{"paper_id":"65653af4-c453-41d6-986e-42846d126449","body_text":"24 The Open Food Science Journal,  2007, 1, 24-30  \n \n 1874-2564/07 2007 Bentham Science Publishers Ltd.  \nAdverse Effects of Dietary Habits on Menstrual Disorders in Young \nWomen \nTomoko Fujiwara*,1, Natsuyo Sato2, Hiroyo Awaji2 and Rieko Nakata2 \n1Faculty of Home Economics, Ashiya College, Ashiya, 2Department of Food Science and Nutrition, Nara Women’s  \nUniversity, Nara, Japan \nAbstract: It has been accepted that food customs are closely associated with quality of life in women of the reproductive \nage. Food customs are speculated to not only influence the present life style but also to induce gynecological disorders \nsuch as dysmenorrhea and irregular menstruation. Although there is no constant defin ition of regular or normal menstrua-\ntion, epidemiologic evaluation of menstrual cycle has been becoming an important issue. In addition, latent development \nof organic diseases such as endometriosis, which are accompanied by dysmenorrhea, is a concern under the current nutri-\ntional environment in young women. Thus, it is an important issue to evaluate the present situation of eating habits in \nyoung women and estimate the influence of these habits on the quality of reproductive functions. Therefore, in this re-\nview, recent articles that are concerned with these issues have been reevaluated.  \nKeywords: Dysmenorrhea, food intake, irregular menses, menstrual disorder, nutrition, reproduction. \nINTRODUCTION \n Dietary habits are fundamental factors that influence hu-\nman life styles and individual quality of life (QOL). In addi-\ntion, the adverse effects of environmental hormones or tox-\nins on human health, which will be manifested in later life, \nhave been pointed out [1-3]. Thus, dietary habits in young \nwomen may determine their QOL in subsequent middle or \nold age and should be evaluated from the perspective of total \nbenefit throughout whole life.  \n In Japan, widespread consumption of fast food, skipping \nof food intake, and the shift from Japanese to Western foods \nare increasing among young women [4,5]. One of the most \ncommon nutritional issues among young women in Japan is \npoor energy intake and/or inappropriate food selection due to \ndietary limitations for cosmetic purposes, which can lead to \npoor intake of protein, carbohydrate and essential fatty acids \nalong with diet-related psychological stress [5]. These fac-\ntors are speculated to influence not only the present life style \nbut also future medical disorders such as cardiovascular and \nmetabolic diseases [6, 7]. Furthermore, menstrual and repro-\nductive factors have also been proposed to be associated \nwith malignant diseases in the uterus as well as in other or-\ngans [8]. Accordingly, it is important to evaluate the present \nsituation of eating habits in young women and estimate their \ninfluence on menstrual disorders.  \n Although epidemiologic evaluation of menstrual cycle is \nan important, it is difficult to precisely determine the normal \nlength of menstrual cycles in individuals with cyclic variabil-\nity because there is considerable variation in menstrual cy-\ncles among women [9]. When researchers strictly exclude \nwomen with irregular menstrual cycles, they tend to rigidly \nselect the group with a narrow range of menstrual cycles as \nnormal menstrual intervals from 25-28 to 32 days [10]. In  \n \n \n*Address correspondence to this author at the Faculty of Home Economics, \nAshiya College, 14-10 Rokurokuso-cho, Ashiya, 659-8511, Japan; Tel: 81-\n797-23-0663; Fax: 81-797-38-6705; E-ma il: tomokof@bd5.so-net.ne.jp \ncontrast, if researchers want to strictly select the group with \nirregular menstrual cycles, they will define the normal spec-\ntrum as a rather broader range, frequently 20 to 40 days [11].  \n Based on this background, we think that the proposal of \nstandard normal menstrual function for epidemiologic \nevaluation is necessary for adequate assessment of young \nwomen health. In addition, the relationship between food \ncustoms and menstrual dysfunction has been becoming im-\nportant issue in the world. Therefore, this review article de-\nscribed the optimal definition of regular or normal menstrua-\ntion according to the aims and subjects of the study and pos-\nsible influence of food intake on menstrual disorders in \nyoung women. \nNORMAL MENSTRUAL CYCLE \n Menstruation is defined as the periodic discharge of \nblood, mucus, and cellular debris from the uterine mucosa. \nThe menstrual cycle is a repetitive phenomenon caused by \nthe interaction of the hypothalamic-pituitary-ovarian system \nand can be divided into three stages: the follicular phase, \nrecruitment and growth of a new follicle; the ovulatory pe-\nriod, at which time an oocyte is released into the peritoneal \ncavity; the luteal phase, at which time a newly formed cor-\npus luteum produces progesterone [12]. The cycle is mainly \nregulated by the hypothalamus, in which gonadotropin-\nreleasing hormone (Gn-RH) is released in pulses to stimulate \npituitary gonadotropes to secrete follicle-stimulating hor-\nmone (FSH) and luteinizing hormone (LH). These go-\nnadotropins in turn promote follicular development with \novulation and corpus luteum formation in the ovary, induc-\ning steroid hormone production. The estradiol-positive feed-\nback loop causes the midcycle Gn-RH and LH surges to in-\nduce ovulation in the matured preovulatory follicle.  \n Since positive estrogen feedback system on the hypo-\nthalamus and pituitary is developing throughout puberty, \nmenstruation following menarche is usually irregular and/or \nanovulatory. The frequency of ovulation gradually increases \nas puberty progresses, but it is common for 25-50% of \nadolescents to still be anovulatory 4 years after menarche \n\nFood Intake and Menstrual Disorders The Open Food Science Journal, 2007, Volume 1    25 \nlescents to still be anovulatory 4 years after menarche [13]. \nSeveral years after menarche, transient disturbances of pro-\ngesterone secretion in the luteal phase are commonly ob-\nserved in adolescents [13]. The average age of menarche in \nWestern European countries appears to have declined over \nthe past 150 years from over 16 to under 14 years [14]. In the \nUnited States, the normal age range of menarche is 9.1-17.7 \nyears with a median of 12.8 years [15,16]. There is no evi-\ndence that the age of menarche has decreased over the past \n30 years in USA [17]. The declining age of puberty has been \nattributed to improved standards of living such as adequate \nnutrition and health care [17, 18].  \n Menstrual cycle length is mainly determined by the rate \nand quality of follicular growth and development. Although \nmany textbooks in reproductive medicine describe typical \nmenstrual cycle as 28 days [19], there is limited discussion \nregarding the definition of normal range of the regular men-\nstrual cycle. This is probably because there is considerable \nvariation in menstrual cycles among women.  \n More than one hundred years ago, it was reported that \nmean and/or median menstrual cycles are between 28 to 30 \ndays [20, 21]. In 1939, Arey analyzed 12 reports from 1989 \nto 1937 and reported that the mean interval of menstrual cy-\ncles was 28.4 days [22]. In 1942, Haman showed an almost \nidentical distribution of menstrual cycle by analyzing 150 \nnormal housewives [23]. In 1968, the mean of menstrual \nintervals was reported to be 29.1 days by analyzing 2,316 \nwomen [24]. In this study, when the study population was \nlimited to women having menstrual intervals between 15 and \n45 days, the mean of menstruation was re-calculated as 28.1 \ndays.  \n Treloar et al . demonstrated that the mean of the men-\nstrual intervals gradually decreased from 30 to 26 days along \nwith the narrowing of the 90 percentile ranges [25]. Variabil-\nity in cycle length among females is in principle due to the \nvarying number of days required for follicular growth and \ndevelopment. The key hormone was shown to be inhibin, not \nestrogen [26]. In the late 30’s years when FSH increases and \ninhibin decreases [27, 28], the mean length and variability of \nmenstrual cycles become the shortest. In 1984, Lenton et al. \nanalyzed 293 British women with ovulatory menstrual cycles \nand reported that mean interval of follicular phase was 12.9 \ndays with 95% confidence limits between 10.3 to 16.3 days \n[29]. This study also showed that follicular phase length was \nsignificantly decreased along with aging, from 14.2 days in \nwomen aged 18-24 years old to 10.4 days in women aged \n40-44 years old. In 1992, Munster et al. analyzed 3743 Dan-\nish women aged 15-44 with regular menstrual cycles and \nfound that in women with regular menstrual cycles, the 5-95 \npercentile range of usual cycle length of 23-35 days in the \n15-19 years age group decreased to 23-30 days in the 40-44 \nyears age group [30]. Based on these findings, it can be con-\ncluded that the interval between menstrual periods has not \nbeen changed during a century and that the median interval \nis 28 days during active reproductive years [19].  \nMENSTRUAL DISORDERS \nA. Irregular Menstruation \n To predict dysfunction in the hypothalamic-pituitary-\novarian axis, irregular menstruation is one of the positive \nclinical symptoms. Therefore, increasing attention has been \npaid to abnormality of the menstrual cycle in various fields. \nFor example, the National Institute for Nursing Research in \nthe USA has been active in developing research addressing \nthe cause and consequences of menstrual cycle and meno-\npause- related health problems, suggesting that menstrual \ncycle research is a strong area of interest in nursing science \n[31]. Irregular menses are also a concern among college-age \nwomen. These problems may reflect normal ovulatory men-\nstrual symptoms or be suggestive of significant pathology \nthat can have a major impact on future reproductive and gen-\neral health [32]. In addition, by analyzing 33,434 postmeno-\npausal women, it was reported that women having both ir-\nregular menstrual cycles and irregular menstrual bleeding \nhad about 2-fold higher risk of hip fracture than did women \nwho reported neither irregularity [33]. \n Based on the analysis of over 20 papers from 7 develop-\ning countries, Harlow and Campbell indicated that studies \ndid not use consistent definitions of menstrual disorders and \nsummarized the results in broad categories, defining oli-\ngomenorrhea as menstrual cycles of 35-90 days [9]. There-\nfore, researchers must define the optimal range of regular or \nnormal menstruation according to the aims and subjects of \nthe study. In general, if the researchers want to strictly select \nthe group with irregular menstrual cycles, they will define \nthe normal spectrum as a rather broader one. For this pur-\npose, the range between 20 and 40 days is frequently em-\nployed [11]. Especially, to examine the effects of various \nfactors on menstrual irregularity during early postmenarcheal \nage, this broad definition is used [34]. In 2003, Schneider et \nal. reported that fresh female military cadets had consider-\nable menstrual irregularity. In this study, although the \nauthors defined the normal range of menstrual length more \nbroadly from 21 to 45 days, they found that only 12 % of \ncadets belonged to the range within 21-45 days [35]. In con-\ntrast, when researchers want to strictly exclude women with \nirregular menstrual cycles, they rigidly select the group with \na narrow range of menstrual cycles as normal menstrual in-\ntervals. For example, Battaglia et al . used a strict criteria of \n28-32 days as regular menstrual cycles to estimate the rela-\ntion between utero-ovarian ultrasonographic analyses and \ncirculating FSH levels in female childhood cancer survivors \n[10]. Another recent st udy defined 25-32 days as regular \nmenstrual cycle [36]. In our recent study to analyze premen-\nstrual symptoms in college-aged women (18-20 years) in \nJapan, we strictly defined regular menstrual cycles as 26-32 \ndays. Under this condition, two thirds of the students were \nclassified into the group with regular menstruation. This \npopulation almost corresponded to the range of ±1SD of the \nwhole population, indicating that the strict selection of regu-\nlar menstruation is reliable [in submission]. On the other \nhand, when the restriction is not so severe, researchers have \ndefined normal menstrual length as 23-25 days to 35 days \n[37, 38].  \nB. Dysmenorrhea \n Dysmenorrhea is an important sign of functional distur-\nbance in the hypothalamic-pituitary-ovarian axis and subse-\nquent local inflammation in the pelvic cavity [39-43], which \nalso is an excellent parameter that reflects female psycho-\nphysiological status. It begins within 6-12 months from the \nmenarche and is characterized by localized pain in the ab-\ndominal inferior quadrants. Pathophysiologically, pelvic pain \n\n26    The Open Food Science Journal, 2007, Volume 1 Fujiwara et al. \nis conducted through afferent pathways by the hypogastric \nsympathetic and parasympathetic nerves. However, pelvic \npain is an integrated physical sense and sensitivity to pain \ncan easily be influenced by various factors such as stress \n[44,45], the intensity of dysmenorrhea is usually defined \naccording to subjective complains. For example, it is classi-\nfied into 3 grades (score 1, not requiring analgesic; score 2, \npainful, requiring analgesic; score 3, painful, not relieved by \nanalgesic) [4].  \n Hormonal disorders in ovarian function or pelvic organic \ndiseases are mainly considered to cause dysmenorrhea [40]. \nPrimary dysmenorrhea is derived from an abnormal increase \nin the contractile activity of the uterus [41]. It is usually due \nto functional immaturity in ovarian sex steroid hormone pro-\nduction that stimulates local production of chemical media-\ntors such as prostaglandins E2, F2 and leukotrienes in the \nuterus during menstruation [42]. Clinically, when the ma-\ntured women have dysmenorrhea without apparent signs for \novarian dysfunction such as irregular menstruation, several \norganic disorders such as uterine myoma should be sus-\npected. Endometriosis is one of the most important gyneco-\nlogical diseases manifested as dysmenorrhea, which needs \nlaparoscopic examination for accurate diagnosis [46]. The \naffected lesions are considered to gradually spread all over \nthe pelvic cavity through periodic ovulation and menstrua-\ntion, resulting in severe tissue adhesion, pelvic pain and in-\nfertility in reproductive age [46]. Dysmenorrhea is an impor-\ntant initial symptom for endometriosis, which causes local \ninflammation with pelvic pain and infertility. \nC. Premenstrual Syndrome \n Premenstrual syndrome is a multifactorial syndrome that \naffects adolescent girls with a high frequency. This syn-\ndrome is characterized by manifestation of pschychological \ndisorders such as irritability, depression, and mood swings \nand/or somatic complaints including abdominal bloating, \nperipheral edema, general fatigue and acne before menstrua-\ntion [47]. These symptoms are recurrent according to men-\nstrual cycles and rapidly disappeared just after onset of men-\nstruation. Although various etiologies of premenstrual syn-\ndrome such as elevated prolactin levels, hypoglycemia or \nvitamin deficiencies have been proposed, none of these theo-\nries has been definitively proven [48]. Although more than \n100 symptoms and/or signs are considered to involved in \npremenstrual syndrome, there is no specific laboratory test to \nprecisely diagnose premenstrual syndrome [49]. The high \nincidence of premenstrual syndrome in young women was \nrecently reported showing that a bout 60% of adolescence \ncomplain of premenstrual syndrome based on the criteria \ndescribed in the Manual of Mental Disorders-IV [50, 51].  \nFOOD INTAKE AND MENSTRUAL DISORDERS \nA. Influence of Low Calorie Intake on Menstrual Disor-\nders \n Nutritional deficiency is considered one of the important \nfactors that induces hypothalamic-pituitary-ovarian dysfunc-\ntion. Recently, adolescents have tended to try to lose body \nweight by dietary restriction for cosmetic purpose. In Japa-\nnese young women, more than 60% college students used \ndiet control to reduce weight despite a normal or low body \nmass index [52, 53]. Montero et al . reported that among \n1147 urban Spanish adolescents, aged between 14 and 20 \nyears, nearly 40% of the adolescents tried to lose weight and \nthat attempting to lose weight is significantly associated with \nan increase in irregular menstruation and dysmenorrhea \nwithout a significant relation with body mass index [54]. The \nepidemiological study showed that circulating level of go-\nnadal steroids is suppressed in Bushwomen except when \nfood is plentiful and hunting activities restricted, suggesting \nclose relationship between nutritional deficiency and hypo-\nthalamic-pituitary-ovarian suppression [55]. It has been also \nreported that vegetarians frequently have menstrual distur-\nbances [56-59]. To predict dysfunction in the hypothalamic-\npituitary-ovarian axis, irregular menstruation is one of the \npositive clinical symptoms. An experimental vegetarian diet \nwith low calorie was reported to induce menstrual cycle dis-\norders, showing a short luteal phase [60]. In women who \nhave diets with high in fiber, low in fat, or both, concentra-\ntions of ovarian hormones or their metabolites were shown \nto be lower at various points in the menstrual cycle [61-67]. \nLow weight and fat mass, low calorie intake and eating dis-\norders are speculated to disturb the pulsatile secretion of \npituitary gonadotropins. In Japanese women, a positive rela-\ntionship between monounsaturated fat intakes and serum \nestrogen concentration, and an inverse relation between fiber \nand serum estrogen were also observed [68,69]. However, it \nshould be noted that there was a unique report demonstrating \nthat female dieters appear to make more healthy food choices \nthan non-dieters and so may be tuning into healthy eating \nmessages more effectively [70]. \n On the other hand, several studies reported that vitamin \ndeficiency or hypoglycemia can induce premenstrual syn-\ndrome in which patients complain of irritability, constipation \nand edema several days before the onset of menstruation \n[71]. It was also reported that deficiency of vitamin B1 and \nmagnesium may cause dysmenorrhea, suggesting supple-\nmentation of these agents can relieve menstrual symptoms \n[71]. Very recently, we confirmed that the frequency of ir-\nregular menstruation was increased in young women who \nwere currently on a diet and found that the intensity of dys-\nmenorrhea was high in those with a history of dieting in ado-\nlescence, suggesting that diet in adolescence has long-lasting \nadverse effects on reproductive function in young women \n[53]. These findings notably warn of the possibility that diet \nlimitation in adolescence becomes a trigger for the subse-\nquent development of organic gynecologic diseases, support-\ning the concept that inadequate dietary habits may influence \nwomen’s QOL not only in the present but also in the future.  \nB. Influence of Excess Calorie Intake on Menstrual Dis-\norders \n It is well known that excess weight and obesity are asso-\nciated with irregular menstrual cycles, which reduce fertility \nand increase hormone-sensitive cancers in young women \n[72,73]. Obesity is considered to cause abnormality of sex \nsteroid hormone balance and serum sex hormone binding \nglobulin level. In young women, the onset of obesity is sig-\nnificantly correlated with menstrual irregularities in later \nreproductive age. Irregular menstruation is more frequently \nobserved in women who became obesity during puberty than \nin those who were obese during infancy [74]. Recently, \nleptin, which is a novel hormone produced mainly by adi-\npose cells [75], was demonstrated to regulate gonadotropin \n\nFood Intake and Menstrual Disorders The Open Food Science Journal, 2007, Volume 1    27 \nsurge during puberty, providing a new explanation for men-\nstrual irregularities observed in obese women [76,77]. In \noverweight women, a low fat diet was shown to decrease \nsymptoms of dysmenorrhea along with increasing serum sex \nhormone binding globulin concentration [78,79]. Further-\nmore, since a long-term follow-up study showed that the \nprevalence of type 2 diabetes was seven times higher in \nwomen with polycystic ovarian syndrome (PCOS) [80] that \nis frequently associated with irregular menstruation, irregular \nmenstruation is assumed to be one of risk factors for meta-\nbolic diseases [81].  \n Excessive caloric intake observed in young women is \nfrequently due to excess intake of confectionary and sweet \ndrinks containing artificial sweeteners. It should be noted \nthat the safety of these sweeteners on human health has not \nyet been proven [82]. On the other hand, Nagata et al . re-\nported that intake of green and yellow vegetables, which are \nrich in carotenoids, could accelerate onset of menopause \n[83].  \nC. The Influence of Dietary Customs on Menstrual Dis-\norders \nFood Skipping \n Evidence suggests that breakfast consumption may im-\nprove cognitive function related to memory, test grades, and \nschool attendance. Breakfast as part of a healthful diet and \nlifestyle can positively impact children's health and well-\nbeing [84]. On the other hand, breakfast skipping increased \nduring the transition to adulthood, and is associated with \nincreased weight gain from adolescence to adulthood [85]. \nSchweiger et al . reported that daily eating habits signifi-\ncantly influence menstrual function in young women. In this \nstudy, the authors concluded that high cognitive limitation in \ndaily eating behavior may be a risk factor for the develop-\nment of menstrual disturbance in young women, showing \nlower serum progesterone concentration and shorter length \nof luteal phase [86]. We recently found that young women \nwho skip breakfast have a significantly higher degree of \ndysmenorrhea symptoms than young women who eat break-\nfast, suggesting a positive correlation between skipping \nbreakfast and menstrual disorders [4]. We also confirmed the \nprevious report that breakfast-skipping induced constipation \nthat can cause various organic disorders in the pelvic cavity \n[87, 88]. Although the mechanism is completely unknown, it \nis possible that some factors that become deficient by break-\nfast skipping may be involved in the development of dysme-\nnorrhea [4].  \nUnsaturated Fatty Acids \n Unsaturated fatty acids were reported to be concerned \nwith menstrual disorders. \u0002-6 fatty acids (e.g., vegetable oil, \neggs, and margarine) contribute to the formation of proin-\nflammatory eicasanoids, such as PGE2, thromboxane A2, \nand leukotriene B4, whereas \u0002-3 fatty acids (e.g., fish, \ncanola oil, and wheat germ), mainly eicosapentanoic acid \nand docosahexanoic acid, lead to the formation of less in-\nflammatory eicasanoids (e.g., PGE3, thromboxane A3, and \nleukotriene B5) [89]. Because prostaglandins derived from \nmarine polyunsaturated fatty acids are usually less aggres-\nsive, intake of these fatty acids are expected to reduce dys-\nmenorrhea. Several studies showed that dietary sulpplemen-\ntation of \u0002-3 polyunsaturated fatty acids had a beneficial \neffect on symptoms of dysmenorrhea in young women [90, \n91]. Lower consumption of fish, eggs, and fruit was reported \nto be a risk factor for this pathology together with early \nmenarche, and long and heavy menstrual flow [92]. These \nfacts suggest that fish intake facilitates reduction of dysme-\nnorrhea. Vitamin E may involve a reduction in prostaglandin \nformation by inhibiting arachidonic acid release [93]. It was \nreported that dysmenorrhea was significantly reduced by \nshort daily administration of vitamin E before and during \nmenses [93, 94]. Recently, polyunsaturated fat intake was \nreported to significantly decrease menstrual cycle length \n[95]. \nPhytoestrogens \n It has been reported that meat contains considerable \namount of natural sex steroid hormones such as 17 \u0001-\nestradiol [96], whereas soybeans have isoflavone that pos-\nsesses estrogenic and antioxidant actions [97, 98]. In general, \nphytoestrogens are grouped into four main categories: \nisoflavones, coumestans, lignans, and flavonoids [99]. Soy \nisoflavones are expected to prevent postmenopausal osteopo-\nrosis [100]. However, high short-term isoflavone-containing \nsoy intake had no significant effects on most circulating sex \nhormones in young healthy women [101]. Supplementation \nwith lignans was reported to increase the length of the luteal \nphase and the ratio of progesterone to estradiol during the \nluteal phase [102]. However, Cassidy et al . observed that \nisoflavones increased the follicular phase without affecting \nluteal phase length [103]. It was also reported that black \nsoybean has the potential to improve the anovular menstrual \ncycle [104]. A significant negative correlation between soy \nisoflavones intake and perimenstrual symptoms was reported \n[105]. Recent studies showed that catechins, which are \nabundant in green teas, have cancer preventing effects \n[106,107]. These polyphenols were also demonstrated to \nmodulate estrogen action through molecular mechanisms at \nthe serum concentration after tea-drinking [108,109].  \nSupplement \n Supplement of FertilityBlend (Daily Wellness Co., \nSunnyvale, California), a proprietary nutritional supplement \ncontaining chasteberry and green tea extracts, L-arginine, \nvitamins (including folate) and minerals was shown to in-\ncrease mean midluteal phase progesterone level and the av-\nerage number of high temprature days during the luteal \nphase [110].  \n In patients with premenstrual syndrome, a daily calcium \nsupplement (1200 mg) positively reduced the symptoms rat-\nings [111,112]. A daily magnesium supplement (200 mg) \nimproved fluid retention and mood [113], and a daily sup-\nplement of vitamin B6 reduced premenstrual syndrome \n[114]. In add ition, it was also reported that treatment once \ndaily with 20 mg of extract of agnus castus fruit, or chaste \nberry, reduced irritability, mood changes, rage, headache and \nbreast swelling by 50% or more [115].  \nCONCLUSION \n Although epidemiologic evaluation for disturbance of \nmenstrual cycle is important to predict various factors that \nare associated with women’s reproductive function, there is \nno constant definition of regular or normal menstruation \n\n28    The Open Food Science Journal, 2007, Volume 1 Fujiwara et al. \nsince there is considerable variation in menstrual cycles \namong women. Therefore, researchers should define the op-\ntimal range as regular or normal menstruation from the per-\nspectives of the aims and subjects of the study. Accumulat-\ning evidence suggests that food customs influence gyneco-\nlogical disorders such as irregular menses, dysmenorrhea and \npremenstrual syndrome in young women. 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