Effect of Oestrogen on Musculoskeletal Outcomes (E2)

The Effect of Menstrual Cycle Phase and Hormonal Contraceptives on Bone Metabolism, Reproductive Status, Iron Status and Musculoskeletal Health

This cross-sectional comparison and prospective cohort design study will investigate differences in calcium metabolism, biochemical markers of bone and reproductive health, musculoskeletal health, and iron status between women using different hormonal contraceptives (combined oral contraceptive pill (COCP), hormonal implant, hormonal intra-uterine system (IUS), hormonal contraceptive injection, and eumenorrheic non-hormonal contraceptive users). The same outcomes will also be examined across a menstrual cycle in the eumenorrheic non-hormonal contraceptive users.

The study will test the following hypotheses:

Hormonal contraceptive use

1. Biochemical markers of bone resorption and formation and ratio of urinary 44Ca:42Ca will be higher in the implant and injection groups compared with IUS (which exerts localised effects) and non-HC users (ovulatory phase), and lower in COCP compared with non-HC users;
2. Oestradiol and progesterone will be lower in hormonal contraceptive users compared with non-HC users during the ovulatory phase;
3. Bone macro- and microstructure, muscle strength, and tissue properties are different in hormonal contraceptive users compared with non-HC users;
4. Calcium and bone metabolism, reproductive hormones and musculoskeletal function are different between the pill phase and non-pill phase of COCP use.

Menstrual cycle phase

1. Calcium and bone metabolism are lower during the ovulatory phase compared with menses, mid follicular and mid luteal phases.
2. Muscle strength and tissue properties are different across the menstrual cycle in non-HC users.

Study Overview

• Status: Recruiting
• Conditions: Contraception; Estrogen Deficiency; Estrogen Excess

Detailed Description

Women of reproductive age experience cyclical variation during the menstrual cycle in the female sex steroid hormones, oestrogens and progesterone. Oestrogens performs a primary function in sexual development and reproduction; but, non-reproductive effects on bone, muscle, sinew tissue (e.g. ligaments and tendons) and metabolism may influence injury risk and physical performance. Hormonal contraceptive use, which is common in athletes and military service women, disrupts the reproductive axis and suppresses endogenous hormone production. The purpose of this study is to compare calcium metabolism, biochemical markers of bone and reproductive health, iron status and musculoskeletal health between women using one of four methods of hormonal contraceptives-combined oral contraceptive pill (COCP), hormonal implant, hormonal intra-uterine system (IUS) and hormonal contraceptive injection-and eumenorrheic, non-hormonal contraceptive users (non-HC).

The study will involve a pre-screening visit followed by the main study visits. During the pre-screen visit a venous blood sample will be taken to assess vitamin D status alongside several questionnaires to evaluate health and lifestyle and determine eligibility. Eumenorrheic women will be given a commercially available fertility tracking wearable bracelet (Ava Science Inc.) which will be worn throughout at least two menstrual cycles in the non-HC group for prediction and detection of ovulation. Following pre-screen, the non-HC group will attend the laboratory on four occasions corresponding to the start of the menstrual bleed, the mid-follicular phase, ovulatory phase and mid-luteal phase; the COCP users will attend on two occasions corresponding to the end of the pill phase and the end of the pill-free phase; and the Long Acting Reversible Contraceptives (LARC) users (hormonal injection, hormonal implant, IUS) will attend for a single study visit. On each study visit, participants will provide a urine and venous blood sample, undertake muscle function tests (isokinetic dynamometry and single-leg drop) and have tendon, muscle and ligament characteristic measurements taken (digital palpation). Bone measurements (DXA, HRpQCT, ultrasound) will be taken on one occasion, (day 14 for the non-HC group; day 21 for the COCP group (i.e. end of pill-using weeks); and the single testing day for other LARC groups. The final measurement of impact microindentation (IMI) will be performed using the Osteoprobe within 4 weeks after the skeletal imaging; the IMI is a specialised procedure and will be scheduled in set sessions each month.

Primary Outcomes: Bone calcium balance (44Ca:42Ca) measured in urine.

Secondary Outcomes: Markers of bone turnover, reproductive function, iron status and musculoskeletal health.

• Study Type: Observational
• Enrollment (Anticipated): 100

Contacts and Locations

• Study Contact: Name: Julie P Greeves, PhD; Phone Number: 03001597149; Email: julie.greeves143@mod.gov.uk
• Study Contact Backup: Name: Rebecca L Double, BSc(Hons); Phone Number: 0300 155 9516; Email: rebecca.double102@mod.gov.uk

Study Locations

• United Kingdom
  • Surrey
    • Camberley, Surrey, United Kingdom, GU15 4PQ
      • Recruiting
      • Army Health and Performance Laboratory
      • Contact: Thomas J O'Leary, PhD; Phone Number: 03001638204; Email: thomas.oleary100@mod.gov.uk
      • Contact: Charlotte V Coombs, PhD; Phone Number: 03001548583; Email: charlotte.coombs.102@mod.gov.uk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 40 years (Adult)
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

Healthy women of reproductive age.

Description

Inclusion Criteria:

1. Aged 18-40 years old
2. No hormonal contraceptive use (with regular menstrual cycles 24-35 days in length, and have not been taking any hormonal contraceptives for at least 12 months), or;
3. Use of the combined oral contraceptive pill containing ≥25 mg ethinyl-oestradiol (EE) and an anti/low androgenic progestin for at least 12 months, or;
4. Use of the hormonal coil (IUS) continuously for at least 2 years, or;
5. Use of the hormonal implant continuously for at least 2 years, or;
6. Use of the hormonalDMPA injection continuously for at least 2 years;
7. Weight stable (no change in self-reported body mass ≥ 5% over the previous 3 months);
8. BMI between 18 and 30 kg·m2.

Exclusion Criteria:

1. Taking a hormonal contraceptive other than the combined oral contraceptive pill containing ≥25 mg EE and an anti/low androgenic progestin, hormonal coil (IUS), the hormonal contraceptive implant or the DMPA hormonal injection;
2. History of DMPA hormonal injection use in those women not currently using the DMPA hormonal injection;
3. Diagnosed Premature Ovarian Insufficiency;
4. Pregnancy;
5. Less than 2 years postpartum;
6. Given birth to more than 2 children;
7. Evidence of disordered eating (≥ 20 on the EAT-26);
8. Any self-diagnosed eating disorder;
9. Self-reported change in body mass of ≥ 5% over the previous 3 months;
10. Body mass index of < 18 or > 30 kg·m2;
11. Evidence of menstrual disturbance (oligomenorrhea: < 9 menstrual cycles in previous 12 months or amenorrhoea: ≤ 3 menstrual cycles in the previous 12 months);
12. Habitual smoking (regularly smoking more than 10 cigarettes per day);
13. Taking any medications known to affect bone or calcium metabolism (e.g., treatment for thyroid disorders).
14. Total 25-hydroxyvitamin D (25(OH)D)level < 30 nmol/l at baseline, confirmed with a venous blood sample;
15. Self-declared history of heart, liver or kidney disease, diabetes, or thyroid disorder;
16. Self-reported bone fracture in the previous 12 months.

Exclusion Criteria for Reference Point Indentation Only:

1. Local oedema;
2. Local skin infection or cellulitis;
3. Prior clinical or stress fracture in the tibial diaphysis;
4. Dermatological lesions around the measurement site;
5. Focal tibial lesions like in primary or metastatic tumour, Paget's disease, Gaucher;
6. Osteomyelitis of the tibia;
7. Systemic infection or fever (unless unrelated to infection);
8. Allergy to lidocaine.

Study Plan

How is the study designed?

Design Details

• Observational Models: Case-Control
• Time Perspectives: Cross-Sectional

Number of groups / cohorts

5

Cohorts and Interventions

Group / Cohort
Non-hormonal contraceptive users; Women not using any form of hormonal contraceptive.
Combined oral contraceptive pill users; Women using the oral combined oral contraceptive pill.
Hormonal IUS; Women using the hormonal intrauterine system contraceptive.
Hormonal implant; Women using the hormonal contraceptive implant contraceptive.
Hormonal injection; Women using the hormonal injection contraceptive.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Calcium balance.	The ratio of the calcium isotopes 44Ca:42Ca in first morning void urine.	Baseline measurement for long acting reversible contraceptive users. Day 21 and 28 of the pill cycle for the combined oral contraceptive pill users. Menses (day 0), mid-follicular, ovulation, and mid-luteal phase for non-users.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Circulating concentrations of reproductive hormones at rest following an overnight fast.	Fasted circulating concentration of luteinising hormone, follicle stimulating hormone, oestradiol, progesterone, testosterone, sex-hormone binding globulin.	Baseline measurement for long acting reversible contraceptive users. Day 21 and 28 of the pill cycle for the combined oral contraceptive pill users. Menses (day 0), mid-follicular, ovulation, and mid-luteal phase for non-users.
Circulating concentrations of metabolic hormones at rest following an overnight fast.	Fasted circulating concentration of cortisol, cortisol binding globulin, insulin-like growth factor-1 (IGF-1), IGF binding protein 1, IGF binding protein 3, prolactin, relaxin, dehydroepiandrosterone sulfate, thyroid stimulating hormone, free thyroxine, free triiodothyronine.	Baseline measurement for long acting reversible contraceptive users. Day 21 and 28 of the pill cycle for the combined oral contraceptive pill users. Menses (day 0), mid-follicular, ovulation, and mid-luteal phase for non-users.
Circulating concentrations of bone turnover markers at rest following an overnight fast.	Fasted circulating concentration of procollagen type 1 N-terminal propeptide (P1NP), bone specific alkaline phosphatase (bone ALP), beta carboxy-terminal cross-linking telopeptide of type 1 collagen (βCTX), intact parathyroid hormone, osteoprotegerin, receptor activator of nuclear factor kappa B ligand (RANKL), ionised and albumin-adjusted calcium, and phosphate.	Baseline measurement for long acting reversible contraceptive users. Day 21 and 28 of the pill cycle for the combined oral contraceptive pill users. Menses (day 0), mid-follicular, ovulation, and mid-luteal phase for non-users.
Circulating concentrations of markers of resting iron status following an overnight fast.	Fasted circulating concentration of hepcidin-25, ferritin, soluble transferrin receptor, haemoglobin, and haematocrit.	Baseline measurement for long acting reversible contraceptive users. Day 21 and 28 of the pill cycle for the combined oral contraceptive pill users. Menses (day 0), mid-follicular, ovulation, and mid-luteal phase for non-users.
Areal bone mineral density.	Whole-body, lumbar spine, and neck of femur bone mineral density measured by dual-energy x-ray absorptiometry (DXA) scan.	Single measurement at baseline for long acting reversible contraceptive users, day 21 for combined oral contraceptive users and at ovulation for non-users.
Volumetric bone mineral density at the tibia and radius.	Tibial (4% and 30% site) and radial volumetric bone mineral density measured by high-resolution peripheral quantitative computed tomography.	Single measurement at baseline for long acting reversible contraceptive users, day 21 for combined oral contraceptive users and at ovulation for non-users
Microarchitecture and structure at the tibia and radius.	Tibial (4% and 30% site) and radial microarchitecture, and geometry measured by high-resolution peripheral quantitative computed tomography.	Single measurement at baseline for long acting reversible contraceptive users, day 21 for combined oral contraceptive users and at ovulation for non-users
Tibial bone material properties and strength	Tibial bone strength measured by reference point indentation.	Single measurement for all groups taken no more than one month after completion of the study period.
Muscle function.	Isometric single-leg testing consisting of three maximal isometric contractions at 90° of knee flexion. Dynamic single-leg testing consisting of six repetitions at 60°/s, followed by 15 repetitions at 180°/s. Single-leg drop on each leg from a raised platform.	Baseline measurement for long acting reversible contraceptive users. Day 21 and 28 of the pill cycle for the combined oral contraceptive pill users. Menses (day 0), mid-follicular, ovulation, and mid-luteal phase for non-users.
Muscle and tendon properties.	Digital palpation measurement of tone (Hz), stiffness (N/m) and elasticity of the rectus femoris, gastrocnemius, soleus, patella tendon and Achilles tendon using the Myoton device.	Baseline measurement for long acting reversible contraceptive users. Day 21 and 28 of the pill cycle for the combined oral contraceptive pill users. Menses (day 0), mid-follicular, ovulation, and mid-luteal phase for non-users.

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Agreement between wearable detection of ovulation and ovulation inferred from luteinising hormone surge tests.	Urinary luteinising hormone surge test and menstrual cycle tracking using the commercially available Ava Bracelet.	For one month prior to the start of the study period, and during the entire study period
Agreement between dual-energy x-ray absorptiometry and Echolight ultrasound bone mineral density.	Bone mineral density of the lumbar spine and neck of femur, measured by dual-energy x-ray absorptiometry and Echolight ultrasound.	Single measurement at baseline for long acting reversible contraceptive users, day 21 for combined oral contraceptive users, and at ovulation for non-users
Body composition.	Body mass, lean mass, and fat mass measured by dual energy x-ray absorptiometry.	Single measurement at baseline for long acting reversible contraceptive users, day 21 for combined oral contraceptive users, and at ovulation for non-users
Circulating concentrations of markers of vitamin D at rest.	Fasted circulating concentration of total 25-hydroxyvitamin D (25(OH)D), free total vitamin D (25(OH)D), total 24,25 dihydroxyvitamin D, 1,25 dihydroxyvitamin D, and vitamin D binding protein.	Single measurement for all groups at pre-study visit.

Collaborators and Investigators

• Sponsor: Army Health Branch, British Army
• Collaborators: University of East Anglia, Norwich, United Kingdom; Osteolabs, Kiel, Germany; University of Salford, Salford, United Kingdom; University of Southampton, Southampton, United Kingdom

Study record dates

Study Major Dates

• Study Start (Actual): December 1, 2021
• Primary Completion (Anticipated): December 1, 2023
• Study Completion (Anticipated): June 1, 2024

Study Registration Dates

• First Submitted: September 2, 2022
• First Submitted That Met QC Criteria: October 18, 2022
• First Posted (Actual): October 20, 2022

Study Record Updates

• Last Update Posted (Actual): April 21, 2023
• Last Update Submitted That Met QC Criteria: April 20, 2023
• Last Verified: April 1, 2023

More Information

Terms related to this study

• Other Study ID Numbers: 1042/MODREC/20

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED
• IPD Plan Description: Data will be shared pending approval from the UK Ministry of Defence.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No