CaREFREE Study (Calorie Restriction, Environment and Fitness: Reproductive Effects Evaluation Study)
CaREFREE Study (Calorie Restriction, Environment and Fitness: Reproductive Effects Evaluation Study)
Background:

 Functional hypothalamic amenorrhea (functional HA) is a condition where a woman s period
 stops for a temporary time. This is due to improper function of the hypothalamus. This is the
 part of the brain that directs the whole reproductive system. Researchers want to learn more
 about functional HA. They also want to learn how diet, exercise, and other factors may change
 women s menstrual cycles.

 Objective:

 To better understand functional HA.

 Eligibility:

 Healthy women ages 18-28 years old who:

 -  Have regular periods

 -  Exercise no more than 4 hours a week

 -  Had their first period at age 11-14

 Design:

 Participants will be prescreened over the phone.

 Participants will be screened with:

 -  Blood and urine tests

 -  Medical history

 -  Physical exam.

 Participants will have 9 or 10 visits over about 3 menstrual cycles. These include:

 -  Repeat of screening tests

 -  Questionnaires

 -  Exercise test

 -  Resting energy expenditure test: Participants fast overnight before the test. They lie
 on their back under a

 canopy for a half hour.

 -  Body composition test: This is done with a dual energy x-ray absorptiometry (DXA) scan.

 -  Pelvic ultrasound

 -  For two full-day visits, an IV is inserted into an arm vein. The IV takes a blood sample
 every 10 minutes for 8 hours.

 Participants will keep logs:

 -  Menstrual cycle log

 -  Diet log for three 4-day cycles

 Participants will receive test kits to complete at home:

 -  Daily blood and urine sample

 -  Ovulation

 Participants will take a daily iron supplement. They will wear a wristband that monitors
 activity 24 hours a day.

 Participants will stick to a special diet for two 5-day periods of time. They will complete
 two 4-day exercise programs.

 ...
Functional hypothalamic amenorrhea (HA) is a reversible form of hypogonadotropic hypogonadism
 (HH) that can be triggered by stressors such as exercise, nutritional deficits, and
 psychological stress. Dysfunction of the hypothalamic component of the reproductive axis
 plays a key role in functional HA and is manifest by an altered pattern of luteinizing
 hormone (LH) pulses detectable in peripheral blood. There is ample evidence supporting the
 use of LH as a surrogate marker of hypothalamic gonadotropin-releasing hormone (GnRH)
 secretion from the hypothalamus. There is also significant evidence that women vary in their
 susceptibility to such stress-induced amenorrhea, pointing to a role for both environmental
 and genetic factors in the etiology of functional HA. However, the variation in changes in
 GnRH pulse frequency in response to stressors in healthy women has not been defined. Data
 from previous work in our lab has suggested that rare variants in genes associated with other
 forms of HH may also contribute to the variability seen in susceptibility to functional HA.
 The long-term goal of our research is to examine the interaction of environment and genes in
 HA. In this pilot study we propose to examine the inter-individual variability in pulsatile
 LH secretion in response to standardized neutral and deficient energy availability (NEA and
 DEA, respectively) in normal women. We will then relate this primary end-point to proposed
 predictive factors including past reproductive and family history and markers of current
 metabolic status and their response to energy availability. Our initial analyses will help to
 determine simplified biomarkers that can be translated to larger studies examining the
 potential combined effect of energy availability and genotype.

 The proposed pilot study is a single-site, 2-period study in healthy female volunteers. The
 study will enroll approximately 150 participants over 2 years with a target for study
 completion of 25 subjects. Eligible participants will be females greater than or equal to 18
 years of age. Eligible participants will have had menarche at or before 14 years of age and
 no earlier than age 11. Eligible participants will have a gynecological age (years after
 menarche) of 14 years or less. The upper age limit will vary based on each subject s age of
 menarche and fall between 25 and 28 among participants. Eligible participants will confirm at
 the pre-screening call having normal menstrual cycles (self-reported) for at least the
 previous 2 months and ovulation will be confirmed during the menstrual cycle before the start
 of intervention.

 The primary outcome will be changes in daytime LH pulse frequency, when comparing NEA vs DEA.
 Secondary measures will evaluate past reproductive history, family history, and current
 metabolic status using medical history interviews, lifestyle questionnaires and maximum
 oxygen uptake (as a measure of fitness). Resting energy expenditure, body composition as well
 as metabolic and stress hormones will be measured at baseline and in association with the
 interventions. Blood samples will be collected for eventual genotyping.
-  INCLUSION CRITERIA:

 1. Female

 2. Between 18 and 28 years of age (inclusive)

 3. Reported menarche between the ages of 11 and 14 years

 4. Gynecological age of less than or equal to 14 years

 5. A history of self-reported regular menstrual cycles when not on contraceptive
 medication of between 25 and 35 days (inclusive) at prescreen and knowledge of
 date of onset of menses before the screening visit

 6. A BMI of 18.5 to 27 kg (Summation)m(2) and a weight >= 93 lbs.

 7. Agrees to use barrier contraception method for the duration of the study

 8. Agrees to abstain from alcohol consumption during both 5-day diet/exercise study
 interventions

 9. Agrees to abstain from donating blood during the study and within 30 days of
 completing the study

 10. Is willing and able to fulfill the requirements of the protocol and to provide
 informed consent

 11. Able to speak and read English

 12. Lives within 50 miles of the Clinical Research Unit

 EXCLUSION CRITERIA:

 1. Currently lactating or pregnant or planning on becoming pregnant for the duration of
 the study

 2. Has ever given birth

 3. History in the past 3 months of dieting or weight loss amounting to greater than 2 kg
 (4.4 lbs)

 4. > 4 hours per week of aerobic exercise for the past 3 months

 5. Has initiated training for an athletic sport or event in the past 3 months that, in
 the opinion of the investigator, may interfere with the results of the study

 6. Currently using hormone-based contraception, including those administered orally,
 vaginally, via injection, sub-dermally, or transdermally

 7. Current use of medications or supplements that may interfere with the results of the
 study, including:

 i.Steroids

 ii.Hormone-based contraception

 iii.Sleeping pills

 iv.Homeopathic substances (e.g. Chinese herbs, protein or other powders, and
 other-the-counter extracts)

 v.Stimulants (e.g. Ritalin)

 vi.Antidepressants or anti-epileptic medications or centrally acting anti-hypertensive
 medications

 8. Current use of recreational drugs (alcohol intake will be monitored and excluded
 during the two intervention periods)

 9. Unable to consume food containing dairy or nuts

 10. Has currently or has a history of any of the following: autoimmune, heart, liver,
 renal disease, diabetes, or another health condition deemed by the PI to be a
 contraindication to study participation. History of thyroid disorder is permissible if
 the patient is biochemically euthyroid on replacement.

 Additional Eligibility Criteria to be Met Prior to Start of Intervention(s):

 Criteria 1 Habitual energy intake between 35-55 kcal/kg LBM*day

 Criteria 2 VO2max less than or equal to 40 ml/kg/min with the option to increase this at
 the discretion of the PI, depending on the current and past exercise level of the
 participant

 Criteria 3 Hemoglobin, prolactin and TSH within normal female range for testing laboratory.

 Criteria 4 Ovulation confirmed in the cycle before each study intervention by self-reported
 positive urine test, ultrasound and/or progesterone blood-levels