energy for sport, emphasizing that there are consequences of low energy availability (EA; typically defined as <30 kcal·kg^-1 fat-free mass·day^-1) beyond the important and well-established female athlete triad, and that low EA affects populations other than women. As the prevalence and consequences of Relative Energy Deficiency in Sport become more apparent, it is important to understand the current knowledge of the hormonal changes that occur with decreased EA. This paper highlights endocrine changes that have been observed in female and male athletes with low EA. Where studies are not available in athletes, results of studies in low EA states, such as anorexia nervosa, are included. Dietary intake/appetite-regulating hormones, insulin and other glucose-regulating hormones, growth hormone and insulin-like growth factor 1, thyroid hormones, cortisol, and gonadal hormones are all discussed. The effects of low EA on body composition, metabolic rate, and bone in female and male athletes are presented, and we identify future directions to address knowledge gaps specific to athletes.

The physiology of functional hypothalamic amenorrhea associated with energy deficiency in exercising women and in women with anorexia nervosa

An energy deficiency is the result of inadequate energy intake relative to high energy expenditure. Often observed with the development of an energy deficiency is a high drive for thinness, dietary restraint, and weight and shape concerns in association with eating behaviors. At a basic physiologic level, a chronic energy deficiency promotes compensatory mechanisms to conserve fuel for vital physiologic function. Alterations have been documented in resting energy expenditure (REE) and metabolic hormones. Observed metabolic alterations include nutritionally acquired growth hormone resistance and reduced insulin-like growth factor-1 (IGF-1) concentrations; hypercortisolemia; increased ghrelin, peptide YY, and adiponectin; and decreased leptin, triiodothyronine, and kisspeptin. The cumulative effect of the energetic and metabolic alterations is a suppression of the hypothalamic-pituitary-ovarian axis. Gonadotropin releasing hormone secretion is decreased with consequent suppression of luteinizing hormone and follicle stimulating hormone release. Alterations in hypothalamic-pituitary secretion alters the production of estrogen and progesterone resulting in subclinical or clinical menstrual dysfunction.

Elite synchronized swimmers display decreased energy availability during intensified training

Elite synchronized swimmers follow high-volume training regimen that result in elevated rates of exercise energy expenditure (ExEE). While adequate energy intake (EI) is important to optimize recovery, a number of sport-specific constraints may lead to chronically low energy availability (EA = EI-ExEE). This study aimed to quantify changes in EA, endocrine markers of energy conservation, and perceived fatigue in synchronized swimmers, during a week of baseline training followed by 4 weeks of intensified training (IT). EI, ExEE, and body composition were measured in nine swimmers at Baseline, midpoint (IT_WK2 ), and end of IT (IT_WK4 ). Waking saliva samples were obtained to measure [leptin]_s , [ghrelin]_s , and [cortisol]_s . Fatigue ratings were provided daily. ExEE increased by 27% during IT. Swimmers increased EI from Baseline to IT_WK2 , but decreased it significantly from IT_WK2 to IT_WK4 . EA, fat mass, and [leptin]_s decreased from Baseline to IT_WK4 , while [ghrelin]_s increased significantly. Fatigue at IT_WK4 was inversely correlated with Baseline EI and EA. The significant decrease in EA was accompanied by endocrine signs of energy conservation in elite swimmers. As perceived fatigue was associated with low EA, particular attention should be paid to these athletes' energy intake during phases of heavy training.

Metabolic and reproductive consequences of the serotonin transporter promoter polymorphism (5-HTTLPR) in adult female rhesus monkeys (Macaca mulatta)

The serotonin (5HT) reuptake transporter (SERT) plays a key role in 5HT homeostasis by recycling 5HT into the presynaptic neurons. Recently, polymorphisms in the length of the promoter region of the gene that encodes SERT have been linked to functional differences in reactivity to psychosocial stress, as the short (s) promoter length allele shows reduced transcriptionally activity in vitro and is associated with reduced 5HT activity and increased vulnerability to affective disorders. Given 5HT's important role in appetite regulation, polymorphisms in the SERT gene could also affect metabolic parameters. In addition, since reduced 5HT activity may also predispose females to reproductive deficits, polymorphisms in the SERT gene may help explain individual differences in ovulatory function. The present study, using a rhesus monkey model, tested the hypothesis that the presence of the s-variant allele would be associated with altered metabolic regulation and impaired ovulatory cycles compared with the l/l genotype. Females homozygous for the long allele in the SERT gene (l/l, n = 19) were compared to those with the s-variant allele (l/s or s/s, n = 20). All females had similar social histories. Body weights (P = 0.026) but not heights (P = 0.618) were significantly lower in s-variant compared to l/l females. In addition, both BMI (P = 0.032) and sagittal abdominal diameters (SAD) (P = 0.031), as indices of adiposity, were significantly lower in s-variant females. Consistent with these differences, fasting and non-fasting levels of leptin were significantly lower in s-variant females (P = 0.002). While there were no genotype differences in non-fasting levels of insulin, s-variant females had significantly lower concentrations of insulin during a fast than did l/l females (P = 0.052). Neither glucose, T 3, T 4, nor ghrelin varied significantly between groups during either the fasted or non-fasted condition (P > 0.05). Analysis of a subset of females indicated that significantly fewer s-variant females (62.5%) exhibited ovulatory cycles than l/l females (100%, P < 0.05). However, there were no differences in serum estradiol or progesterone in l/l females and those s-variant females that did ovulate (P > 0.05). In addition, females with the s-variant genotype also had reduced 5HT activity (P = 0.030), assessed from the acute increase in serum prolactin following the administration of the 5HT reuptake inhibitor, citalopram. Finally, s-variant females were significantly less responsive to glucocorticoid negative feedback (P = 0.030) yet more responsive to corticotropin releasing hormone (CRH, P = 0.016) in terms of plasma cortisol than were l/l females. These data indicate that adult female rhesus monkeys with the s-variant polymorphism in the SERT gene exhibit metabolic and reproductive alterations in conjunction with reduced serotonergic responsivity and increased LHPA activity and suggest the possibility that this genotype may predispose females exposed to psychosocial stressors to further metabolic and reproductive deficits.

Increased cortisol responsivity to adrenocorticotropic hormone and low plasma levels of interleukin-1 receptor antagonist in women with functional hypothalamic amenorrhea

OBJECTIVE

To assess the hypothalamic-pituitary-adrenal (HPA) axis at all levels, to determine the origin of the previously reported hypercortisolism in patients with functional hypothalamic amenorrhea. A secondary aim was to evaluate factors outside the central nervous system which are known to affect the HPA axis, i.e., circulating levels of interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1Ra), and fat mass-adjusted leptin levels, in patients with functional hypothalamic amenorrhea and healthy controls.

DESIGN

Cross-sectional study.

SETTING

Umeå University Hospital, Umeå, Sweden.

PATIENTS

Fifteen subjects with hypothalamic amenorrhea, and 14 age- and weight-matched controls.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

We collected blood samples four times during a 24-hour interval for analysis of cortisol, leptin, IL-1Ra, and IL-6 levels. We performed a low-dose oral dexamethasone test and a low-dose ACTH test. We measured body-fat percentage using a dual-energy X-ray absorptiometer.

RESULTS

Patients with hypothalamic amenorrhea had increased diurnal cortisol levels (P<.001). The cortisol response to intravenous low-dose ACTH was increased in functional hypothalamic amenorrhea patients compared to control subjects (P<.01), but they had similar rates of dexamethasone suppression. Patients with hypothalamic amenorrhea also had decreased diurnal leptin (P<.05), and decreased diurnal IL-1Ra levels (P<.05), compared to controls. Body-fat percentage was the main predictor of leptin levels.

CONCLUSION

The present study suggests novel links for the development of functional hypothalamic amenorrhea, including increased adrenal responsiveness and impairments in proinflammatory cytokine pathways.

Menstrual disorders in athletes

The various menstrual disorders in athletes may reflect different degrees of exposure to a disrupting factor or differences in the susceptibility of various women to disruption. The incidences of these disorders are not well documented, but they appear to be highest in aesthetic, endurance and weight-class sports, and at younger ages, higher training volumes and lower bodyweights. The morbid effects of these disorders include infertility, low bone mass, impaired endothelium-dependent vasodilation, and impaired skeletal muscle oxidative metabolism. The high incidences of menstrual disorders in athletes may derive in part from the self-selection of extraneously affected women into athletics, but many women acquire their menstrual disorders in athletics by failing to adequately increase dietary energy intake in compensation for exercise energy expenditure. Applied research is needed to develop effective dietary interventions that are acceptable to athletes.

Physical activity in the prevention and amelioration of osteoporosis in women : interaction of mechanical, hormonal and dietary factors

Osteoporosis is a serious health problem that diminishes quality of life and levies a financial burden on those who fear and experience bone fractures. Physical activity as a way to prevent osteoporosis is based on evidence that it can regulate bone maintenance and stimulate bone formation including the accumulation of mineral, in addition to strengthening muscles, improving balance, and thus reducing the overall risk of falls and fractures. Currently, our understanding of how to use exercise effectively in the prevention of osteoporosis is incomplete. It is uncertain whether exercise will help accumulate more overall peak bone mass during childhood, adolescence and young adulthood. Also, the consistent effectiveness of exercise to increase bone mass, or at least arrest the loss of bone mass after menopause, is also in question. Within this framework, section 1 introduces mechanical characteristics of bones to assist the reader in understanding their responses to physical activity. Section 2 reviews hormonal, nutritional and mechanical factors necessary for the growth of bones in length, width and mineral content that produce peak bone mass in the course of childhood and adolescence using a large sample of healthy Caucasian girls and female adolescents for reference. Effectiveness of exercise is evaluated throughout using absolute changes in bone with the underlying assumption that useful exercise should produce changes that approximate or exceed the absolute magnitude of bone parameters in a healthy reference population. Physical activity increases growth in width and mineral content of bones in girls and adolescent females, particularly when it is initiated before puberty, carried out in volumes and at intensities seen in athletes, and accompanied by adequate caloric and calcium intakes. Similar increases are seen in young women following the termination of statural growth in response to athletic training, but not to more limited levels of physical activity characteristic of longitudinal training studies. After 9-12 months of regular exercise, young adult women often show very small benefits to bone health, possibly because of large subject attrition rates, inadequate exercise intensity, duration or frequency, or because at this stage of life accumulation of bone mass may be at its natural peak. The important influence of hormones as well as dietary and specific nutrient abundance on bone growth and health are emphasised, and premature bone loss associated with dietary restriction and estradiol withdrawal in exercise-induced amenorrhoea is described. In section 3, the same assessment is applied to the effects of physical activity in postmenopausal women. Studies of postmenopausal women are presented from the perspective of limitations of the capacity of the skeleton to adapt to mechanical stress of exercise due to altered hormonal status and inadequate intake of specific nutrients. After menopause, effectiveness of exercise to increase bone mineral depends heavily on adequate availability of dietary calcium. Relatively infrequent evidence that physical activity prevents bone loss or increases bone mineral after menopause may be a consequence of inadequate calcium availability or low intensity of exercise in training studies. Several studies with postmenopausal women show modest increases in bone mineral toward the norm seen in a healthy population in response to high-intensity training. Physical activities continue to stimulate increases in bone diameter throughout the lifespan. These exercise-stimulated increases in bone diameter diminish the risk of fractures by mechanically counteracting the thinning of bones and increases in bone porosity. Seven principles of bone adaptation to mechanical stress are reviewed in section 4 to suggest how exercise by human subjects could be made more effective. They posit that exercise should: (i) be dynamic, not static; (ii) exceed a threshold intensity; (iii) exceed a threshold strain frequency; (iv) be relatively brief but intermittent; (v) impose an unusual loading pattern on the bones; (vi) be supported by unlimited nutrient energy; and (vii) include adequate calcium and cholecalciferol (vitamin D3) availability.

Physical health of the female athlete: observations, effects, and causes of reproductive disorders

This review begins by summarizing the state of knowledge about menstrual disorders in athletes at the turn of the 21st Century. It then highlights the most important developments of outstanding interest that have been reported in the 18 months since then. New observations of the characteristics of these disorders are followed by new reports of clinical consequences and recommendations for treatment, and discoveries about their physiological mechanism. In general, evidence is continuing to accumulate that exercise has no suppressive effect on the reproductive system beyond the impact of its energy cost on energy availability. These results encourage the hope that athletic women may be able to prevent or reverse menstrual disorders by dietary supplementation without any moderation of their exercise regimen.

Treadmill exercise training augments brain norepinephrine response to familiar and novel stress

In a test of hypothalamic-pituitary-adrenal (HPA) cortical and hypothalamic-pituitary-gonadal (HPG) interaction during familiar and novel stress, we previously reported that treadmill exercise training led to blunted plasma adrenocorticotrophin (ACTH) response to acute treadmill running but a hyper-responsiveness of ACTH after novel immobilization. In this follow-up analysis, we examined whether those results might be plausibly explained by a similar effect of treadmill exercise training on increased levels of norepinephrine (NE) in hypothalamic and limbic brain regions which synergize to modulate the release of ACTH during stress. Ovariectomized Sprague-Dawley rats that had been exercise trained by treadmill running or remained sedentary for 6 weeks received intramuscular injections of estradiol benzoate (Eb) or sesame oil on each of 3 days prior to 15 min of familiar treadmill running or novel immobilization. Treadmill exercise training, regardless of Eb treatment or type of stress, increased NE levels in the paraventricular (PVN), arcuate, medial preoptic, and ventromedial areas of the hypothalamus and protected against depletion of NE in the locus coeruleus, amygdala, and hippocampus. We conclude that treadmill exercise training has a hyperadrenergic effect in brain areas that modulate hypothalamic regulation of ACTH release during stress that is independent of HPA-HPG interaction and novelty of the stressor. To help elucidate these findings, the effects of treadmill exercise training on A1-A2 nuclei which innervate the PVN and their relationship with the limbic and hypothalamic responses we report require study.

Reduced cortisol potentiates the exercise-induced increase in corticotropin to a greater extent in trained compared with untrained men

We examined the effect of acute exercise and reduced cortisol on pituitary and adrenal responsiveness and the impact of reduced plasma cortisol on maximal oxygen consumption (VO2max) in eight trained (T) and eight untrained (UT) males. Subjects completed two graded maximal exercise tests (GXT), each preceded by either overnight metyrapone (MET) or placebo (PLA) administration. Blood samples were collected before and after GXT. With PLA, resting corticotropin (ACTH) levels were higher in T versus UT men; however, cortisol and 11-deoxycortisol were similar between groups. Following GXT on PLA, cortisol was unchanged but 11-deoxycortisol increased in both groups; however, ACTH increased only in UT men. For both groups, cortisol, 11-deoxycortisol, and ACTH were different post-GXT with MET versus PLA. Furthermore, following GXT with MET, the ACTH response was greater in T versus UT subjects. VO2max was not altered by MET in either group. We conclude that (1) at rest, only ACTH levels differed between T and UT men; (2) individually, the GXT and MET provide a similar ACTH response in UT but not in T subjects; (3) when GXT and MET are superimposed, they provide a stronger stimulus to pituitary and adrenal reserve than either test alone; (4) the combination of MET and GXT elicits a greater ACTH response in T compared with UT men; and (5) an acute reduction in plasma cortisol does not alter VO2max.

Corticotroph axis sensitivity after exercise in endurance-trained athletes

OBJECTIVE

The present study was conducted in order to describe human hypothalamo-pituitary adrenal (HPA) axis adaptation in a model of repeated physical stress (endurance training) that causes a moderate increase in cortisol levels.

SUBJECTS

We performed the same stimulation tests (adrenal stimulation with ACTH or pituitary stimulation with combined CRH/LVP) in a population of 8 endurance-trained athletes in two distinct situations: resting (baseline cortisol values) and 2 h after the end of strenuous exercise (increased cortisol values) to evaluate the HPA axis sensitivity to endogenous sustained increases in cortisol concentrations.

MEASUREMENTS

During these tests, saliva and plasma cortisol (Fs and Fp, respectively) were assessed and compared.

RESULT

Cortisol values in both plasma and saliva at the end of 2 h of exercise were significantly higher than in rested controls: Fs 11.5 +/- 1.3 vs 6.5 +/- 0.8 nmol.l-1 and Fp 428 +/- 36 vs 279 +/- 27 nmol.l-1 (post exercise vs post rest sessions, respectively, P < 0.001 for both). After either hormone test (CRH/LVP or ACTH), cortisol levels in plasma and saliva increased similarly when rest was compared to post exercise. Saliva variations (delta %) under exogenous hormone stimulation were dramatically greater than plasma variations. For example, under ACTH stimulation, the relative increments in cortisol were on control day: delta Fs 980 +/- 139 vs delta Fp 218 +/- 43% (saliva vs plasma, respectively, P < 0.05) and on exercise day: delta Fs 605 +/- 89 vs delta Fp 102 +/- 14% (saliva vs plasma, respectively, P < 0.05).

CONCLUSIONS

In endurance-trained athletes, displaying a moderate but sustained endogenous cortisol increase: (1) ACTH responses following pituitary stimulation are not blunted, (2) cortisol responses following maximal adrenal stimulation are not blunted. Our results favour the hypothesis of a decreased pituitary sensitivity to cortisol negative feedback whereas the hypothesis of a major decreased adrenal sensitivity to ACTH was discarded. The greater ability of saliva assays to detect a cortisol increase strongly supports its use in the study of HPA physiology, whether under basal or dynamic conditions.

Activity wheel running blunts increased plasma adrenocorticotrophin (ACTH) after footshock and cage-switch stress

We examined whether chronic circadian physical activity attenuates hypothalamic-pituitary-adrenal hormone responses after footshock with or without cage-switch stress. Young (45 g) male Fischer 344 rats were randomly assigned to individual suspended home cages (HC) or cages with activity wheels (AW) (12 h:12 h light-dark photoperiod). After 6 weeks, each animal from a pair matched on mass (HC and AW) and average weekly running distance (AW) was randomly assigned to controllable or uncontrollable footshock on 2 days separated by 24 h. Half the animals were returned to the HC after the first day of shock, and half were switched to a new shoebox cage. One animal of each pair could end the shock for both rats by performing an FR-2 lever press. The yoked animal could not control the shock. After shock on Day 2, trunk blood was collected after decapitation. Plasma adrenocorticotrophin (ACTH), corticosterone, and prolactin were determined by radioimmunoassay. ANOVA for a 2 Group (AW vs. sedentary) x 2 Test (controllable vs. uncontrollable shock) x 2 Condition (HC vs. cage-switch) design indicated a Group x Test x Condition effect [F(1, 48) = 5.07, p = 0.03] and a Test main effect [F(1, 47) = 6.93, p = 0.01] for ACTH. ACTH was higher for sedentary animals after uncontrollable footshock under cage-switch conditions and higher after uncontrollable versus controllable footshock when averaged across groups and cage conditions. No effects were found for corticosterone or prolactin. Our results extend to activity wheel running prior findings of a cross-stressor attenuation in plasma [ACTH] in response to cage-switch after treadmill exercise training, though the cross-stressor effect was additive with footshock. Consistent with our prior reports, the cross-stressor effect of wheel running was not apparent after footshock administered under home-cage conditions.

Reduced meal-related gastrointestinal hormone response to adrenocorticotropic hormone stimulation test in female athletes

This study was undertaken to elucidate the impact of hypercortisolism in meal-related gastrointestinal hormone secretion and appetite in female endurance athletes. Thirteen elite runners and seven sedentary women participated on two occasions, either receiving intravenous injection of 250 micrograms synthetic adrenocorticotropic hormone (ACTH) 1-24 or saline. Blood samples were collected before and after the injection, and then in connection with a standardized meal. Serum concentrations of cortisol, cholecystokinin (CCK), gastrin, insulin and glucose were analyzed. Self-ratings of appetite were assessed by visual analog scales. Elevated basal levels of cortisol and glucose were found in the athletes. ACTH-induced cortisol response was comparable between groups, but a negative correlation between basal cortisol levels and the ACTH-induced response was found. In sedentary women, ACTH challenge enhanced meal-related CCK and gastrin responses, whereas athletes showed a blunted response of these hormones combined with decreased satiety and reduced levels of insulin. Blunted meal-related response of gastrointestinal hormones and decreased satiety in female runners after ACTH stimulation compared to sedentary women are probably due to difference in the effect of cortisol, which could be explained by cortisol insensitivity as a result of basal hypercortisolism in the athletes. Decreased CCK response and satiety in female athletes may reflect increased nutritional requirements.