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Bone mineral density and bone turnover changes with advanced menstrual recovery: The REFUEL study
Ana Carla C Salamunes1, Nancy I Williams1, Emily A Ricker2
1Women's Health and Exercise Laboratory, The Pennsylvania State University, 112 Noll Laboratory, 328 N. Burrowes Road, University Park, PA, 16802, United States of America.
Bone
|February 18, 2026
Summary
Restoring regular menstrual cycles through increased energy intake improved bone mineral density and bone turnover markers in exercising women with oligo-amenorrhea. This nutrition intervention supports bone health recovery in this population.
Area of Science:
- Exercise physiology
- Bone metabolism
- Reproductive endocrinology
Background:
- Oligo-amenorrhea in exercising women is associated with low bone mineral density (BMD) and altered bone turnover.
- Increased energy intake is a key strategy to restore menstrual function and improve bone health.
- The REFUEL study investigated the impact of nutritional intervention on bone health markers in this population.
Purpose of the Study:
- To determine if achieving ≥2 consecutive menstrual cycles of <36 days improved bone mineral density (BMD) and bone turnover markers.
- To assess the response to increased energy intake in young exercising women with oligo-amenorrhea.
- To evaluate the effectiveness of a nutrition intervention on hormonal and bone health indicators.
Main Methods:
- The REFUEL study was a 12-month randomized controlled trial (RCT) focusing on increasing energy intake.
- Participants were categorized as recovered (REC) or non-recovered (non-REC) based on menstrual cycle frequency.
- Bone mineral density (BMD) was assessed using DXA scans, and various bone turnover markers (e.g., IGF-1, CTx, P1NP) were measured.
Main Results:
- The recovered group (REC) showed significant improvements in lumbar spine BMD, bone balance (calculated from P1NP and CTx), and estrogen levels (E1G) compared to the non-recovered group (non-REC).
- Significantly higher insulin-like growth factor-1 (IGF-1) levels were observed in the REC group.
- These findings indicate a positive impact of restored menstrual cycles on bone health indicators.
Conclusions:
- Achieving ≥2 consecutive menstrual cycles of <36 days following a nutrition intervention is linked to improved bone health.
- The findings suggest that nutritional strategies can effectively enhance bone mineral density and bone turnover markers in exercising women with oligo-amenorrhea.
- Restoration of eumenorrhea is a critical factor for improving bone health outcomes in this cohort.
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