International Journal of Obesity (2007) 31, 1777–1785

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REVIEW
Impact of the menstrual cycle on determinants of
energy balance: a putative role in weight loss attempts
L Davidsen, B Vistisen and A Astrup

Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, Frederiksberg, Denmark

Women’s weight and body composition is significantly influenced by the female sex-steroid hormones. Levels of these
hormones fluctuate in a defined manner throughout the menstrual cycle and interact to modulate energy homeostasis. This
paper reviews the scientific literature on the relationship between hormonal changes across the menstrual cycle and
components of energy balance, with the aim of clarifying whether this influences weight loss in women. In the luteal phase of
the menstrual cycle it appears that women’s energy intake and energy expenditure are increased and they experience more
frequent cravings for foods, particularly those high in carbohydrate and fat, than during the follicular phase. This suggests that
the potential of the underlying physiology related to each phase of the menstrual cycle may be worth considering as an element
in strategies to optimize weight loss. Studies are needed to assess the weight loss outcome of tailoring dietary recommendations
and the degree of energy restriction to each menstrual phase throughout a weight management program, taking these
preliminary findings into account.
International Journal of Obesity (2007) 31, 1777–1785; doi:10.1038/sj.ijo.0803699; published online 7 August 2007

Keywords: menstrual cycle; weight loss attempts; energy intake; energy expenditure; food cravings; mood

Introduction Weight loss strategies include eating fewer calories, eating

Around the world obesity is becoming an increasing problem
and it is accompanied by major health consequences for the
individual and society. This has prompted more people to
attempt to prevent weight gain, or to lose weight, by altering
dietary habits, eating behavior and physical activity. The
National Health Interview Survey conducted in 1998, which
included 32 440 Americans, showed that 24% of the male
and 38% of the female population were trying to lose
weight.1 The percentage of the population attempting to lose
weight rose as body mass index (BMI) increased. In men the
number trying to lose weight climbed from 6% in the normal
weight population (BMIo25) to 50% in the obese popula-
tion (BMIX30). For women the comparable estimates were
24 and 58%, respectively. In a Danish study interviews with
1200 men and women revealed that approximately half of
this population had attempted to lose weight.2 Also here the
prevalence of trying to lose weight increased with BMI.
Correspondence: L Davidsen, Department of Human Nutrition, Faculty of Life
Sciences, University of Copenhagen, Rolighedsvej 30, DK-1958, Frederiks-
berg, Denmark.
E-mail: idaole@yahoo.com
Received 26 September 2006; revised 29 May 2007; accepted 4 June 2007;
published online 7 August 2007
less fat or carbohydrate, exercising more, skipping meals,
attending weight loss programs, taking diet pills or diuretics
and even fasting for more than 24 h.1 Americans spend more
than $33 billion on weight loss products and services every
year.1 However, despite the numerous strategies used, the
prevalence of obesity is still increasing. More than 30% of
Americans are now obese,3 and increasing prevalences are
reported from most other parts of the world.4–7 For those
who achieve weight loss, scientific evidence indicates that
only 23% of the initial weight loss is sustained 5 years after
completing a structured weight loss program.8
When commencing with a diet, cosmetic factors are
clearly important motivational factors especially for women,
who appear more motivated to diet because of dissatisfaction
with their body appearance than men.1 Nevertheless,
women may have more difficulty in losing weight, and
generally lose less weight than men during weight manage-
ment programs.9,10 This may partly be due to gender
differences in energy metabolism and in appetite control
brought about by secretion of reproductive hormones. In
women these hormones control the menstrual cycle and
coordinate changes in energy intake (EI), expenditure and
storage, while preparing the body for pregnancy every
month.11 As reproduction is a primary biological function,
these hormones may be such strong mediators of eating
 Menstrual cycle and energy balance
L Davidsen et al
1778
behavior that they influence the outcome of a weight loss
attempt. The menstrual cycle should therefore be taken into
consideration as a factor in the physiology of energy balance
in premenopausal women. This paper reviews the literature
on appetite, cravings, pattern of food intake, energy
metabolism and mood across the menstrual cycle. An in-
depth understanding of any mechanisms that change
determinants of energy balance during the course of the
menstrual cycle could provide helpful tools for the preven-
tion and treatment of obesity. The potential of the
physiology related to each phase of the menstrual cycle to
optimize weight loss outcome is discussed.
Hormonal changes during the menstrual cycle
The menstrual cycle is coordinated by the hypothalamic –
pituitary – gonadal (HPG) axis and is influenced by
physiological and pathological changes that occur through-
out life.12 The menarche (the first menstruation) is often
considered the central event of female puberty, as it signals
the commencement of fertility. The average age for
menarche is between 12 and 13.5 years.13 It seems to occur
most frequently when a young woman reaches around 17%
body fat.14 However, it may not be the amount of body fat
per se that affects the timing of menarche. Height, weight
and skinfold thickness all appear to play a role.15 Race and
socioeconomic status have also been suggested to influence
menarcheal age.15,16 The menstrual cycle continues until the
onset of menopause around the age of 5017 when the ovaries
stop producing estrogens. The reproductive system then
gradually shuts down.18
In the majority of women the menstrual cycle averages 28
days, where the day of onset of menstruation is generally
referred to as day 1.19 The cycle can be divided into four phases:
menstruation or early follicular phase (days 1–4), late follicular
phase (days 5–11), periovulation (days 12–15) and the luteal
phase (days 16–28).19 The culmination of the follicular phase
occurs when ovulation takes place around day 14 or 15. After
ovulation the luteal phase begins and lasts about 14 days until
the onset of the next menstruation.20 However, when studying
energy balance across the menstrual cycle it is often divided
into two phases separated by menstruation, with a pre- and
postmenstrual phase,19 which is also the case for several of the
studies included in this review.
The predominant hormones that regulate the menstrual
cycle are gonadotropin-releasing hormone (GnRH), follicle-
stimulating hormone (FSH), luteinizing hormone (LH),
progesterone and estrogen.20 There are three major forms
of estrogen: estradiol, estrone and estriol. Estradiol is the
most potent of these.21
Hormones are secreted at various sites. GnRH is secreted by
the hypothalamus, the gonadotropins FSH and LH are
secreted by the anterior pituitary gland and estrogens and
progesterone are secreted from the ovaries. GnRH stimulates
International Journal of Obesity
the release of LH and FSH from the anterior pituitary, which
in turn stimulate release of estrogens and progesterone from
the ovaries.22
In the early follicular phase follicular enlargement begins
and is characterized by high circulating levels of FSH, which
stimulate follicular growth. Levels of plasma LH, estradiol
and progesterone are low in this phase. Plasma FSH induces a
rise in the concentration of estradiol, which starts in the mid
follicular phase and continues until the late follicular phase,
when it finally peaks. This event triggers the mid cycle LH
surge, which lasts for 40–48 h and induces ovulation.
Consequently, the level of plasma estradiol decreases,
though it remains slightly elevated throughout the luteal
phase.20
When ovulation has occurred progesterone is secreted and
its concentration increases until it reaches its peak in the mid
luteal phase, and LH and FSH return to their previous levels.
If the ovum is not fertilized the plasma concentrations of
estradiol and progesterone drop at the end of the luteal
phase, which initiates menstruation and thereby a new
menstrual cycle.23 The cyclic changes in hormones and body
temperature are illustrated in Figure 1.
Energy intake
It has been observed in animal studies that EI is reduced at
the time of ovulation, when plasma estrogen levels peak, and
that EI is increased after ovulation, when plasma progester-
Luteinizing hormone
Follicle stimulating hormone
Oestrogen
Progesterone
37°C
Temperature
36°C
Ovulation
Follicular phase Luteal phase
Menses
day 1 day 14 day 28
Figure 1 The menstrual cycle: changes in hormones and in body
temperature. Modified from Wikipedia.org. This Wikipedia and Wikimedia
Commons image is from the user Chris 73 and is freely available at http://
commons.wikimedia.org/wiki/Image:MenstrualCycle.png under the creative
commons cc-by-sa 2.5 license.

one is elevated.24–30 Consequently, it has been hypothesized
that estrogens reduce appetite and EI and are thus reciprocal
to a possible appetite-stimulating effect of progesterone in
animals. In humans, a review has summarized EI in relation
to menstrual cycle phases in 30 studies, which included a
total of 37 groups of women.31 Twenty-seven of the groups
demonstrated significantly higher EI in the luteal phase than
in the follicular phase. In seven groups no effect was seen,
although a general tendency toward a higher luteal EI was
observed. The remaining four groups had a higher EI in the
follicular phase than in the luteal phase, but these results
were nonsignificant.
More recent studies support the findings of luteal
hyperphagia,32–35 where women’s EI has been reported to
increase with as much as 90–500 kcal/day compared to the
follicular phase.33,34,36–46 Thus, most of the data from
human studies also indicate that EI changes in response to
changes in levels of ovarian hormones, and possibly to
estrogens in particular.37,41,45,47 This is supported by data on
progesterone-treated ovariectomized rats, where progester-
one had no apparent effect on EI.26 This suggests that the
observations listed above may be due to an inverse,
noncausal association between the plasma concentration of
estrogens and EI, rather than due to an appetite-stimulating
effect of progesterone.24,30,48 In this context estradiol is
thought to be the crucial inhibitory signal linking the HPG
axis to the neural control of feeding, and thereby inhibiting
EI by reducing the amount of food consumed at a single
meal.49 Ovariectomy on rats, which disrupts the normal
HPG function by preventing the secretion of estrogens and
nearly eliminating all estradiol from the circulation, has
been shown to increase EI, resulting in a 10–30% increase in
body fat.50,51 This effect of estrogen in animals may also
occur in humans. However, it is possible that progesterone,
perhaps without an apparent appetite-stimulating effect on
its own, may still increase EI when interacting with estrogen.
Table 1 presents reference values for normal ranges of
estrogen and progesterone in premenopausal and postme-
nopausal women and in men. It can be seen from Table 1
and Figure 1 that the ranges of estrogen (estradiol) in the
Table 1 Normal reference ranges for estrogen (estradiol) and progesterone
Early follicular Late follicular Luteal phase
phase phase
Estrogen, estradiol (pmol/l)
Premenopausal women 75–250 250–1500 250–750
Postmenopausal women o100 F F
Men o250 F F
Progesterone (nmol/l)
Premenopausal women o2 o2 5–90
Postmenopausal women o2 F F
Men o2 F F
Endocrinology Reference Ranges, Royal Prince Alfred Hospital. Rodney
Shearman Endocrinology Laboratory (www.gw.cs.nsw.gov.au/csls/RPAH/
endo/searchres.asp?TEST_GRP ¼ REPRODUCTIVE%20HORMONES).
Menstrual cycle and energy balance
L Davidsen et al
1779
luteal phase, where women’s EI is increased, are somewhat
higher compared to levels in the early follicular phase, in
which EI appears to be lower. This suggests that it is perhaps
not estrogen per se that mediates EI but that it might also be
affected by progesterone. A certain increase in progesterone,
as occurs in the luteal phase, may somehow interact with
estrogen and thus antagonize the metabolic effects of
estrogen and thus increase EI. Further studies are required
to examine this hypothesis. Additionally, it would be
interesting to investigate whether postmenopausal women,
and men (who have lower circulating levels of both estrogen
and progesterone than premenopausal women), exhibit
similar patterns in EI in response to fluctuations in these
hormones.
Estrogens seem to possess potential for a beneficial effect
in women attempting to lose weight. However, it has been
speculated that women with a greater tendency toward
obesity are more sensitive to luteal hyperphagia and perhaps
do not respond adequately to this imbalance by lowering EI
in the follicular phase when estrogen levels are elevated.19
Additionally, when progesterone is elevated in the luteal
phase it has been shown to promote fat storage by decreasing
lipoprotein lipase activity in the adipose tissue.51 This results
in a decline in plasma triacylglycerols, and potentially in a
concomitant increased desire for fat-rich foods.52 This is
inappropriate when trying to lose weight as high-fat foods
are associated with higher overall EI53 and may also impede
weight loss.
The changes in appetite regulation that occur during the
menstrual cycle have been suggested to be related to glucose
homeostasis, which may be an important determinant of
eating behavior in premenopausal women. So far studies in
this area have yielded conflicting results. However, it has
been proposed that insulin responsiveness is modified by sex
hormones54,55 and that insulin sensitivity is lower in the
luteal phase than in the follicular phase.56–58
It is well known that sex hormones also influence appetite
peptides such as ghrelin, leptin, glucagon-like-peptide 1,
cholecystokinin and peptide YY.59 Studies of leptin show
gender difference with respect to levels of this peptide, also
after controlling for body fat.60,61 However, within-gender
difference is also seen as premenopausal women exhibit
higher levels than postmenopausal women.61 This suggests
that cyclic changes in estrogen-responsive peptides such as
leptin occur. However, we have been unable to find studies
that have investigated whether sex hormones also interact
with appetite peptides to control changes in appetite over
the course of one menstrual cycle.
Macronutrient intake, food cravings and the
premenstrual syndrome
Reports on macronutrient intake across the menstrual cycle
are inconsistent.31 Different studies have shown increases
International Journal of Obesity
 Menstrual cycle and energy balance
L Davidsen et al
1780
during the luteal phase in carbohydrate,32,33,38,42,44,62–66
fat33,44,45,62,65 and protein consumption.44,62 Although re-
ported independently of each other these increases may
partly reflect a general increase in appetite rather than an
increase in the intake of a particular macronutrient.31
Furthermore, methodological issues such as the ability of
the test population to adequately differentiate between
carbohydrates and fat can be problematic as there are many
‘sweet-fat’-combination foods (for example, donuts). This
challenges the interpretation of data as it is impossible to
determine whether the consumption of something like a
donut is elicited by a craving for carbohydrate or fat, or
perhaps even the combination of the two.
Nevertheless, the increase in carbohydrate consumption
has been referred to as carbohydrate craving (craving is
defined as an intense desire for a particular food or type of
food67). Retrospective data on food cravings provided by 758
women and 380 men showed that women especially craved
chocolate, and that they did so more frequently than men,
and that they also preferred it to any other type of food.68
Other surveys also indicate chocolate as the most frequently
craved food among women,68–70 and there seems to be no
substitute that satisfies a chocolate craving.68 Interestingly,
in one of the surveys 85% of women reported that they
satisfied their cravings on more than 50% of occasions.68
Moreover, chocolate cravings seem to be more frequent in
the luteal phase than at any other time of the cycle.71,72 This
could result in an excessive intake of calories during this
phase and consequently affect weight.
Food cravings have been suggested to be influenced by the
premenstrual syndrome (PMS).73 This can interfere with
normal activities and/or interpersonal relationships, thus
distinguishing this syndrome from the premenstrual dis-
comfort experienced by most women. The prevalence of PMS
is uncertain as various criteria are used to define the
condition. Prevalences from 5 to 60% have been reported,
with the highest rates seen in adolescent girls.74,75 In a study
of 313 women screened for PMS by questionnaires, women
with PMS exhibited a greater number of ‘episodes of eating’
premenstrually than a control group.32 Furthermore, women
with PMS experienced more severe cravings than women
who reported no PMS symptoms.66,73 The etiology of PMS is
unknown, but it is interesting to note that food can affect
mood, and it is well documented that mood changes are seen
premenstrually.31,66,73 In a study of 919 women, selected on
the basis of their clear patterns of depression during three
menstrual cycles, it was observed that depression was
positively related to food craving.31
It is possible that PMS and food craving share a common
biochemical basis, in which giving into cravings actually
works to improve women’s mood. However, this has not yet
been established.
Although the food consumed during the periods of
cravings seems to be high in carbohydrates, it also tends to
be high in fat (for example, chocolate).33,40,44,45,62 As fat
provides flavor to foods, it is possible that the sensory
International Journal of Obesity
properties of a fat-rich food are also an element of the
experienced craving.
One study attempted to differentiate between the biologi-
cal and sensory properties of the satiation of nondrug
cravings using chocolate.70 It seems that the urge to smoke
a cigarette is satisfied by the pharmacological effect of
nicotine,76 whereas chocolate cravings do not seem to be
satisfied by the pharmacological properties of chocolate, but
more by sensory experiences involving aroma, sweetness and
texture.70 In this context a woman’s ability to correctly
perceive sweet taste seems to play a primary role in
determining her hedonic and other perceptual responses to
substances such as chocolate.77 This perception of sweetness
may vary across the menstrual cycle as sensory research
suggests that women’s preferences for the sweet tastes and
smells are increased in the luteal phase.46,63 This may be the
reason for the higher frequency of craving premenstrually.
Thus the reported changes in macronutrient intake during
the luteal phase may be elicited by a natural preference for
pleasant tasting, sweet, high-fat foods,19,78 which may be
enhanced premenstrually, thus possibly impeding adherence
to a weight management program.
Resting metabolic rate and 24-h energy
expenditure
A number of studies have indicated that daily energy
expenditure (EE) changes with phases of the menstrual
cycle. Premenstrual increases in sleeping metabolic rate
(SMR),79,80 basal metabolic rate (BMR)81–86 and 24-h
EE79,87,88 have been reported. However, the increments in
EE in the luteal phase vary from one study to another. The
mean difference in SMR between the follicular and luteal
phase has been reported to be 6.1–7.7%,54,80 while mean
increases in 24-h EE of 2.5–11.5% have been shown.54,88 The
luteal increase in 24-h EE corresponds to an increase of
89–279 kcal.
Nevertheless, EE tends to vary substantially and mean
interindividual variation (CV) in BMR has been estimated to
8–11.8%.89,90 More interestingly, the daily intraindividual
variation is wide ranging (1.7–10.4%, mean: 4.6%).89,91
Some of the factors known to contribute to intraindividual
variation in EE are stress, changes in nutritional status,
weight, physical activity and seasonal changes.92 Factors that
influence interindividual variation include body size, age,
gender, nutritional status and activities such as work, leisure
pursuits, fidgeting and exercising.92 Interindividual variation
in 24-h EE, adjusted for gender, is dependent on family traits,
because fat-free mass and fat mass are correlated within
families.93 Furthermore, it seems that both 24-h EE and SMR,
independent of body composition and spontaneous physical
activity, are determined by plasma concentrations of the
thyroid hormone triiodothyronine (T3) and norepinephr-
ine.93 Thus, many factors seem to contribute to variations in

EE. However, when investigating a woman’s EE across one
menstrual cycle per se, some of the above-mentioned factors
such as size, gender, age and family traits remain constant
and thus do not contribute to intraindividual variation.
Instead, factors such as T3 and b-adrenergic hormones could
more likely explain cyclic variations in EE if, for example,
diet and physical activity were to be held constant. One
study showed that the b-adrenergic support of resting energy
expenditure (REE) tended to be lower when suppressing sex
hormones by GnRH antagonist therapy suggesting sympa-
thetic nervous system support of REE as a potential
mechanism mediating the reduction in REE with sex
hormones suppression.94 However, to this date this possible
association has not been clarified.
Nevertheless, it has been proposed that the reported
premenstrual increase in EE may be a result, at least in part,
of an increase in the concentration of progesterone.81,87,88 In
studies where increases in EE have been registered, a
concomitant increase in progesterone or its metabolic
product in urine, pregnandiol (indicating an elevated level
of secreted progesterone), has been measured.87,88 Addition-
ally, progesterone has been shown to be hyperthermic both
in normal and in ovariectomized women,95,96 possibly
mediated by a direct influence on the thermoregulatory
center in the hypothalamus.97 This suggests that progester-
one is a general metabolic stimulator.
It has been suggested that changes in BMR may parallel
changes in EI across the menstrual cycle as the two
parameters have shown similar patterns independently of
each other.88 To investigate this, data on EI and EE need to be
obtained from the same group of women. To the authors’
knowledge only one study has provided such data. This
study showed no correlation between EI and EE, although
the changes in the two parameters across the menstrual cycle
were of the same magnitude.35 It therefore remains un-
known whether the changes in EI across the menstrual cycle
are driving changes in EE or vice versa.
The difference in methodologies used in the various
trials assessing these parameters probably contributes to
the divergence in results in this area. One factor that may be
a major bias is time and confirmation of ovulation as
the event separating the follicular and luteal phases. In the
latter study ovulation was tested repeatedly over numerous
cycles in 20 women. Only a few subjects had typical
28-day cycles in which ovulation occurred close to day 14.
Ovulation ranged otherwise from day 10 to day 20.
Relying on an average 28-day cycle may thus increase error
variance.
Hormonal contraceptives and energy balance
In the United States approximately 25% of all women using
contraception rely upon oral contraceptives for birth con-
trol.98 Several types of oral contraceptives exist. These
Menstrual cycle and energy balance
L Davidsen et al
1781
contain either a combination of synthetically derived
components of both estrogen (ethinylestradiol) and proges-
terone (progestins), or progestins alone. The contraceptive
efficacy of these hormones lies in the suppression of
ovulation and thickening of the cervical mucus,99 which
prevents pregnancy by preventing implantation of a ferti-
lized egg. These contraceptives interfere with the naturally
occurring fluctuations in hormones in the menstrual cycle
and it can therefore be anticipated that this may exert an
effect upon energy balance, which may either benefit or
impede weight loss as the natural fluctuations in women’s
sex hormones are controlled.
To date only a few studies have investigated the effect of
oral contraceptives on energy and macronutrient intake, and
the findings are contradictory. Significant increases in fat
and EI have been reported in women using oral contra-
ceptives compared to non-pill users.100,101 But there are also
studies showing no differences in EI between pill users and
non-pill users.35,102,103 When interpreting the above-men-
tioned results one should consider the formula of the oral
contraceptives that are investigated in these studies. Com-
bined and progestin-only pills as well as triphasic contra-
ceptives are used. It is possible that the different formulas of
oral contraceptives may result in diverse effects on EI.
Moreover, the methods used for registering EI vary from
one study to another. More studies are warranted to clarify
this issue.
The effect of oral contraceptives on EE has also been
studied. It appears that physiological variations in the
secretion of estrogens and progesterone affect EE, so
exogenous administration of these hormones is likely to
have an effect. One study showed that women who used oral
contraceptives had a significantly increased BMR (almost
5%) compared to non-pill users, even after adjustment for
differences in body weight and self-reported levels of
physical activity.104 However, this was in contrast to a
number of other studies, which reported no difference,35,100
or even a decrease in daily BMR102 and EE88 with the use of
oral contraceptives compared to no use. It is therefore not
possible to draw any conclusions about the effect of oral
contraceptive agents on EE.
Body weight in relation to oral contraceptive use has also
been investigated.105–107 A recent review evaluated the
association between contraceptive use and changes in body
weight by including randomized controlled trials that
compared oral contraceptives with placebo or with another
oral contraceptive.106 Weight change comparisons during
3–24 cycles of 47 different contraceptives and/or placebo
pairs were represented. Most comparisons showed no
substantial difference in body weight, which is supported
by other studies.105,107 However, a minority of studies
reported a trend toward weight gain with oral contraceptive
use compared to placebo. It was not possible to detect
whether this was due to the dosage of estrogens or progestins
in the respective contraceptives, or due to other factors
independent of the oral contraceptives.
International Journal of Obesity
 Menstrual cycle and energy balance
L Davidsen et al
1782
Recently, injections of combined hormonal formulations
and progestins-only contraceptives have been introduced. A
recent study showed a significantly greater increase in body
weight for women who received intramuscular injections of
Depo-Provera, a progestins-only contraceptive, for a period
of 30 months, compared to women using no hormonal
contraception.108 Other studies support this finding.108–110
This may indicate a potential weight-inducing effect of
progestins. However, it is uncertain whether the increase in
body weight was caused by the mode of administration
(injection vs oral ingestion), which may alter the metabolic
effects of this hormone; or whether the hormone itself,
regardless of how it is administrated, is weight promoting.
Based on the presented data it seems that oral contra-
ceptive use has no impact on body weight. The observed
weight changes in the trials did not exceed those of the
natural fluctuations in body weight which can occur during
a single day or across a menstrual cycle, for example, where
women may experience a minor increase in body weight
premenstrually and during the first days of the menstruation
due to water retention.111 However, weight gain may be
promoted when transdermal contraceptives with specific
progestin-only formulations are used.
Generally, our knowledge of the effect of hormonal
contraceptives on energy balance is limited. Thus it remains
unclear to what extent hormonal contraceptives that inter-
fere with hormones of the normal menstrual cycle may
influence weight loss efforts.
Implications for weight management programs
Energy intake
It may be worth considering which stage of the menstrual
cycle is appropriate for initiation of a weight loss regimen. It
appears that the body’s physiological needs for energy are
increased premenstrually, which gives rise to cravings and an
increased EI. One strategy may be to commence the diet on
the first day of menses (day 1), or in the late follicular phase
(days 5–11), when food cravings appear to be less intense,
thereby making it easier to adapt to energy restriction and
establish a good basis for adherence to the diet. Carbo-
hydrate, fat and total EI could be moderately increased 5–8
days before menstruation to meet the body’s increased
energy demands, rather than rigidly adhering to a subopti-
mal caloric level. Cravings for carbohydrate should be
alleviated mainly by foods such as fruit, which, apart from
sugar, contain some vital nutritive elements. As chocolate is
frequently craved, and is seemingly irreplaceable, a small
daily allowance of chocolate may improve adherence to the
diet in the premenstrual period, preventing a sudden over-
consumption of craved foods, such as chocolate, due to a
longer period of suppressing the craving. Dark chocolate
may be preferable as it contains the healthier monounsatu-
rated oleic acid. Furthermore, moderate consumption of
International Journal of Obesity
dark chocolate may be associated with reduced risk of
vascular diseases as its high content of cocoa contains
nutrients which have been shown to exert strong antiox-
idant effects in vitro and in vivo in humans.112,113 Addition-
ally, it may be of interest to investigate whether the powerful
taste of dark chocolate compared to light chocolate may
better satisfy a woman’s craving and thus preventing over-
consumption of chocolate. No data on this subject has yet
been published.
It may be relevant to investigate which food items are
actually eaten to examine whether it is realistic to expect
that craved foods (other than chocolate) can be successfully
replaced by foods that contain less sugar and fat, while still
satisfying women’s cravings. Women who suffer from PMS,
and thus from more severe symptoms of depression and food
cravings and so on, may benefit from some kind of
nutritional supplement/medication, as conscious changes
in food intake alone may not be sufficient to relieve the
premenstrual discomfort. It is not the purpose of this review
to evaluate possible treatments for PMS, but any supplement
that can diminish premenstrual depression and thus im-
prove mood would probably improve these women’s ad-
herence to a diet.114
Long-term weight management programs
When attempting to develop a systematic weight manage-
ment program based on menstrual phases, factors that may
affect the chances of success must be considered. Pretreat-
ment body weight is an important independent predictor of
weight loss and slightly overweight women may not respond
as well to a weight management program as women who are
obese.115 Nor do all women experience changes in cravings
and in food intake related to the menstrual cycle. This review
addresses whether hormonal changes affect different com-
ponents of energy balance, such as food intake, but food
intake can also affect hormones. Women who exhibit
cognitive restrained eating, for the purpose of either losing
weight or controlling other factors, may experience irregula-
rities in the menstrual cycle116 due to insufficient EI.117 They
therefore cannot rely on a weight management program
based on the assumption of a regular menstrual cycle. In
investigations of the effects of the menstrual cycle on energy
balance components women have usually been kept on
energy balanced diets to prevent weight changes. However,
any given cyclic effect found under these circumstances
(when energy balance is maintained) may change when
women adhere to an energy-deficient diet and consequently
lose weight. This may induce an upregulation of appetite-
stimulating hormones, for example, ghrelin,118,119 along
with an altered ratio between estrogens and progesterone,
which may constitute a mechanism of counterregulation. It
may therefore be necessary to take into account the
changing metabolic state when dieting continues over a
longer period by readjusting diet composition, calorie
consumption and physical activity level.

L Davidsen et al
Conclusion
In the luteal phase of the menstrual cycle it appears that
women’s EI and EE are higher than in the follicular phase.
Additionally, women more frequently experience food crav-
ings, particularly for foods high in carbohydrate and fat, in the
luteal phase. This indicates that it may be worth taking the
underlying physiological mechanisms related to each menstru-
al phase into account in weight management attempts.
Short-term studies are needed to assess the weight loss
outcome, that is, initial weight loss and dropout rate, for
weight loss strategies involving changes in diet composition
and energy restriction tailored to each menstrual phase
based on the presented data. This may provide a useful tool
for improving adherence to weight management programs
and consequently enhance weight loss outcome.
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