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The effect of the menstrual cycle on anterior

cruciate ligament injuries in women as
determined by hormone levels. Am J Sports Med

ARTICLE in THE AMERICAN JOURNAL OF SPORTS MEDICINE · JANUARY 2002

Impact Factor: 4.36 · DOI: 10.1177/03635465020300020601 · Source: PubMed

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Laura J Huston Kurt P Spindler

Vanderbilt University Cleveland Clinic
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 THE EFFECT OF THE MENSTRUAL CYCLE ON ACL INJURIES IN WOMEN AS DETERMINED BY HORMONE LEVELS
+*Wojtys, E; *Huston, L; **Boynton, M; ***Spindler, K; ****Lindenfeld, T
+*MedSport; University of Michigan, Ann Arbor, MI. 734-998-7410, Fax: 734-998-7993, edwojtys@umich.edu

INTRODUCTION Expected versus Observed Rates of Injuries: A significant association was

Female athletes at the high school and collegiate level in the United States are found between the distribution of ACL injuries and the phase of the menstrual
expected to suffer over 30,000 serious knee injuries per year.1,2 Why women cycle (Table 2; χ2=27.7, p<0.001). This association was documented by
are two to eight times more likely to sustain anterior cruciate ligament (ACL) hormone metabolite identification of cycle phase within 24 hours of injury.
tears depending on the sport and level of competition continues to challenge Overall, more ACL injuries than expected were found during ovulation, based
clinical and basic science researchers. Because the menstrual cycle and its on the length of this phase, while less injuries than expected were found
hormone fluctuations are one of the most important differences between male during the luteal phase (Figure 1).
and female athletes, previous studies have concentrated on the recall ability of
questionnaires in order to associate hormone levels with the time of an ACL Table 2. Chi-Squared Analysis of Overall ACL Injuries
injury.3,4 In order to overcome this limitation, the present study sought to Phase Expected Rate Observed Rate*
document hormone levels within 24 hours of injury and at the start of the
1 (Follicular) 9/28=32% 15/65=23%
athlete’s next menstrual cycle in women with acute ACL tears. Our study
2 (Ovulatory) 5/28=18% 28/65=43%
objective was to determine if an association exists between the menstrual
cycle phase and the distribution of ACL injuries in female athletes. Our 3 (Luteal) 14/28=50% 22/65=34%
research hypothesis was that the menstrual cycle phase affects the *χ2=27.7, p<0.001
susceptibility of female athletes to ACL injury.

METHODS Figure 1. Histogram of observed ACL injuries plotted by day of cycle.

Sample Size Justification: Preliminary studies showed a 1.6 times greater than
expected incidence of ACL injuries in the ovulatory phase of the menstrual
cycle. To achieve 80% power to detect an effect size of 0.40 with two degrees
of freedom and an alpha of 0.05, we calculated a required sample size of 60 X=ACL Injury
subjects.
Subjects: After IRB approval, sixty-nine women sustaining acute (less than
24 hours) non-contact ACL injuries from four test sites were recruited for this
study. Pregnant, or non-pregnant women with a history of either irregular
(defined as greater than three days variation between cycle period length) or XX X
missed menstrual cycles were excluded from the study (n=4). Meeting these X X XX
X X X X XX X
inclusionary criteria yielded a final subject database of 65 women. Oral X X X X X XX X X X X
contraceptive (OC) use was not used as exclusionary criteria, but was X
XX
XX X X X X X X X X X X
X X X XX X X X XX X X X
X X XX
X X X X X XX
documented so that this sub-group could be analyzed separately (n=51 non-
OC users; 14 OC users).
Urine Assays: Each subject provided two urine samples: one within 24 hours
of injury and the second sample within 24 hours of the first day of her next DISCUSSION
menstrual cycle. Each sample was analyzed for E1G (total estrogen The results of this investigation indicate that the phase of the menstrual cycle
metabolite), PDG (progesterone metabolite), LH (lutenizing hormone may be associated with the susceptibility of the female athlete to ACL injury.
metabolite), and creatinine (a normalizing agent). A higher number of ACL injuries occurred during the ovulatory phase
Statistics: To test the hypothesis that the observed versus expected frequency compared with the follicular or luteal phases. The observed number of ACL
of ACL injuries was independent of menstrual cycle phase, a Pearson chi- tears during ovulation was more than 2.5 times the expected number.
square test was used. The expected rate was computed by dividing the Previous studies have suggested an association was present, however, this is
number of days in that phase by the total number of days in the cycle. The the first study to document the phase of the menstrual cycle at the time of
observed rate was computed by dividing the actual number of injuries that injury with hormone metabolite measurements.
occurred in each phase, divided by the total number of injuries.
REFERENCES
RESULTS 1. Hewett TE; Sports Medicine 29:313-327, 2000.
Hormone Metabolite Levels via Urine Assays: Total estrogen, progesterone, 2. National High School Sports Participation Survey 1999-2000; National
and lutenizing hormone metabolite levels are summaried in Table 1. Even Federation of State High School Assoc., Indianapolis, IN, 2000.
though these hormone metabolite levels were found to be within normal 3. Myklebust G, et al; Scand J Med Sci Sports 8:149-153, 1998.
clinical range, the hormone levels at the time of injury were significantly 4. Wojtys EM, et al; AJSM 26:614-619, 1998.
higher when compared with the first day of the subject’s next menstrual cycle.
Table 1. Mean (SD) Normalized Hormone Metabolite Levels at Specified
Days in the Subject’s Cycle
Day 1 in Cycle Day of Injury
Total Estrogen (µg/24 hrs) 45.5 (5.8) 80.2 (13.0)
Progesterone (mg/24 hrs) 1.1 (0.2) 2.0 (0.4)
Lutenizing Hormone (IU/24 hrs) 6.7 (1.4) 19.5 (5.1)

**Vermont Orthopaedic Clinic, Killington, VT.

***Vanderbilt Sportsmedicine Center, Nashville, TN.
****Cincinnati Sportsmedicine and Orthopaedic Center, Cincinnati, OH.

48th Annual Meeting of the Orthopaedic Research Society

Paper No: 0172