{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T04:44:55Z","timestamp":1791953095069,"version":"4.3.4"},"reference-count":123,"publisher":"Springer Science and Business Media LLC","license":[{"start":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T00:00:00Z","timestamp":1791849600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T00:00:00Z","timestamp":1791849600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sports Med"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>This is an emerging evidence statement from the Female and Male Athlete Triad Coalition. This paper complements the 2025 updates to the Female Athlete Triad Coalition Consensus Statements addressing the State of the Science and Clinical Guidelines for Screening, Diagnosis, Treatment and Return to Play. This paper examines emerging evidence of cardiovascular alterations in Triad-affected female athletes with functional hypothalamic amenorrhea and functional hypothalamic oligomenorrhea, including vascular, hemodynamic, autonomic and lipid perturbations. The clinical significance of these surrogate markers of cardiovascular function and their long-term cardiovascular implications remain to be determined. Notwithstanding, the current work extends existing Triad frameworks by recognizing cardiovascular perturbations potentially associated with energy deficiency and hypoestrogenism as an important consideration in female athlete health. We outline an evidence-informed research framework, including longitudinal, dose\u2013response, and multimodal assessments, to characterize the onset, magnitude, physiological significance, and reversibility of cardiovascular alterations in athletes with functional hypothalamic amenorrhea and functional hypothalamic oligomenorrhea. By integrating evidence from sports physiology, endocrinology, and cardiovascular medicine, this state-of-the-science synthesis provides a roadmap for future research, screening, and intervention strategies. It also underscores the importance of evaluating cardiovascular health as a potential component of the broader physiological consequences of energy deficiency, alongside menstrual dysfunction, and impaired bone health.<\/jats:p>","DOI":"10.1007\/s40279-026-02525-1","type":"journal-article","created":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T15:06:55Z","timestamp":1791904015000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cardiovascular Effects Associated with the Female Athlete Triad: Emerging Evidence Statement from the Female and Male Athlete Triad Coalition"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4037-4213","authenticated-orcid":false,"given":"Emma","family":"O\u2019Donnell","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3690-6691","authenticated-orcid":false,"given":"Nancy I.","family":"Williams","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9405-2981","authenticated-orcid":false,"given":"Madhusmita","family":"Misra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-5999-7154","authenticated-orcid":false,"given":"Aurelia","family":"Nattiv","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4473-1038","authenticated-orcid":false,"given":"Elizabeth","family":"Joy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5185-9710","authenticated-orcid":false,"given":"Mary Jane","family":"De Souza","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,10,13]]},"reference":[{"issue":"2","key":"2525_CR1","doi-asserted-by":"publisher","first-page":"327","DOI":"10.1007\/s40279-025-02333-z","volume":"56","author":"MJ De Souza","year":"2026","unstructured":"De Souza MJ, Williams NI, Misra M, Nattiv A, Joy E, Barrack M, et al. 2025 Update to the Female Athlete Triad Coalition Consensus Statement Part 1: state of the science and introduction of a new adolescent model. Sports Med. 2026;56(2):327\u201373.","journal-title":"Sports Med"},{"issue":"2","key":"2525_CR2","doi-asserted-by":"publisher","first-page":"375","DOI":"10.1007\/s40279-025-02332-0","volume":"56","author":"NI Williams","year":"2026","unstructured":"Williams NI, De Souza MJ, Misra M, Nattiv A, Joy E, Barrack M, et al. 2025 Update to the Female Athlete Triad Coalition Consensus Statement Part 2: clinical guidelines for screening, diagnosis, treatment, and return to play for adolescents and adults. Sports Med. 2026;56(2):375\u2013427.","journal-title":"Sports Med"},{"key":"2525_CR3","doi-asserted-by":"publisher","first-page":"157","DOI":"10.1016\/j.atherosclerosis.2015.11.011","volume":"244","author":"JA Augustine","year":"2016","unstructured":"Augustine JA, Lefferts WK, Dowthwaite JN, Brann LS, Brutsaert TD, Heffernan KS. Subclinical atherosclerotic risk in endurance-trained premenopausal amenorrheic women. Atherosclerosis. 2016;244:157\u201364.","journal-title":"Atherosclerosis"},{"issue":"1","key":"2525_CR4","doi-asserted-by":"publisher","first-page":"73","DOI":"10.1016\/S0015-0282(97)00428-7","volume":"69","author":"S Ayres","year":"1998","unstructured":"Ayres S, Baer J, Subbiah MT. Exercised-induced increase in lipid peroxidation parameters in amenorrheic female athletes. Fertil Steril. 1998;69(1):73\u20137.","journal-title":"Fertil Steril"},{"issue":"1","key":"2525_CR5","first-page":"29","volume":"15","author":"JT Baer","year":"1999","unstructured":"Baer JT. Lipid status in female athletes with low estrogen: applications to cardiovascular risk. Am J Health Studies. 1999;15(1):29\u201335.","journal-title":"Am J Health Studies"},{"issue":"6","key":"2525_CR6","first-page":"1605","volume":"77","author":"KE Friday","year":"1993","unstructured":"Friday KE, Drinkwater BL, Bruemmer B, Chesnut C 3rd, Chait A. Elevated plasma low-density lipoprotein and high-density lipoprotein cholesterol levels in amenorrheic athletes: effects of endogenous hormone status and nutrient intake. J Clin Endocrinol Metab. 1993;77(6):1605\u20139.","journal-title":"J Clin Endocrinol Metab"},{"issue":"3","key":"2525_CR7","doi-asserted-by":"publisher","first-page":"205","DOI":"10.1097\/JSM.0b013e3181df59f4","volume":"20","author":"AZ Hoch","year":"2010","unstructured":"Hoch AZ, Lynch SL, Jurva JW, Schimke JE, Gutterman DD. Folic acid supplementation improves vascular function in amenorrheic runners. Clin J Sport Med. 2010;20(3):205\u201310.","journal-title":"Clin J Sport Med"},{"issue":"2","key":"2525_CR8","doi-asserted-by":"publisher","first-page":"119","DOI":"10.1097\/JSM.0b013e3182042a9a","volume":"21","author":"AZ Hoch","year":"2011","unstructured":"Hoch AZ, Papanek P, Szabo A, Widlansky ME, Schimke JE, Gutterman DD. Association between the female athlete triad and endothelial dysfunction in dancers. Clin J Sport Med. 2011;21(2):119\u201325.","journal-title":"Clin J Sport Med"},{"issue":"2","key":"2525_CR9","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1249\/00005768-198904000-00002","volume":"21","author":"S Kaiserauer","year":"1989","unstructured":"Kaiserauer S, Snyder AC, Sleeper M, Zierath J. Nutritional, physiological, and menstrual status of distance runners. Med Sci Sports Exerc. 1989;21(2):120\u20135.","journal-title":"Med Sci Sports Exerc"},{"issue":"1","key":"2525_CR10","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1210\/jcem-68-1-17","volume":"68","author":"S Lamon-Fava","year":"1989","unstructured":"Lamon-Fava S, Fisher EC, Nelson ME, Evans WJ, Millar JS, Ordovas JM, et al. Effect of exercise and menstrual cycle status on plasma lipids, low density lipoprotein particle size, and apolipoproteins. J Clin Endocrinol Metab. 1989;68(1):17\u201321.","journal-title":"J Clin Endocrinol Metab"},{"issue":"6","key":"2525_CR11","doi-asserted-by":"publisher","first-page":"1054","DOI":"10.1111\/sms.13647","volume":"30","author":"E O'Donnell","year":"2020","unstructured":"O\u2019Donnell E, Goodman JM, Floras JS, Harvey PJ. Indexes of aortic wave reflection are not augmented in estrogen-deficient physically active premenopausal women. Scand J Med Sci Sports. 2020;30(6):1054\u201363.","journal-title":"Scand J Med Sci Sports"},{"issue":"5","key":"2525_CR12","doi-asserted-by":"publisher","first-page":"1798","DOI":"10.1210\/jc.2013-3398","volume":"99","author":"E O'Donnell","year":"2014","unstructured":"O\u2019Donnell E, Goodman JM, Mak S, Harvey PJ. Impaired vascular function in physically active premenopausal women with functional hypothalamic amenorrhea is associated with low shear stress and increased vascular tone. J Clin Endocrinol Metab. 2014;99(5):1798\u2013806.","journal-title":"J Clin Endocrinol Metab"},{"issue":"5","key":"2525_CR13","doi-asserted-by":"publisher","first-page":"1089","DOI":"10.1161\/HYPERTENSIONAHA.114.04976","volume":"65","author":"E O'Donnell","year":"2015","unstructured":"O\u2019Donnell E, Goodman JM, Mak S, Murai H, Morris BL, Floras JS, et al. Discordant orthostatic reflex renin-angiotensin and sympathoneural responses in premenopausal exercising-hypoestrogenic women. Hypertension. 2015;65(5):1089\u201395.","journal-title":"Hypertension"},{"issue":"10","key":"2525_CR14","doi-asserted-by":"publisher","first-page":"885","DOI":"10.1042\/CS20150209","volume":"129","author":"E O'Donnell","year":"2015","unstructured":"O\u2019Donnell E, Goodman JM, Morris BL, Floras JS, Harvey PJ. Augmented vagal heart rate modulation in active hypoestrogenic pre-menopausal women with functional hypothalamic amenorrhoea. Clin Sci (Lond). 2015;129(10):885\u201393.","journal-title":"Clin Sci (Lond)"},{"issue":"2","key":"2525_CR15","doi-asserted-by":"publisher","first-page":"294","DOI":"10.1111\/j.1365-2265.2008.03332.x","volume":"70","author":"E O'Donnell","year":"2009","unstructured":"O\u2019Donnell E, Harvey PJ, De Souza MJ. Relationships between vascular resistance and energy deficiency, nutritional status and oxidative stress in oestrogen deficient physically active women. Clin Endocrinol (Oxf). 2009;70(2):294\u2013302.","journal-title":"Clin Endocrinol (Oxf)"},{"issue":"5","key":"2525_CR16","doi-asserted-by":"publisher","first-page":"E1401","DOI":"10.1152\/ajpendo.00547.2006","volume":"292","author":"E O'Donnell","year":"2007","unstructured":"O\u2019Donnell E, Harvey PJ, Goodman JM, De Souza MJ. Long-term estrogen deficiency lowers regional blood flow, resting systolic blood pressure, and heart rate in exercising premenopausal women. Am J Physiol Endocrinol Metab. 2007;292(5):E1401\u20139.","journal-title":"Am J Physiol Endocrinol Metab"},{"issue":"4","key":"2525_CR17","doi-asserted-by":"publisher","first-page":"544","DOI":"10.1111\/sms.13354","volume":"29","author":"E O'Donnell","year":"2019","unstructured":"O\u2019Donnell E, Scheid JL, West SL, De Souza MJ. Impaired vascular function in exercising anovulatory premenopausal women is associated with low bone mineral density. Scand J Med Sci Sports. 2019;29(4):544\u201353.","journal-title":"Scand J Med Sci Sports"},{"issue":"1","key":"2525_CR18","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1123\/ijsn.6.1.3","volume":"6","author":"AC Perry","year":"1996","unstructured":"Perry AC, Crane LS, Applegate B, Marquez-Sterling S, Signorile JF, Miller PC. Nutrient intake and psychological and physiological assessment in eumenorrheic and amenorrheic female athletes: a preliminary study. Int J Sport Nutr. 1996;6(1):3\u201313.","journal-title":"Int J Sport Nutr"},{"issue":"6","key":"2525_CR19","doi-asserted-by":"publisher","first-page":"3162","DOI":"10.1210\/jc.2004-1964","volume":"90","author":"A Rickenlund","year":"2005","unstructured":"Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Oral contraceptives improve endothelial function in amenorrheic athletes. J Clin Endocrinol Metab. 2005;90(6):3162\u20137.","journal-title":"J Clin Endocrinol Metab"},{"issue":"3","key":"2525_CR20","doi-asserted-by":"publisher","first-page":"1354","DOI":"10.1210\/jc.2004-1286","volume":"90","author":"A Rickenlund","year":"2005","unstructured":"Rickenlund A, Eriksson MJ, Schenck-Gustafsson K, Hirschberg AL. Amenorrhea in female athletes is associated with endothelial dysfunction and unfavorable lipid profile. J Clin Endocrinol Metab. 2005;90(3):1354\u20139.","journal-title":"J Clin Endocrinol Metab"},{"issue":"1","key":"2525_CR21","doi-asserted-by":"publisher","first-page":"34","DOI":"10.1249\/MSS.0b013e3181e91ece","volume":"43","author":"K Schaal","year":"2011","unstructured":"Schaal K, Van Loan MD, Casazza GA. Reduced catecholamine response to exercise in amenorrheic athletes. Med Sci Sports Exerc. 2011;43(1):34\u201343.","journal-title":"Med Sci Sports Exerc"},{"issue":"2","key":"2525_CR22","doi-asserted-by":"publisher","first-page":"590","DOI":"10.1152\/japplphysiol.01477.2005","volume":"101","author":"MM Wenner","year":"2006","unstructured":"Wenner MM, Prettyman AV, Maser RE, Farquhar WB. Preserved autonomic function in amenorrheic athletes. J Appl Physiol. 2006;101(2):590\u20137.","journal-title":"J Appl Physiol"},{"issue":"1","key":"2525_CR23","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1161\/01.ATV.0000199102.60747.18","volume":"26","author":"N Yoshida","year":"2006","unstructured":"Yoshida N, Ikeda H, Sugi K, Imaizumi T. Impaired endothelium-dependent and -independent vasodilation in young female athletes with exercise-associated amenorrhea. Arterioscler Thromb Vasc Biol. 2006;26(1):231\u20132.","journal-title":"Arterioscler Thromb Vasc Biol"},{"issue":"3","key":"2525_CR24","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1249\/01.MSS.0000053661.27992.75","volume":"35","author":"A Zeni Hoch","year":"2003","unstructured":"Zeni Hoch A, Dempsey RL, Carrera GF, Wilson CR, Chen EH, Barnabei VM, et al. Is there an association between athletic amenorrhea and endothelial cell dysfunction? Med Sci Sports Exerc. 2003;35(3):377\u201383.","journal-title":"Med Sci Sports Exerc"},{"issue":"3","key":"2525_CR25","doi-asserted-by":"publisher","first-page":"413","DOI":"10.1016\/S0735-1097(02)02763-8","volume":"41","author":"CN Bairey Merz","year":"2003","unstructured":"Bairey Merz CN, Johnson BD, Sharaf BL, Bittner V, Berga SL, Braunstein GD, et al. Hypoestrogenemia of hypothalamic origin and coronary artery disease in premenopausal women: a report from the NHLBI-sponsored WISE study. J Am Coll Cardiol. 2003;41(3):413\u20139.","journal-title":"J Am Coll Cardiol"},{"issue":"5","key":"2525_CR26","doi-asserted-by":"publisher","first-page":"2013","DOI":"10.1210\/jcem.87.5.8471","volume":"87","author":"CG Solomon","year":"2002","unstructured":"Solomon CG, Hu FB, Dunaif A, Rich-Edwards JE, Stampfer MJ, Willett WC, et al. Menstrual cycle irregularity and risk for future cardiovascular disease. J Clin Endocrinol Metab. 2002;87(5):2013\u20137.","journal-title":"J Clin Endocrinol Metab"},{"issue":"4","key":"2525_CR27","doi-asserted-by":"publisher","first-page":"620","DOI":"10.1161\/CIRCRESAHA.115.306301","volume":"118","author":"MA Gimbrone Jr","year":"2016","unstructured":"Gimbrone MA Jr, Garcia-Cardena G. Endothelial cell dysfunction and the pathobiology of atherosclerosis. Circ Res. 2016;118(4):620\u201336.","journal-title":"Circ Res"},{"issue":"4","key":"2525_CR28","doi-asserted-by":"publisher","first-page":"365","DOI":"10.1056\/NEJMcp0912024","volume":"363","author":"CM Gordon","year":"2010","unstructured":"Gordon CM. Clinical practice. Functional hypothalamic amenorrhea. N Engl J Med. 2010;363(4):365\u201371.","journal-title":"N Engl J Med"},{"issue":"5","key":"2525_CR29","doi-asserted-by":"publisher","first-page":"1413","DOI":"10.1210\/jc.2017-00131","volume":"102","author":"CM Gordon","year":"2017","unstructured":"Gordon CM, Ackerman KE, Berga SL, Kaplan JR, Mastorakos G, Misra M, et al. Functional hypothalamic amenorrhea: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(5):1413\u201339.","journal-title":"J Clin Endocrinol Metab"},{"issue":"1","key":"2525_CR30","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1152\/jappl.1998.84.1.37","volume":"84","author":"AB Loucks","year":"1998","unstructured":"Loucks AB, Verdun M, Heath EM. Low energy availability, not stress of exercise, alters LH pulsatility in exercising women. J Appl Physiol. 1998;84(1):37\u201346.","journal-title":"J Appl Physiol"},{"issue":"11","key":"2525_CR31","doi-asserted-by":"publisher","first-page":"5184","DOI":"10.1210\/jcem.86.11.8024","volume":"86","author":"NI Williams","year":"2001","unstructured":"Williams NI, Helmreich DL, Parfitt DB, Caston-Balderrama A, Cameron JL. Evidence for a causal role of low energy availability in the induction of menstrual cycle disturbances during strenuous exercise training. J Clin Endocrinol Metab. 2001;86(11):5184\u201393.","journal-title":"J Clin Endocrinol Metab"},{"key":"2525_CR32","doi-asserted-by":"crossref","unstructured":"Mallinson RJ, Williams NI, Ricker EA, Allaway HCM, De Souza MJ. Multiple eumenorrheic cycles are necessary to observe a significant increase in estrogen exposure and ovulation in exercising women with functional hypothalamic oligo\/amenorrhea undergoing a nutritional intervention: insights from the REFUEL study. PM R. 2026;18(Suppl. 2):S104\u201316.","DOI":"10.1002\/pmrj.70024"},{"key":"2525_CR33","doi-asserted-by":"publisher","first-page":"227","DOI":"10.1007\/978-3-319-70178-3_12","volume":"1043","author":"BT Palmisano","year":"2017","unstructured":"Palmisano BT, Zhu L, Stafford JM. Role of estrogens in the regulation of liver lipid metabolism. Adv Exp Med Biol. 2017;1043:227\u201356.","journal-title":"Adv Exp Med Biol"},{"issue":"2","key":"2525_CR34","doi-asserted-by":"publisher","first-page":"210","DOI":"10.1124\/pr.107.08002","volume":"60","author":"VM Miller","year":"2008","unstructured":"Miller VM, Duckles SP. Vascular actions of estrogens: functional implications. Pharmacol Rev. 2008;60(2):210\u201341.","journal-title":"Pharmacol Rev"},{"issue":"7","key":"2525_CR35","doi-asserted-by":"publisher","first-page":"3536","DOI":"10.1210\/jc.2003-032007","volume":"89","author":"MJ De Souza","year":"2004","unstructured":"De Souza MJ, Leidy HJ, O\u2019Donnell E, Lasley B, Williams NI. Fasting ghrelin levels in physically active women: relationship with menstrual disturbances and metabolic hormones. J Clin Endocrinol Metab. 2004;89(7):3536\u201342.","journal-title":"J Clin Endocrinol Metab"},{"issue":"12","key":"2525_CR36","first-page":"4301","volume":"81","author":"GA Laughlin","year":"1996","unstructured":"Laughlin GA, Yen SS. Nutritional and endocrine-metabolic aberrations in amenorrheic athletes. J Clin Endocrinol Metab. 1996;81(12):4301\u20139.","journal-title":"J Clin Endocrinol Metab"},{"issue":"2","key":"2525_CR37","first-page":"514","volume":"75","author":"AB Loucks","year":"1992","unstructured":"Loucks AB, Laughlin GA, Mortola JF, Girton L, Nelson JC, Yen SS. Hypothalamic-pituitary-thyroidal function in eumenorrheic and amenorrheic athletes. J Clin Endocrinol Metab. 1992;75(2):514\u20138.","journal-title":"J Clin Endocrinol Metab"},{"issue":"4","key":"2525_CR38","doi-asserted-by":"publisher","first-page":"760","DOI":"10.1016\/j.bone.2010.12.018","volume":"48","author":"E O'Donnell","year":"2010","unstructured":"O\u2019Donnell E, De Souza MJ. Increased serum adiponectin concentrations in amenorrheic physically active women are associated with impaired bone health but not with estrogen exposure. Bone. 2010;48(4):760\u20137.","journal-title":"Bone"},{"issue":"6","key":"2525_CR39","doi-asserted-by":"publisher","first-page":"2037","DOI":"10.1152\/jappl.2000.88.6.2037","volume":"88","author":"FS Thong","year":"2000","unstructured":"Thong FS, McLean C, Graham TE. Plasma leptin in female athletes: relationship with body fat, reproductive, nutritional, and endocrine factors. J Appl Physiol. 2000;88(6):2037\u201344.","journal-title":"J Appl Physiol"},{"issue":"25","key":"2525_CR40","doi-asserted-by":"publisher","first-page":"2892","DOI":"10.1161\/CIRCULATIONAHA.118.036859","volume":"139","author":"AR Cappola","year":"2019","unstructured":"Cappola AR, Desai AS, Medici M, Cooper LS, Egan D, Sopko G, et al. Thyroid and cardiovascular disease: research agenda for enhancing knowledge, prevention, and treatment. Circulation. 2019;139(25):2892\u2013909.","journal-title":"Circulation"},{"issue":"1","key":"2525_CR41","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1038\/nrcardio.2009.224","volume":"7","author":"G Sweeney","year":"2010","unstructured":"Sweeney G. Cardiovascular effects of leptin. Nat Rev Cardiol. 2010;7(1):22\u20139.","journal-title":"Nat Rev Cardiol"},{"issue":"2","key":"2525_CR42","doi-asserted-by":"publisher","first-page":"491","DOI":"10.1093\/humrep\/dep411","volume":"25","author":"MJ De Souza","year":"2010","unstructured":"De Souza MJ, Toombs RJ, Scheid JL, O\u2019Donnell E, West SL, Williams NI. High prevalence of subtle and severe menstrual disturbances in exercising women: confirmation using daily hormone measures. Hum Reprod. 2010;25(2):491\u2013503.","journal-title":"Hum Reprod"},{"key":"2525_CR43","first-page":"1","volume":"47","author":"S West","year":"2002","unstructured":"West S, King V, Carey TS, Lohr KN, McKoy N, Sutton SF, et al. Systems to rate the strength of scientific evidence. Evid Rep Technol Assess (Summ). 2002;47:1\u201311.","journal-title":"Evid Rep Technol Assess (Summ)"},{"key":"2525_CR44","doi-asserted-by":"crossref","unstructured":"American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR, et al. American College of Sports Medicine position stand: exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510\u201330.","DOI":"10.1249\/MSS.0b013e3181a0c95c"},{"issue":"8","key":"2525_CR45","doi-asserted-by":"publisher","first-page":"1273","DOI":"10.1161\/CIRCRESAHA.116.307547","volume":"118","author":"M Garcia","year":"2016","unstructured":"Garcia M, Mulvagh SL, Merz CN, Buring JE, Manson JE. Cardiovascular disease in women: clinical perspectives. Circ Res. 2016;118(8):1273\u201393.","journal-title":"Circ Res"},{"key":"2525_CR46","doi-asserted-by":"publisher","DOI":"10.1136\/heartjnl-2024-324625","author":"U Tayal","year":"2024","unstructured":"Tayal U, Pompei G, Wilkinson I, Adamson D, Sinha A, Hildick-Smith D, et al. Advancing the access to cardiovascular diagnosis and treatment among women with cardiovascular disease: a joint British Cardiovascular Societies\u2019 consensus document. Heart. 2024. https:\/\/doi.org\/10.1136\/heartjnl-2024-324625.","journal-title":"Heart"},{"issue":"10","key":"2525_CR47","doi-asserted-by":"publisher","first-page":"1867","DOI":"10.1249\/mss.0b013e318149f111","volume":"39","author":"A Nattiv","year":"2007","unstructured":"Nattiv A, Loucks AB, Manore MM, Sanborn CF, Sundgot-Borgen J, Warren MP. American College of Sports Medicine position stand: the female athlete triad. Med Sci Sports Exerc. 2007;39(10):1867\u201382.","journal-title":"Med Sci Sports Exerc"},{"issue":"5","key":"2525_CR48","doi-asserted-by":"publisher","first-page":"i","DOI":"10.1097\/00005768-199705000-00037","volume":"29","author":"CL Otis","year":"1997","unstructured":"Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand: the female athlete triad. Med Sci Sports Exerc. 1997;29(5):i\u2013ix.","journal-title":"Med Sci Sports Exerc"},{"issue":"4","key":"2525_CR49","doi-asserted-by":"publisher","first-page":"549","DOI":"10.1161\/CIRCULATIONAHA.118.038754","volume":"139","author":"BM Kuehn","year":"2019","unstructured":"Kuehn BM. Rising heart risks for young women linked to low estrogen. Circ. 2019;139(4):549\u201350.","journal-title":"Circ"},{"issue":"9","key":"2525_CR50","doi-asserted-by":"publisher","first-page":"601","DOI":"10.2165\/00007256-200434090-00004","volume":"34","author":"E O'Donnell","year":"2004","unstructured":"O\u2019Donnell E, De Souza MJ. The cardiovascular effects of chronic hypoestrogenism in amenorrhoeic athletes: a critical review. Sports Med. 2004;34(9):601\u201327.","journal-title":"Sports Med"},{"issue":"12","key":"2525_CR51","doi-asserted-by":"publisher","first-page":"3638","DOI":"10.1210\/jc.2011-1223","volume":"96","author":"E O'Donnell","year":"2011","unstructured":"O\u2019Donnell E, Goodman JM, Harvey PJ. Cardiovascular consequences of ovarian disruption: a focus on functional hypothalamic amenorrhea in physically active women. J Clin Endocrinol Metab. 2011;96(12):3638\u201348.","journal-title":"J Clin Endocrinol Metab"},{"issue":"3","key":"2525_CR52","doi-asserted-by":"publisher","first-page":"256","DOI":"10.1055\/s-0037-1603581","volume":"35","author":"CL Shufelt","year":"2017","unstructured":"Shufelt CL, Torbati T, Dutra E. Hypothalamic amenorrhea and the long-term health consequences. Semin Reprod Med. 2017;35(3):256\u201362.","journal-title":"Semin Reprod Med"},{"issue":"6","key":"2525_CR53","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.123.033154","volume":"13","author":"NL Tegg","year":"2024","unstructured":"Tegg NL, Myburgh C, O\u2019Donnell E, Kennedy M, Norris CM. Impact of secondary amenorrhea on cardiovascular disease risk in physically active women: a systematic review and meta-analysis. J Am Heart Assoc. 2024;13(6):e033154.","journal-title":"J Am Heart Assoc"},{"issue":"4","key":"2525_CR54","doi-asserted-by":"publisher","first-page":"947","DOI":"10.1016\/S0015-0282(02)04850-1","volume":"79","author":"A Rickenlund","year":"2003","unstructured":"Rickenlund A, Carlstrom K, Ekblom B, Brismar TB, von Schoultz B, Hirschberg AL. Hyperandrogenicity is an alternative mechanism underlying oligomenorrhea or amenorrhea in female athletes and may improve physical performance. Fertil Steril. 2003;79(4):947\u201355.","journal-title":"Fertil Steril"},{"issue":"11","key":"2525_CR55","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.115.002270","volume":"4","author":"Y Matsuzawa","year":"2015","unstructured":"Matsuzawa Y, Kwon TG, Lennon RJ, Lerman LO, Lerman A. Prognostic value of flow-mediated vasodilation in brachial artery and fingertip artery for cardiovascular events: a systematic review and meta-analysis. J Am Heart Assoc. 2015;4(11):e0022702015.","journal-title":"J Am Heart Assoc"},{"issue":"2","key":"2525_CR56","doi-asserted-by":"publisher","first-page":"257","DOI":"10.1016\/S0735-1097(01)01746-6","volume":"39","author":"MC Corretti","year":"2002","unstructured":"Corretti MC, Anderson TJ, Benjamin EJ, Celermajer D, Charbonneau F, Creager MA, et al. Guidelines for the ultrasound assessment of endothelial-dependent flow-mediated vasodilation of the brachial artery: a report of the International Brachial Artery Reactivity Task Force. J Am Coll Cardiol. 2002;39(2):257\u201365.","journal-title":"J Am Coll Cardiol"},{"issue":"1","key":"2525_CR57","doi-asserted-by":"publisher","first-page":"H2","DOI":"10.1152\/ajpheart.00471.2010","volume":"300","author":"DH Thijssen","year":"2011","unstructured":"Thijssen DH, Black MA, Pyke KE, Padilla J, Atkinson G, Harris RA, et al. Assessment of flow-mediated dilation in humans: a methodological and physiological guideline. Am J Physiol Heart Circ Physiol. 2011;300(1):H2-12.","journal-title":"Am J Physiol Heart Circ Physiol"},{"issue":"1","key":"2525_CR58","doi-asserted-by":"publisher","first-page":"283","DOI":"10.1093\/cvr\/cvac095","volume":"119","author":"C Heiss","year":"2023","unstructured":"Heiss C, Rodriguez-Mateos A, Bapir M, Skene SS, Sies H, Kelm M. Flow-mediated dilation reference values for evaluation of endothelial function and cardiovascular health. Cardiovasc Res. 2023;119(1):283\u201393.","journal-title":"Cardiovasc Res"},{"issue":"1","key":"2525_CR59","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1016\/S0021-9150(99)00288-9","volume":"149","author":"X Zhang","year":"2000","unstructured":"Zhang X, Zhao SP, Li XP, Gao M, Zhou QC. Endothelium-dependent and -independent functions are impaired in patients with coronary heart disease. Atherosclerosis. 2000;149(1):19\u201324.","journal-title":"Atherosclerosis"},{"issue":"6","key":"2525_CR60","doi-asserted-by":"publisher","first-page":"640","DOI":"10.1161\/01.CIR.0000028581.07992.56","volume":"106","author":"JA Vita","year":"2002","unstructured":"Vita JA, Keaney JF Jr. Endothelial function: a barometer for cardiovascular risk? Circulation. 2002;106(6):640\u20132.","journal-title":"Circulation"},{"issue":"2","key":"2525_CR61","doi-asserted-by":"publisher","first-page":"499","DOI":"10.1152\/japplphysiol.01245.2003","volume":"97","author":"KE Pyke","year":"2004","unstructured":"Pyke KE, Dwyer EM, Tschakovsky ME. Impact of controlling shear rate on flow-mediated dilation responses in the brachial artery of humans. J Appl Physiol. 2004;97(2):499\u2013508.","journal-title":"J Appl Physiol"},{"issue":"4","key":"2525_CR62","doi-asserted-by":"publisher","first-page":"351","DOI":"10.1111\/j.1365-2796.2006.01621.x","volume":"259","author":"DG Harrison","year":"2006","unstructured":"Harrison DG, Widder J, Grumbach I, Chen W, Weber M, Searles C. Endothelial mechanotransduction, nitric oxide and vascular inflammation. J Intern Med. 2006;259(4):351\u201363.","journal-title":"J Intern Med"},{"issue":"3","key":"2525_CR63","doi-asserted-by":"publisher","first-page":"241","DOI":"10.1111\/jch.12904","volume":"19","author":"BM Egan","year":"2017","unstructured":"Egan BM, Kai B, Wagner CS, Fleming DO, Henderson JH, Chandler AH, et al. Low blood pressure is associated with greater risk for cardiovascular events in treated adults with and without apparent treatment-resistant hypertension. J Clin Hypertens (Greenwich). 2017;19(3):241\u20139.","journal-title":"J Clin Hypertens (Greenwich)"},{"key":"2525_CR64","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1016\/j.puhe.2022.03.020","volume":"208","author":"K He","year":"2022","unstructured":"He K, Chen X, Shi Z, Shi S, Tian Q, Hu X, et al. Relationship of resting heart rate and blood pressure with all-cause and cardiovascular disease mortality. Public Health. 2022;208:80\u20138.","journal-title":"Public Health"},{"issue":"4","key":"2525_CR65","doi-asserted-by":"publisher","first-page":"770","DOI":"10.1097\/gme.0b013e318198cddb","volume":"16","author":"E O'Donnell","year":"2009","unstructured":"O\u2019Donnell E, Kirwan LD, Goodman JM. Aerobic exercise training in healthy postmenopausal women: effects of hormone therapy. Menopause. 2009;16(4):770\u20136.","journal-title":"Menopause"},{"issue":"1","key":"2525_CR66","doi-asserted-by":"publisher","first-page":"807","DOI":"10.1152\/physrev.00006.2018","volume":"99","author":"N Goswami","year":"2019","unstructured":"Goswami N, Blaber AP, Hinghofer-Szalkay H, Convertino VA. Lower body negative pressure: physiological effects, applications, and implementation. Physiol Rev. 2019;99(1):807\u201351.","journal-title":"Physiol Rev"},{"issue":"5","key":"2525_CR67","doi-asserted-by":"publisher","first-page":"742","DOI":"10.1093\/europace\/eus341","volume":"15","author":"S Hillebrand","year":"2013","unstructured":"Hillebrand S, Gast KB, de Mutsert R, Swenne CA, Jukema JW, Middeldorp S, et al. Heart rate variability and first cardiovascular event in populations without known cardiovascular disease: meta-analysis and dose-response meta-regression. Europace. 2013;15(5):742\u20139.","journal-title":"Europace"},{"issue":"25","key":"2525_CR68","first-page":"e1046","volume":"139","author":"SM Grundy","year":"2018","unstructured":"Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA\/ACC\/AACVPR\/AAPA\/ABC\/ACPM\/ADA\/AGS\/APhA\/ASPC\/NLA\/PCNA guideline on the management of blood cholesterol: executive summary: a report of the American College of Cardiology\/American Heart Association Task Force on clinical practice guidelines. Circulation. 2018;139(25):e1046\u201381.","journal-title":"Circulation"},{"issue":"10","key":"2525_CR69","doi-asserted-by":"publisher","first-page":"1108","DOI":"10.1161\/hc3501.095214","volume":"104","author":"AR Sharrett","year":"2001","unstructured":"Sharrett AR, Ballantyne CM, Coady SA, Heiss G, Sorlie PD, Catellier D, et al. Coronary heart disease prediction from lipoprotein cholesterol levels, triglycerides, lipoprotein(a), apolipoproteins A-I and B, and HDL density subfractions: the Atherosclerosis Risk in Communities (ARIC) study. Circulation. 2001;104(10):1108\u201313.","journal-title":"Circulation"},{"issue":"1","key":"2525_CR70","doi-asserted-by":"publisher","first-page":"49","DOI":"10.1089\/ars.2019.7955","volume":"34","author":"E Gianazza","year":"2021","unstructured":"Gianazza E, Brioschi M, Martinez Fernandez A, Casalnuovo F, Altomare A, Aldini G, et al. Lipid peroxidation in atherosclerotic cardiovascular diseases. Antioxid Redox Signal. 2021;34(1):49\u201398.","journal-title":"Antioxid Redox Signal"},{"issue":"12","key":"2525_CR71","doi-asserted-by":"publisher","first-page":"1952","DOI":"10.1161\/01.ATV.0000041200.85946.4A","volume":"22","author":"KJ Ho","year":"2002","unstructured":"Ho KJ, Liao JK. Nonnuclear actions of estrogen. Arterioscler Thromb Vasc Biol. 2002;22(12):1952\u201361.","journal-title":"Arterioscler Thromb Vasc Biol"},{"issue":"3","key":"2525_CR72","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1111\/j.1474-9726.2005.00151.x","volume":"4","author":"C Borras","year":"2005","unstructured":"Borras C, Gambini J, Gomez-Cabrera MC, Sastre J, Pallardo FV, Mann GE, et al. 17Beta-oestradiol up-regulates longevity-related, antioxidant enzyme expression via the ERK1 and ERK2[MAPK]\/NFkappaB cascade. Aging Cell. 2005;4(3):113\u20138.","journal-title":"Aging Cell"},{"issue":"5","key":"2525_CR73","doi-asserted-by":"publisher","first-page":"R498","DOI":"10.1152\/ajpregu.00182.2014","volume":"307","author":"E O'Donnell","year":"2014","unstructured":"O\u2019Donnell E, Floras JS, Harvey PJ. Estrogen status and the renin angiotensin aldosterone system. Am J Physiol Regul Integr Comp Physiol. 2014;307(5):R498-500.","journal-title":"Am J Physiol Regul Integr Comp Physiol"},{"issue":"6","key":"2525_CR74","doi-asserted-by":"publisher","first-page":"622","DOI":"10.1111\/1440-1681.12392","volume":"42","author":"MI Pinkham","year":"2015","unstructured":"Pinkham MI, Barrett CJ. Estradiol alters the chemosensitive cardiac afferent reflex in female rats by augmenting sympathoinhibition and attenuating sympathoexcitation. Clin Exp Pharmacol Physiol. 2015;42(6):622\u201331.","journal-title":"Clin Exp Pharmacol Physiol"},{"issue":"9","key":"2525_CR75","doi-asserted-by":"publisher","first-page":"827","DOI":"10.1111\/j.1440-1681.2007.04663.x","volume":"34","author":"TM Saleh","year":"2007","unstructured":"Saleh TM, Connell BJ. Role of oestrogen in the central regulation of autonomic function. Clin Exp Pharmacol Physiol. 2007;34(9):827\u201332.","journal-title":"Clin Exp Pharmacol Physiol"},{"issue":"17","key":"2525_CR76","doi-asserted-by":"publisher","first-page":"1196","DOI":"10.1056\/NEJM199110243251702","volume":"325","author":"BW Walsh","year":"1991","unstructured":"Walsh BW, Schiff I, Rosner B, Greenberg L, Ravnikar V, Sacks FM. Effects of postmenopausal estrogen replacement on the concentrations and metabolism of plasma lipoproteins. N Engl J Med. 1991;325(17):1196\u2013204.","journal-title":"N Engl J Med"},{"issue":"4","key":"2525_CR77","doi-asserted-by":"publisher","first-page":"328","DOI":"10.1097\/MOL.0000000000000432","volume":"28","author":"SR El Khoudary","year":"2017","unstructured":"El Khoudary SR. HDL and the menopause. Curr Opin Lipidol. 2017;28(4):328\u201336.","journal-title":"Curr Opin Lipidol"},{"issue":"1A","key":"2525_CR78","doi-asserted-by":"publisher","first-page":"40S","DOI":"10.1016\/S0002-9343(99)80058-8","volume":"98","author":"SM Haffner","year":"1995","unstructured":"Haffner SM, Valdez RA. Endogenous sex hormones: impact on lipids, lipoproteins, and insulin. Am J Med. 1995;98(1A):40S-S47.","journal-title":"Am J Med"},{"issue":"2","key":"2525_CR79","doi-asserted-by":"publisher","first-page":"269","DOI":"10.1016\/j.mcna.2012.01.012","volume":"96","author":"LH Duntas","year":"2012","unstructured":"Duntas LH, Brenta G. The effect of thyroid disorders on lipid levels and metabolism. Med Clin N Am. 2012;96(2):269\u201381.","journal-title":"Med Clin N Am"},{"issue":"1","key":"2525_CR80","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1007\/s40279-024-02115-z","volume":"55","author":"NA Smart","year":"2025","unstructured":"Smart NA, Downes D, van der Touw T, Hada S, Dieberg G, Pearson MJ, et al. The effect of exercise training on blood lipids: a systematic review and meta-analysis. Sports Med. 2025;55(1):67\u201378.","journal-title":"Sports Med"},{"issue":"3 Pt 2","key":"2525_CR81","first-page":"R817","volume":"266","author":"AB Loucks","year":"1994","unstructured":"Loucks AB, Heath EM. Induction of low-T3 syndrome in exercising women occurs at a threshold of energy availability. Am J Physiol. 1994;266(3 Pt 2):R817\u201323.","journal-title":"Am J Physiol"},{"issue":"17","key":"2525_CR82","doi-asserted-by":"publisher","first-page":"6659","DOI":"10.1073\/pnas.0308291101","volume":"101","author":"L Fontana","year":"2004","unstructured":"Fontana L, Meyer TE, Klein S, Holloszy JO. Long-term calorie restriction is highly effective in reducing the risk for atherosclerosis in humans. Proc Natl Acad Sci USA. 2004;101(17):6659\u201363.","journal-title":"Proc Natl Acad Sci USA"},{"issue":"4","key":"2525_CR83","doi-asserted-by":"publisher","first-page":"644","DOI":"10.1111\/j.1474-9726.2012.00825.x","volume":"11","author":"PK Stein","year":"2012","unstructured":"Stein PK, Soare A, Meyer TE, Cangemi R, Holloszy JO, Fontana L. Caloric restriction may reverse age-related autonomic decline in humans. Aging Cell. 2012;11(4):644\u201350.","journal-title":"Aging Cell"},{"issue":"3","key":"2525_CR84","doi-asserted-by":"publisher","first-page":"450","DOI":"10.1161\/HYPERTENSIONAHA.114.03726","volume":"64","author":"Y Mao","year":"2014","unstructured":"Mao Y, Tokudome T, Kishimoto I. Ghrelin as a treatment for cardiovascular diseases. Hypertension. 2014;64(3):450\u20134.","journal-title":"Hypertension"},{"issue":"5","key":"2525_CR85","doi-asserted-by":"publisher","first-page":"463","DOI":"10.1210\/er.2007-0006","volume":"28","author":"R Muniyappa","year":"2007","unstructured":"Muniyappa R, Montagnani M, Koh KK, Quon MJ. Cardiovascular actions of insulin. Endocr Rev. 2007;28(5):463\u201391.","journal-title":"Endocr Rev"},{"issue":"1 Pt 1","key":"2525_CR86","first-page":"E1","volume":"270","author":"GN Wade","year":"1996","unstructured":"Wade GN, Schneider JE, Li HY. Control of fertility by metabolic cues. Am J Physiol. 1996;270(1 Pt 1):E1-19.","journal-title":"Am J Physiol"},{"issue":"4","key":"2525_CR87","doi-asserted-by":"publisher","first-page":"971","DOI":"10.1016\/j.fertnstert.2006.11.171","volume":"88","author":"MJ De Souza","year":"2007","unstructured":"De Souza MJ, Lee DK, VanHeest JL, Scheid JL, West SL, Williams NI. Severity of energy-related menstrual disturbances increases in proportion to indices of energy conservation in exercising women. Fertil Steril. 2007;88(4):971\u20135.","journal-title":"Fertil Steril"},{"issue":"1","key":"2525_CR88","doi-asserted-by":"publisher","first-page":"140","DOI":"10.1016\/j.bone.2008.03.013","volume":"43","author":"MJ De Souza","year":"2008","unstructured":"De Souza MJ, West SL, Jamal SA, Hawker GA, Gundberg CM, Williams NI. The presence of both an energy deficiency and estrogen deficiency exacerbate alterations of bone metabolism in exercising women. Bone. 2008;43(1):140\u20138.","journal-title":"Bone"},{"issue":"1","key":"2525_CR89","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1249\/00005768-199101000-00004","volume":"23","author":"M Myerson","year":"1991","unstructured":"Myerson M, Gutin B, Warren MP, May MT, Contento I, Lee M, et al. Resting metabolic rate and energy balance in amenorrheic and eumenorrheic runners. Med Sci Sports Exerc. 1991;23(1):15\u201322.","journal-title":"Med Sci Sports Exerc"},{"issue":"5","key":"2525_CR90","doi-asserted-by":"publisher","first-page":"R1483","DOI":"10.1152\/ajpregu.2001.280.5.R1483","volume":"280","author":"N Nagaya","year":"2001","unstructured":"Nagaya N, Kojima M, Uematsu M, Yamagishi M, Hosoda H, Oya H, et al. Hemodynamic and hormonal effects of human ghrelin in healthy volunteers. Am J Physiol Regul Integr Comp Physiol. 2001;280(5):R1483\u20137.","journal-title":"Am J Physiol Regul Integr Comp Physiol"},{"issue":"19","key":"2525_CR91","doi-asserted-by":"publisher","first-page":"2986","DOI":"10.1161\/CIRCULATIONAHA.105.553883","volume":"112","author":"M Tesauro","year":"2005","unstructured":"Tesauro M, Schinzari F, Iantorno M, Rizza S, Melina D, Lauro D, et al. Ghrelin improves endothelial function in patients with metabolic syndrome. Circulation. 2005;112(19):2986\u201392.","journal-title":"Circulation"},{"issue":"4","key":"2525_CR92","doi-asserted-by":"publisher","first-page":"228","DOI":"10.2174\/157339910791658871","volume":"6","author":"M Tesauro","year":"2010","unstructured":"Tesauro M, Schinzari F, Caramanti M, Lauro R, Cardillo C. Cardiovascular and metabolic effects of ghrelin. Curr Diabetes Rev. 2010;6(4):228\u201335.","journal-title":"Curr Diabetes Rev"},{"issue":"10","key":"2525_CR93","doi-asserted-by":"publisher","first-page":"3045","DOI":"10.1007\/s00421-024-05497-0","volume":"124","author":"MJ Hutson","year":"2024","unstructured":"Hutson MJ, O\u2019Donnell E, McConnell K, Chauntry AJ, Blagrove RC. Energy availability modulates regional blood flow via estrogen-independent pathways in regularly menstruating young women. Eur J Appl Physiol. 2024;124(10):3045\u201355.","journal-title":"Eur J Appl Physiol"},{"issue":"2","key":"2525_CR94","doi-asserted-by":"publisher","first-page":"549","DOI":"10.1152\/physrev.00035.2013","volume":"95","author":"MJ Joyner","year":"2015","unstructured":"Joyner MJ, Casey DP. Regulation of increased blood flow (hyperemia) to muscles during exercise: a hierarchy of competing physiological needs. Physiol Rev. 2015;95(2):549\u2013601.","journal-title":"Physiol Rev"},{"issue":"3","key":"2525_CR95","doi-asserted-by":"publisher","first-page":"279","DOI":"10.1017\/S0029665118002811","volume":"78","author":"N Casanova","year":"2019","unstructured":"Casanova N, Beaulieu K, Finlayson G, Hopkins M. Metabolic adaptations during negative energy balance and their potential impact on appetite and food intake. Proc Nutr Soc. 2019;78(3):279\u201389.","journal-title":"Proc Nutr Soc"},{"issue":"9","key":"2525_CR96","doi-asserted-by":"publisher","first-page":"853","DOI":"10.1111\/j.1440-1681.2006.04453.x","volume":"33","author":"RH Fagard","year":"2006","unstructured":"Fagard RH. Exercise is good for your blood pressure: effects of endurance training and resistance training. Clin Exp Pharmacol Physiol. 2006;33(9):853\u20136.","journal-title":"Clin Exp Pharmacol Physiol"},{"key":"2525_CR97","doi-asserted-by":"crossref","unstructured":"Leon AS, Sanchez OA. Response of blood lipids to exercise training alone or combined with dietary intervention. Med Sci Sports Exerc. 2001;33(6 Suppl.):S502\u201315 (discussion S28\u2013S29).","DOI":"10.1097\/00005768-200106001-00021"},{"issue":"1","key":"2525_CR98","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1055\/a-1864-9726","volume":"44","author":"CJ Lundstrom","year":"2023","unstructured":"Lundstrom CJ, Foreman NA, Biltz G. Practices and applications of heart rate variability monitoring in endurance athletes. Int J Sports Med. 2023;44(1):9\u201319.","journal-title":"Int J Sports Med"},{"issue":"Pt 1","key":"2525_CR99","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1113\/jphysiol.2004.068197","volume":"561","author":"DJ Green","year":"2004","unstructured":"Green DJ, Maiorana A, O\u2019Driscoll G, Taylor R. Effect of exercise training on endothelium-derived nitric oxide function in humans. J Physiol. 2004;561(Pt 1):1\u201325.","journal-title":"J Physiol"},{"issue":"2","key":"2525_CR100","doi-asserted-by":"publisher","first-page":"229","DOI":"10.1111\/cen.14399","volume":"95","author":"AE Morrison","year":"2021","unstructured":"Morrison AE, Fleming S, Levy MJ. A review of the pathophysiology of functional hypothalamic amenorrhoea in women subject to psychological stress, disordered eating, excessive exercise or a combination of these factors. Clin Endocrinol (Oxf). 2021;95(2):229\u201338.","journal-title":"Clin Endocrinol (Oxf)"},{"issue":"3","key":"2525_CR101","doi-asserted-by":"publisher","first-page":"571","DOI":"10.1016\/S0015-0282(16)55802-6","volume":"59","author":"RE Nappi","year":"1993","unstructured":"Nappi RE, Petraglia F, Genazzani AD, D\u2019Ambrogio G, Zara C, Genazzani AR. Hypothalamic amenorrhea: evidence for a central derangement of hypothalamic-pituitary-adrenal cortex axis activity. Fertil Steril. 1993;59(3):571\u20136.","journal-title":"Fertil Steril"},{"issue":"11","key":"2525_CR102","doi-asserted-by":"publisher","DOI":"10.3390\/brainsci12111448","volume":"12","author":"C Pruneti","year":"2022","unstructured":"Pruneti C, Guidotti S. Cognition, behavior, sexuality, and autonomic responses of women with hypothalamic amenorrhea. Brain Sci. 2022;12(11):1448.","journal-title":"Brain Sci"},{"issue":"4","key":"2525_CR103","doi-asserted-by":"publisher","first-page":"530","DOI":"10.7326\/0003-4819-108-4-530","volume":"108","author":"JH Ding","year":"1988","unstructured":"Ding JH, Sheckter CB, Drinkwater BL, Soules MR, Bremner WJ. High serum cortisol levels in exercise-associated amenorrhea. Ann Intern Med. 1988;108(4):530\u20134.","journal-title":"Ann Intern Med"},{"key":"2525_CR104","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1111\/j.1749-6632.2010.05663.x","volume":"1205","author":"SA Pauli","year":"2010","unstructured":"Pauli SA, Berga SL. Athletic amenorrhea: energy deficit or psychogenic challenge? Ann N Y Acad Sci. 2010;1205:33\u20138.","journal-title":"Ann N Y Acad Sci"},{"key":"2525_CR105","doi-asserted-by":"publisher","DOI":"10.1155\/2020\/5245308","author":"C Khatana","year":"2020","unstructured":"Khatana C, Saini NK, Chakrabarti S, Saini V, Sharma A, Saini RV, et al. Mechanistic insights into the oxidized low-density lipoprotein-induced atherosclerosis. Oxid Med Cell Longev. 2020. https:\/\/doi.org\/10.1155\/2020\/5245308.","journal-title":"Oxid Med Cell Longev"},{"issue":"13","key":"2525_CR106","doi-asserted-by":"publisher","first-page":"1708","DOI":"10.1161\/CIRCULATIONAHA.105.602532","volume":"113","author":"U Forstermann","year":"2006","unstructured":"Forstermann U, Munzel T. Endothelial nitric oxide synthase in vascular disease: from marvel to menace. Circulation. 2006;113(13):1708\u201314.","journal-title":"Circulation"},{"issue":"12","key":"2525_CR107","doi-asserted-by":"publisher","first-page":"830","DOI":"10.1016\/j.autrev.2010.07.016","volume":"9","author":"S Sitia","year":"2010","unstructured":"Sitia S, Tomasoni L, Atzeni F, Ambrosio G, Cordiano C, Catapano A, et al. From endothelial dysfunction to atherosclerosis. Autoimmun Rev. 2010;9(12):830\u20134.","journal-title":"Autoimmun Rev"},{"issue":"6 Pt 2","key":"2525_CR108","doi-asserted-by":"publisher","first-page":"112S","DOI":"10.1016\/S0895-7061(00)00228-4","volume":"13","author":"RD Brook","year":"2000","unstructured":"Brook RD, Julius S. Autonomic imbalance, hypertension, and cardiovascular risk. Am J Hypertens. 2000;13(6 Pt 2):112S-S122.","journal-title":"Am J Hypertens"},{"issue":"4","key":"2525_CR109","doi-asserted-by":"publisher","first-page":"522","DOI":"10.1161\/01.HYP.0000160318.46725.46","volume":"45","author":"K Narkiewicz","year":"2005","unstructured":"Narkiewicz K, Phillips BG, Kato M, Hering D, Bieniaszewski L, Somers VK. Gender-selective interaction between aging, blood pressure, and sympathetic nerve activity. Hypertension. 2005;45(4):522\u20135.","journal-title":"Hypertension"},{"issue":"10","key":"2525_CR110","doi-asserted-by":"publisher","first-page":"619","DOI":"10.1016\/j.annepidem.2017.08.024","volume":"27","author":"Y Kubota","year":"2017","unstructured":"Kubota Y, Chen LY, Whitsel EA, Folsom AR. Heart rate variability and lifetime risk of cardiovascular disease: the Atherosclerosis Risk in Communities Study. Ann Epidemiol. 2017;27(10):619-25.e2.","journal-title":"Ann Epidemiol"},{"issue":"32","key":"2525_CR111","doi-asserted-by":"publisher","first-page":"2478","DOI":"10.1093\/eurheartj\/ehx163","volume":"38","author":"CM Madsen","year":"2017","unstructured":"Madsen CM, Varbo A, Nordestgaard BG. Extreme high high-density lipoprotein cholesterol is paradoxically associated with high mortality in men and women: two prospective cohort studies. Eur Heart J. 2017;38(32):2478\u201386.","journal-title":"Eur Heart J"},{"issue":"12","key":"2525_CR112","doi-asserted-by":"publisher","first-page":"1420","DOI":"10.1016\/j.mayocp.2013.09.011","volume":"88","author":"A Saxena","year":"2013","unstructured":"Saxena A, Minton D, Lee DC, Sui X, Fayad R, Lavie CJ, et al. Protective role of resting heart rate on all-cause and cardiovascular disease mortality. Mayo Clin Proc. 2013;88(12):1420\u20136.","journal-title":"Mayo Clin Proc"},{"issue":"23","key":"2525_CR113","doi-asserted-by":"publisher","first-page":"2244","DOI":"10.1161\/CIRCULATIONAHA.120.052624","volume":"143","author":"H Kaneko","year":"2017","unstructured":"Kaneko H, Yano Y, Itoh H, Morita K, Kiriyama H, Kamon T, et al. Association of blood pressure classification using the 2017 American College of Cardiology\/American Heart Association blood pressure guideline with risk of heart failure and atrial fibrillation. Circulation. 2017;143(23):2244\u201353.","journal-title":"Circulation"},{"issue":"1","key":"2525_CR114","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1258\/ebm.2009.009186","volume":"235","author":"EJ Adkisson","year":"2010","unstructured":"Adkisson EJ, Casey DP, Beck DT, Gurovich AN, Martin JS, Braith RW. Central, peripheral and resistance arterial reactivity: fluctuates during the phases of the menstrual cycle. Exp Biol Med (Maywood). 2010;235(1):111\u20138.","journal-title":"Exp Biol Med (Maywood)"},{"issue":"8","key":"2525_CR115","doi-asserted-by":"publisher","first-page":"1782","DOI":"10.1161\/ATVBAHA.107.145383","volume":"27","author":"A Sherwood","year":"2007","unstructured":"Sherwood A, Bower JK, McFetridge-Durdle J, Blumenthal JA, Newby LK, Hinderliter AL. Age moderates the short-term effects of transdermal 17beta-estradiol on endothelium-dependent vascular function in postmenopausal women. Arterioscler Thromb Vasc Biol. 2007;27(8):1782\u20137.","journal-title":"Arterioscler Thromb Vasc Biol"},{"key":"2525_CR116","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1016\/j.maturitas.2022.08.001","volume":"166","author":"N Torosyan","year":"2022","unstructured":"Torosyan N, Visrodia P, Torbati T, Minissian MB, Shufelt CL. Dyslipidemia in midlife women: approach and considerations during the menopausal transition. Maturitas. 2022;166:14\u201320.","journal-title":"Maturitas"},{"key":"2525_CR117","doi-asserted-by":"publisher","DOI":"10.1016\/j.maturitas.2025.108608","volume":"198","author":"A Vallee","year":"2025","unstructured":"Vallee A. Menopause and arterial stiffness index: insights from the women\u2019s UK Biobank cohort. Maturitas. 2025;198:108608.","journal-title":"Maturitas"},{"issue":"Suppl. 3","key":"2525_CR118","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1111\/sms.12581","volume":"25","author":"BK Pedersen","year":"2015","unstructured":"Pedersen BK, Saltin B. Exercise as medicine: evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25(Suppl. 3):1\u201372.","journal-title":"Scand J Med Sci Sports"},{"issue":"6","key":"2525_CR119","doi-asserted-by":"publisher","first-page":"801","DOI":"10.1503\/cmaj.051351","volume":"174","author":"DE Warburton","year":"2006","unstructured":"Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801\u20139.","journal-title":"CMAJ"},{"issue":"2","key":"2525_CR120","doi-asserted-by":"publisher","first-page":"138","DOI":"10.1161\/CIRCULATIONAHA.117.027834","volume":"136","author":"VL Aengevaeren","year":"2017","unstructured":"Aengevaeren VL, Mosterd A, Braber TL, Prakken NHJ, Doevendans PA, Grobbee DE, et al. Relationship between lifelong exercise volume and coronary atherosclerosis in athletes. Circulation. 2017;136(2):138\u201348.","journal-title":"Circulation"},{"issue":"2","key":"2525_CR121","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1161\/CIRCULATIONAHA.116.026964","volume":"136","author":"A Merghani","year":"2017","unstructured":"Merghani A, Maestrini V, Rosmini S, Cox AT, Dhutia H, Bastiaenan R, et al. Prevalence of subclinical coronary artery disease in masters endurance athletes with a low atherosclerotic risk profile. Circulation. 2017;136(2):126\u201337.","journal-title":"Circulation"},{"issue":"15","key":"2525_CR122","doi-asserted-by":"publisher","first-page":"1903","DOI":"10.1093\/eurheartj\/ehn163","volume":"29","author":"S Mohlenkamp","year":"2008","unstructured":"Mohlenkamp S, Lehmann N, Breuckmann F, Brocker-Preuss M, Nassenstein K, Halle M, et al. Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J. 2008;29(15):1903\u201310.","journal-title":"Eur Heart J"},{"issue":"2","key":"2525_CR123","doi-asserted-by":"publisher","first-page":"88","DOI":"10.1038\/nrcardio.2016.173","volume":"14","author":"E Guasch","year":"2017","unstructured":"Guasch E, Mont L. Diagnosis, pathophysiology, and management of exercise-induced arrhythmias. Nat Rev Cardiol. 2017;14(2):88\u2013101.","journal-title":"Nat Rev Cardiol"}],"container-title":["Sports Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s40279-026-02525-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s40279-026-02525-1","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s40279-026-02525-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T03:48:40Z","timestamp":1791949720000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s40279-026-02525-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,13]]},"references-count":123,"alternative-id":["2525"],"URL":"https:\/\/doi.org\/10.1007\/s40279-026-02525-1","relation":{},"ISSN":["0112-1642","1179-2035"],"issn-type":[{"value":"0112-1642","type":"print"},{"value":"1179-2035","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,13]]},"assertion":[{"value":"23 July 2026","order":1,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"13 October 2026","order":2,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"All authors have no financial interests or relationships to disclose, except as indicated: Mary Jane De Souza is a consultant for the California Prune Board and for Regeneron. Madhusmita Misra has served as a consultant for Regeneron, receives study drug donations from Tonix Pharmaceuticals and Amgen, and honoraria from UpToDate. Aurelia Nattiv has received support as (1) Co-Principal Investigator, Department of Defense and Medical Technology Enterprise Consortium, \u201cExtracorporeal Shockwave Therapy for the Management of Stress Fractures and High-Grad Bone Stress Injuries: A Randomized Double-Blind Controlled Trial\u201d and (2) Co-Principal Investigator, Pac-12 Conference Student-Athlete Health & Well-Being Grant Award, \u201cImproving Bone Health and Reducing the Incidence of Bone Stress Injuries in Pac-12 Distance Runners: An Implementation Plan Focusing on Health Promotion, Optimal Fueling, and Changing Culture\u201d, and (3) as a consultant for the National Football League Research & Innovation Committee.","order":1,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Ethics approval","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":3,"name":"Ethics","label":"Consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":4,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This work is based on a synthesis of previously published studies. No new datasets were generated or analyzed, and therefore data sharing is not applicable.","order":5,"name":"Ethics","label":"Availability of data and material","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":6,"name":"Ethics","label":"Code availability","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"EOD drafted, reviewed, and edited the manuscript. MJD and NIW oversaw all final edits. All authors contributed to writing, editing consensus discussions, development and approval of evidence-based statements and their grading and approval of the final manuscript.","order":7,"name":"Ethics","label":"Author contributions","group":{"name":"EthicsHeading","label":"Declarations"}}]}}