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    Amenorrhea (Holistic)

    Amenorrhea (Holistic)

    About This Condition

    A loss of periods is called amenorrhea, a condition that may result from low levels of certain hormones. According to research or other evidence, the following self-care steps may be helpful.
    • Get enough nutrients

      Eat more food or choose a high-calorie supplement if you are underweight, have low body fat, or are an athlete

    • Look after your bones

      Protect yourself from amenorrhea-related bone loss by taking 800 to 1,500 of calcium and 400 to 800 IU of vitamin D each day

    • Get a checkup

      Visit your doctor to find out if your amenorrhea is the result of a treatable medical problem

    • Regulate your workouts

      Balance hormone function by avoiding intense or excessive exercise

    About

    About This Condition

    Amenorrhea is the absence of menstrual cycles.

    Amenorrhea is called primary when a woman has not started to menstruate by the age of 16 years, while secondary amenorrhea refers to the abnormal cessation of menstruation in a woman who previously has had menstrual cycles.1 In amenorrheic women, the levels of female reproductive hormones are not sufficient to stimulate menstruation. This condition is sometimes associated with malnutrition, such as that which occurs in anorexia nervosa , or with extreme exercise, which puts excessive nutritional and other demands on the body.2 , 3 An association between stress and amenorrhea has also been demonstrated.4 Amenorrhea may also result from potentially serious disorders of the ovaries, the hypothalamus, or the pituitary gland; therefore, a physician should always evaluate chronic absence of menstrual cycles. Prolonged amenorrhea can result in early bone loss and increased risk of osteoporosis .5 Amenorrhea occurs naturally in women who are breast-feeding,6 but in these circumstances it does not put the bones at risk.7

    Symptoms

    Women with amenorrhea may have symptoms of absent periods, increased facial hair, decreased pubic and armpit hair, deeper voice, decreased breast size, and secretions from the breast.

    Healthy Lifestyle Tips

    Moderate exercise has many benefits to the overall health of premenopausal women, but intensive or excessive exercise can contribute to amenorrhea and increase the risk of early bone loss due to detrimental effects on hormone balance.8 Exercise typically increases bone density, but a study of dancers with amenorrhea found that bone density measurements remained below normal for the entire two-year duration of the study.9 The demands placed upon women performers and athletes are believed to contribute to the high incidence of eating disorders among them. This, along with the increased physical and nutritional demands of intensive exercise, can lead to nutrient deficiencies and lowered body-fat percentages that may contribute to amenorrhea and bone loss in women athletes.10 , 11 , 12 Running and ballet dancing are among the activities most closely associated with amenorrhea,13 with as many as 66% of women long-distance runners and ballet dancers experiencing amenorrhea.14 Among women bodybuilders in one study, 81% experienced amenorrhea, and many had nutritionally deficient diets.15 While some amenorrheic athletes have been reported to resume menstruation after adding one day of rest per week and consuming a daily nutritional beverage containing additional calories, protein, carbohydrate, fat, vitamins, and minerals,16 , 17 no controlled trials have investigated this approach.

    Hormonal changes associated with breast-feeding prevent menstruation in healthy women.18 The duration of this interruption in menstruation, known as lactational or postpartum amenorrhea, depends on many factors, including the nutritional health of the mother. Poor maternal nutritional status has been associated with longer periods of lactational amenorrhea in developing countries19 , 20 , 21 , 22 as well as in Great Britain among poor nursing women.23 Better maternal nutritional status was found to be associated with shorter lactational amenorrhea in well-nourished nursing mothers in the United States.24 When malnourished nursing mothers are given food supplements, the length of lactational amenorrhea can be shortened, according to preliminary studies.25 However, one controlled trial found dietary supplementation with skim milk did not shorten the duration of amenorrhea in well-nourished nursing mothers.26 Although prolonged lactational amenorrhea prevents another pregnancy, it has not been shown to result in permanent bone loss.27

    Excessive stress causes the body to produce increased amounts of the adrenal hormone cortisol, and several studies have linked high cortisol levels to low levels of reproductive hormones and to amenorrhea.28 , 29 , 30 In one study, amenorrheic women showed a greater increase in cortisol in response to stress than did women with normal menstrual cycles.31 No research has been done to evaluate stress reduction interventions for the treatment of amenorrhea.

    Smoking may contribute to amenorrhea. A survey study found that young women smoking one pack or more per day were more likely to be amenorrheic than other women.32 However, whether smoking cessation will normalize menstrual function in amenorrheic women is unknown.

    Holistic Options

    In a number of preliminary trials,33 , 34 , 35acupuncture has been shown to induce ovulation in women with disorders involving lack of ovulation. Preliminary studies show that levels of estrogen and progesterone, as well as levels of the related hormones LH (luteinizing hormone) and FSH (follicle-stimulating hormone), may all be affected by acupuncture.36 , 37 Few studies have looked at the use of acupuncture for treatment of amenorrhea, but one preliminary trial found it helpful for women who have widely separated menstrual cycles.38 In one controlled trial, amenorrheic women showed a trend toward normalizing hormone levels following acupuncture.39

    Eating Right

    The right diet is the key to managing many diseases and to improving general quality of life. For this condition, scientific research has found benefit in the following healthy eating tips.

    Recommendation Why
    Add a little more to a low-fat diet
    In one study, women on diets low in fat who were experiencing amenorrhea returned to regular menstruation when they increased their fat intake and percentage of body fat.

    When compared with women who menstruate regularly, women who menstruate infrequently or not at all often have lower dietary intakes of fat (especially saturated fat), protein, and total calories, as well as a greater proportion of carbohydrate and fiber in their diet.40 , 41 , 42 In preliminary studies of normal-weight women with no obvious eating disorders, women who experienced amenorrhea had diets described as ?close to normal? but significantly low in fat. These women had lower percentages of body fat as well.43 , 44 In one of these studies, regular menstruation returned in women who increased their fat intake and percentage of body fat to normal over four months.45

    Balance nutrition
    Ensuring adequate calories, protein, carbohydrates, fat, vitamins, and minerals may help women menstruate regularly.

    It has long been known that extreme dietary restriction can cause amenorrhea.46 , 47 When such restriction is due to eating disorders , such as anorexia and bulimia,48 professional treatment is necessary. Athletic amenorrheic women may have low intakes of calories and other nutrients, and there are reports of some athletes resuming menstruation after adding to their diet a daily nutritional beverage containing additional calories, protein, carbohydrate, fat, vitamins, and minerals.49 , 50 However, these women also decreased their exercise intensity, which likely contributed to normalization of their menstrual function.

    Look at your diet
    A strict raw foods diet has been associated with weight loss and amenorrhea.

    Specific diets may be associated with increased risk of amenorrhea. A strict raw foods diet was found in one preliminary study to be strongly associated with weight loss and amenorrhea.51 Vegetarians have been studied for their susceptibility to amenorrhea, but the results so far have been inconsistent.52 Vegetarian diets tend to be rich in the antioxidant nutrients known as carotenes . Women with excessive carotene levels in their blood appear to be at higher risk of amenorrhea than women with normal levels,53 , 54 and, while research has not shown high carotene levels to directly cause amenorrhea, they may constitute a contributing factor.55 In one preliminary study, women with high levels of both carotenes and amenorrhea had predominantly vegetarian diets, and reducing dietary intake of carotenes led to lower carotene levels and improvement in their amenorrhea.56 Women vegetarians often rely heavily on soy foods as sources of protein, and a number of studies have found that increasing dietary intake of soy reduces levels of estrogen and progesterone in premenopausal women,57 , 58 , 59 , 60 , 61 , 62 although some studies have not found these changes.63 , 64 Changes in menstrual cycles were not consistent in these studies, and none found an increase in missed menses with high-soy diets. The only well-controlled comparison study found that the number of cases of amenorrhea among healthy, stable-weight vegetarian women was not different from that of healthy, stable-weight non vegetarian women.65 The authors of this study speculated that, after reviewing all of the evidence, a vegetarian diet is likely not to contribute to amenorrhea.

    Watch what you eat
    Some vegetarian diets have been associated with weight loss and amenorrhea.

    Specific diets may be associated with increased risk of amenorrhea. A strict raw foods diet was found in one preliminary study to be strongly associated with weight loss and amenorrhea.66 Vegetarians have been studied for their susceptibility to amenorrhea, but the results so far have been inconsistent.67 Vegetarian diets tend to be rich in the antioxidant nutrients known as carotenes . Women with excessive carotene levels in their blood appear to be at higher risk of amenorrhea than women with normal levels,68 , 69 and, while research has not shown high carotene levels to directly cause amenorrhea, they may constitute a contributing factor.70 In one preliminary study, women with high levels of both carotenes and amenorrhea had predominantly vegetarian diets, and reducing dietary intake of carotenes led to lower carotene levels and improvement in their amenorrhea.71 Women vegetarians often rely heavily on soy foods as sources of protein, and a number of studies have found that increasing dietary intake of soy reduces levels of estrogen and progesterone in premenopausal women,72 , 73 , 74 , 75 , 76 , 77 although some studies have not found these changes.78 , 79 Changes in menstrual cycles were not consistent in these studies, and none found an increase in missed menses with high-soy diets. The only well-controlled comparison study found that the number of cases of amenorrhea among healthy, stable-weight vegetarian women was not different from that of healthy, stable-weight non vegetarian women.80 The authors of this study speculated that, after reviewing all of the evidence, a vegetarian diet is likely not to contribute to amenorrhea.

    Supplements

    What Are Star Ratings?

    Our proprietary ?Star-Rating? system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by the medical community, and whether studies have found them to be effective for other people.

    For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.

    3 Stars Reliable and relatively consistent scientific data showing a substantial health benefit.

    2 Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.

    1 Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.

    Supplement Why
    2 Stars
    Progesterone
    Consult a qualified healthcare practitioner
    The oral, micronized form has been shown to successfully induce normal menstrual bleeding in women with secondary amenorrhea. (Use of this natural hormone should always be supervised by a doctor.)

    Oral, micronized progesterone (200 to300 mg per day) has been shown in at least one double-blind trial to successfully induce normal menstrual bleeding in women with secondary amenorrhea.81 Use of this natural hormone should always be supervised by a doctor.

    1 Star
    Acetyl-L-Carnitine
    Refer to label instructions
    Acetyl-L-carnitine may help restore menstruation in some amenorrheic women.

    Acetyl-L-carnitine is an amino acid that may have effects on brain chemicals and hormones that control female reproductive hormones. In a preliminary trial, 2 grams daily of acetyl-L-carnitine was given to amenorrheic women who had either low or normal blood levels of female hormones. Hormone levels improved in the women with low initial levels, and half of all the women resumed menstruating within three to six months after beginning supplementation.82 Controlled trials are needed to confirm these promising results.

    1 Star
    Blue Cohosh
    Refer to label instructions
    Traditional practitioners consider blue cohosh to be a uterine tonic and an agent that stimulates menstrual blood flow, and it is used as a remedy for lack of menstruation.

    Blue cohosh is a traditional remedy for lack of menstruation. It is considered an emmenagogue (agent that stimulates menstrual blood flow) and a uterine tonic. No clinical trials have validated this traditional use.

    1 Star
    Calcium and Vitamin D (Osteoporosis)
    Refer to label instructions
    Despite the lack of evidence that calcium and vitamin D supplements alone are helpful to amenorrheic women, they are still generally recommended to prevent the added burden of calcium and vitamin D deficiency from further contributing to bone loss.

    A preliminary trial showed that bone loss occurred over a one-year period in amenorrheic exercising women despite daily supplementation with 1,200 mg of calcium and 400 IU of vitamin D .83 In a controlled study of amenorrheic nursing women, who ordinarily experience brief bone loss that reverses when menstruation returns, bone loss was not prevented by a multivitamin supplement providing 400 IU of vitamin D along with 500 mg twice daily of calcium or placebo.84 Despite the lack of evidence that calcium and vitamin D supplements alone are helpful to amenorrheic women, they are still generally recommended to prevent the added burden of calcium and vitamin D deficiency from further contributing to bone loss.85 Amounts typically recommended are 1,200 to 1,500 mg calcium and 400 to 800 IU vitamin D daily.

    1 Star
    Motherwort
    Refer to label instructions
    Motherwort has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.

    Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort , rue, partridge berry, and yarrow . None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.

    1 Star
    Partridge Berry
    Refer to label instructions
    Partridge berry has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.

    Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort , rue, partridge berry, and yarrow . None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.

    1 Star
    Rue
    Refer to label instructions
    Rue has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.

    Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort , rue, partridge berry, and yarrow . None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.

    1 Star
    Vitamin B6
    Refer to label instructions
    Preliminary evidence found that vitamin B6 restored menstruation and normalized hormone levels in three women with amenorrhea who had high prolactin levels.

    Prolactin is a hormone that may be elevated in some cases of amenorrhea. A preliminary trial of 200 to 600 mg daily of vitamin B6 restored menstruation and normalized prolactin levels in three amenorrheic women with high initial prolactin levels; however, 600 mg daily of vitamin B6 had no effect on amenorrheic women who did not have high prolactin levels.86 A number of other small, preliminary trials have not demonstrated an effect of either oral or injected vitamin B6 on prolactin levels,87 , 88 , 89 , 90 , 91 and they also have reported inconsistent effects on restoring menstruation.92 , 93 , 94 Larger, controlled trials are needed to better determine the usefulness of vitamin B6 in amenorrhea.

    1 Star
    Vitamin C and Clomiphene
    Refer to label instructions
    Vitamin C combined with the drug clomiphene, which affects female hormone levels, is more effective at stimulating ovulation in women with amenorrhea than either substance alone.

    Vitamin C alone, at 400 mg daily, had no effect on amenorrhea in one preliminary trial, although it was associated with the return of ovulation in some women who were menstruating regularly but not ovulating. In a second phase of the trial, the same amount of vitamin C was combined with a drug that affects female hormone levels, and this combination was associated with return of ovulation in almost half of amenorrheic women who had not benefited from the drug alone.95 More studies of the effect of vitamin C on amenorrhea are needed.

    1 Star
    Vitex
    Refer to label instructions
    In herbal medicine, vitex, also known as chaste tree, is sometimes used to treat amenorrhea. Research suggests it may regulate hormones related to menstruation and fertility.

    In herbal medicine, vitex (Vitex agnus-castus; chaste tree) is sometimes used to treat female infertility and amenorrhea.96 Elevation of prolactin can be a cause of amenorrhea, and vitex has been shown in animals to reduce elevated prolactin levels.97 In a controlled trial, prolactin production was normalized in women with high prolactin levels after three months of treatment with vitex.98 Vitex has also been found to raise levels of luteinizing hormone and subsequent progesterone levels in women with luteal phase defect?a condition that can also lead to menstrual cycle abnormalities, including amenorrhea.99 To date, only one small preliminary trial has studied the effects of vitex on amenorrhea. This study found that ten of fifteen women with amenorrhea began having a normal period after taking 40 drops of a liquid vitex preparation once daily for six months.100 Further research is needed to determine what role vitex may play in the management of amenorrhea.

    1 Star
    Yarrow
    Refer to label instructions
    Yarrow has traditionally been thought to stimulate absent or diminished menses, though it has not been studied clinically.

    Herbal emmenagogues traditionally regarded as stimulating absent or diminished menses are motherwort , rue, partridge berry, and yarrow . None of these herbs has undergone modern clinical trials to determine their efficacy. All emmenagogues should be avoided in pregnancy, as they may possibly cause a spontaneous abortion.

    References

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    4. :Berga SL, Loucks-Daniels TL, Adler LJ, et al. Cerebrospinal fluid levels of corticotropin-releasing hormone in women with functional hypothalamic amenorrhea. Am J Obstet Gynecol 2000;182:776?81.

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    8. Warren MP, Stiehl AL. Exercise and female adolescents: effects on the reproductive and skeletal systems. J Am Med Womens Assoc 1999;54:115?20, 138 [review].

    9. Jonnavithula S, Warren MP, Fox RP, Lazaro MI. Bone density is compromised in amenorrheic women despite return of menses: a 2-year study. Obstet Gynecol 1993;81:669?74.

    10. Sanborn CF, Horea M, Siemers BJ, Dieringer KI. Disordered eating and the female athlete triad. Clin Sports Med 2000;19:199?213 [review].

    11. Manore MM. Nutritional needs of the female athlete. Clin Sports Med 1999;18:549?63 [review].

    12. Benson JE, Engelbert-Fenton KA, Eisenman PA. Nutritional aspects of amenorrhea in the female athlete triad. Int J Sport Nutr 1996;6:134?45 [review].

    13. Frederick L, Hawkins ST. A comparison of nutrition knowledge and attitudes, dietary practices, and bone densities of postmenopausal women, female college athletes, and nonathletic college women. J Am Diet Assoc 1992;92:299?305.

    14. Hirschberg AL, Hagenfeldt K. Athletic amenorrhea and its consequences. Hard physical training at an early age can cause serious bone damage. Lakartidningen 1998;95:5765?70 [review, in Swedish].

    15. Kleiner SM, Bazzarre TL, Ainsworth BE. Nutritional status of nationally ranked elite bodybuilders. Int J Sport Nutr 1994;4:54?69.

    16. Dueck CA, Matt KS, Manore MM, Skinner JS. Treatment of athletic amenorrhea with a diet and training intervention program. Int J Sport Nutr 1996;6:24?40.

    17. Kopp-Woodroffe SA, Manore MM, Dueck CA, et al. Energy and nutrient status of amenorrheic athletes participating in a diet and exercise training intervention program. Int J Sport Nutr 1999;9:70?88.

    18. McNeilly AS, Tay CC, Glasier A. Physiological mechanisms underlying lactational amenorrhea. Ann NY Acad Sci 1994;709:145?55.

    19. Peng YK, Hight-Laukaran V, Peterson AE, Perez-Escamilla R. Maternal nutritional status is inversely associated with lactational amenorrhea in Sub-Saharan Africa: results from demographic and health surveys II and III. J Nutr 1998;128:1672?80.

    20. Delgado HL, Martorell R, Klein RE. Nutrition, lactation, and birth interval components in rural Guatemala. Am J Clin Nutr 1982;35:1468?76.

    21. Lunn PG, Austin S, Prentice AM, Whitehead RG. The effect of improved nutrition on plasma prolactin concentrations and postpartum infertility in lactating Gambian women. Am J Clin Nutr 1984;39:227?35.

    22. Tracer DP. Lactation, nutrition, and postpartum amenorrhea in lowland Papua New Guinea. Hum Biol 1996;68:277?92.

    23. Prema K, Naidu AN, Neelakumari S, Ramalakshmi BA. Nutrition?fertility interaction in lactating women of low income groups. Br J Nutr 1981;45:461?7.

    24. Heinig MJ, Nommsen-Rivers LA, Peerson JM, Dewey KG. Factors related to duration of postpartum amenorrhoea among USA women with prolonged lactation. J Biosoc Sci 1994;26:517?27.

    25. Lunn PG, Prentice AM, Austin S, Whitehead RG. Influence of maternal diet on plasma-prolactin levels during lactation. Lancet 1980 Mar 22;1(8169):623?5 [review].

    26. Tennekoon KH, Karunanayake EH, Seneviratne HR. Effect of skim milk supplementation of the maternal diet on lactational amenorrhea, maternal prolactin, and lactational behavior. Am J Clin Nutr 1996;64:283?90.

    27. Kalkwarf HJ. Hormonal and dietary regulation of changes in bone density during lactation and after weaning in women. J Mammary Gland Biol Neoplasia 1999;4:319?29 [review].

    28. Berga SL, Loucks-Daniels TL, Adler LJ, et al. Cerebrospinal fluid levels of corticotropin-releasing hormone in women with functional hypothalamic amenorrhea. Am J Obstet Gynecol 2000;182:776?81.

    29. Gallinelli A, Matteo ML, Volpe A, Facchinetti F. Autonomic and neuroendocrine responses to stress in patients with functional hypothalamic secondary amenorrhea. Fertil Steril 2000;73:812?6.

    30. Meczekalski B, Tonetti A, Monteleone P, et al. Hypothalamic amenorrhea with normal body weight: ACTH, allopregnanolone and cortisol responses to corticotropin-releasing hormone test. Eur J Endocrinol 2000;142:280?5.

    31. Gallinelli A, Matteo ML, Volpe A, Facchinetti F. Autonomic and neuroendocrine responses to stress in patients with functional hypothalamic secondary amenorrhea. Fertil Steril 2000;73:812?6.

    32. Johnson J, Whitaker AH. Adolescent smoking, weight changes, and binge-purge behavior: associations with secondary amenorrhea. Am J Public Health 1992;82:47?54.

    33. Stener-Victorin E, Waldenstrom U, Tagnfors U, et al. Effects of electro-acupuncture on anovulation in women with polycystic ovary syndrome. Acta Obstet Gynecol Scand 2000;79:180?8.

    34. Mo X, Li D, Pu Y, et al. Clinical studies on the mechanism for acupuncture stimulation of ovulation. J Tradit Chin Med 1993;13:115?9.

    35. Yu J, Zheng HM, Ping SM. Changes in serum FSH, LH and ovarian follicular growth during electroacupuncture for induction of ovulation. Chung Hsi I Chieh Ho Tsa Chih 1989;9:199?202,195 [in Chinese].

    36. Mo X, Li D, Pu Y, et al. Clinical studies on the mechanism for acupuncture stimulation of ovulation. J Tradit Chin Med 1993;13:115?9.

    37. Yu J, Zheng HM, Ping SM. Changes in serum FSH, LH and ovarian follicular growth during electroacupuncture for induction of ovulation. Chung Hsi I Chieh Ho Tsa Chih 1989;9:199?202,195 [in Chinese].

    38. Gerhard I, Postneek F. Possibilities of therapy by ear acupuncture in female sterility. Geburtshilfe Frauenheilkd 1988;48:165?71 [in German].

    39. Kubista E, Boschitsch E, Spona J. Effect of ear-acupuncture on the LH-concentration in serum in patients with secondary amenorrhea. Wien Med Wochenschr 1981;131:123?6 [in German].

    40. Miller KK, Parulekar MS, Schoenfeld E, et al. Decreased leptin levels in normal weight women with hypothalamic amenorrhea: the effects of body composition and nutritional intake. J Clin Endocrinol Metab 1998;83:2309?12.

    41. Snow RC, Schneider JL, Barbieri RL. High dietary fiber and low saturated fat intake among oligomenorrheic undergraduates. Fertil Steril 1990;54:632?7.

    42. Warren MP, Holderness CC, Lesobre V, et al. Hypothalamic amenorrhea and hidden nutritional insults. J Soc Gynecol Investig 1994;1:84?8.

    43. Couzinet B, Young J, Brailly S, et al. Functional hypothalamic amenorrhoea: a partial and reversible gonadotrophin deficiency of nutritional origin. Clin Endocrinol (Oxf) 1999;50:229?35.

    44. Laughlin GA, Dominguez CE, Yen SS. Nutritional and endocrine-metabolic aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 1998;83:25?32.

    45. Couzinet B, Young J, Brailly S, et al. Functional hypothalamic amenorrhoea: a partial and reversible gonadotrophin deficiency of nutritional origin. Clin Endocrinol (Oxf) 1999;50:229?35.

    46. Bringer J, Lefebvre P, Renard E. Nutritional hypogonadism. Rev Prat 1999;49:1291?6 [review, in French].

    47. Yen SS. Effects of lifestyle and body composition on the ovary. Endocrinol Metab Clin North Am 1998;27:915?26,ix [review].

    48. Bringer J, Lefebvre P, Renard E. Nutritional hypogonadism. Rev Prat 1999;49:1291?6 [review, in French].

    49. Dueck CA, Matt KS, Manore MM, Skinner JS. Treatment of athletic amenorrhea with a diet and training intervention program. Int J Sport Nutr 1996;6:24?40.

    50. Kopp-Woodroffe SA, Manore MM, Dueck CA, et al. Energy and nutrient status of amenorrheic athletes participating in a diet and exercise training intervention program. Int J Sport Nutr 1999;9:70?88.

    51. Koebnick C, Strassner C, Hoffmann I, Leitzmann C. Consequences of a long-term raw food diet on body weight and menstruation: results of a questionnaire survey. Ann Nutr Metab 1999;43:69?79.

    52. Barr SI. Vegetarianism and menstrual cycle disturbances: is there an association? Am J Clin Nutr 1999;70:549S?54S [review].

    53. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926?9.

    54. Frumar AM, Meldrum DR, Judd HL. Hypercarotenemia in hypothalamic amenorrhea. Fertil Steril 1979;32:261?4.

    55. Martin-Du Pan RC, Hermann W, Chardon F. Hypercarotenemia, amenorrhea and a vegetarian diet. J Gynecol Obstet Biol Reprod (Paris) 1990;19(3):290?4 [in French].

    56. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926?9.

    57. Cassidy A, Bingham S, Setchell K. Biological effects of isoflavones in young women: importance of the chemical composition of soyabean products. Br J Nutr 1995;74:587?601.

    58. Cassidy A, Bingham S, Setchell KD. Biological effects of a diet of soy protein rich in isoflavones on the menstrual cycle of premenopausal women. Am J Clin Nutr 1994;60:333?40.

    59. Lu LJ, Anderson KE, Grady JJ, et al. Decreased ovarian hormones during a soya diet: implications for breast cancer prevention. Cancer Res 2000;60:4112?21.

    60. Wu AH, Stanczyk FZ, Hendrich S, et al. Effects of soy foods on ovarian function in premenopausal women. Br J Cancer 2000;82:1879?86.

    61. Xu X, Duncan AM, Merz BE, Kurzer MS. Effects of soy isoflavones on estrogen and phytoestrogen metabolism in premenopausal women. Cancer Epidemiol Biomarkers Prev 1998;7:1101?8.

    62. Lu LJ, Anderson KE, Grady JJ, Nagamani M. Effects of soya consumption for one month on steroid hormones in premenopausal women: implications for breast cancer risk reduction. Cancer Epidemiol Biomarkers Prev 1996;5:63?70.

    63. Martini MC, Dancisak BB, Haggans CJ, et al. Effects of soy intake on sex hormone metabolism in premenopausal women. Nutr Cancer 1999;34:133?9.

    64. Duncan AM, Merz BE, Xu X, et al. Soy isoflavones exert modest hormonal effects in premenopausal women. J Clin Endocrinol Metab 1999;84:192?7.

    65. Barr SI. Vegetarianism and menstrual cycle disturbances: is there an association? Am J Clin Nutr 1999;70:549S?54S [review].

    66. Koebnick C, Strassner C, Hoffmann I, Leitzmann C. Consequences of a long-term raw food diet on body weight and menstruation: results of a questionnaire survey. Ann Nutr Metab 1999;43:69?79.

    67. Barr SI. Vegetarianism and menstrual cycle disturbances: is there an association? Am J Clin Nutr 1999;70:549S?54S [review].

    68. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926?9.

    69. Frumar AM, Meldrum DR, Judd HL. Hypercarotenemia in hypothalamic amenorrhea. Fertil Steril 1979;32:261?4.

    70. Martin-Du Pan RC, Hermann W, Chardon F. Hypercarotenemia, amenorrhea and a vegetarian diet. J Gynecol Obstet Biol Reprod (Paris) 1990;19(3):290?4 [in French].

    71. Kemmann E, Pasquale SA, Skaf R. Amenorrhea associated with carotenemia. JAMA 1983;249:926?9.

    72. Cassidy A, Bingham S, Setchell K. Biological effects of isoflavones in young women: importance of the chemical composition of soyabean products. Br J Nutr 1995;74:587?601.

    73. Cassidy A, Bingham S, Setchell KD. Biological effects of a diet of soy protein rich in isoflavones on the menstrual cycle of premenopausal women. Am J Clin Nutr 1994;60:333?40.

    74. Lu LJ, Anderson KE, Grady JJ, et al. Decreased ovarian hormones during a soya diet: implications for breast cancer prevention. Cancer Res 2000;60:4112?21.

    75. Wu AH, Stanczyk FZ, Hendrich S, et al. Effects of soy foods on ovarian function in premenopausal women. Br J Cancer 2000;82:1879?86.

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