E32 月经：不只“麻烦”的血流，而是横跨运动，免疫，饮食的女性生命体征

“那个”，大姨妈，生理期，例假。月经，她有过很多名字，但，却好像一直没有被好好地正视过。
如果不是做这期播客，我不会知道原来职业女性运动员，月经紊乱和闭经比例能达到60%，而且，这不是正常训练的结果，也不应被视为努力冲刺的勋章。我也不会知道，原来经期的子宫，在完成着人类世界里唯一的大规模无疤痕修复，而曾被污名化的经血，现在也是再生医学的研究热点之一。我更不会知道，整个代谢研究领域，至今都还没有高质量的研究，能回答这个很简单的问题：对于有月经的女性来说，断食，到底意味着什么？
长久以来，现代医学研究都系统性地忽视了女性、避开了月经。因为月经，她太复杂又太难标准化。但这也意味着，月经，是足够敏感的，她是一个信号，所能反应的远不止是生殖，还有你身体的整体健康状态。
今天，我们就一起来看看这第五项生命体征 - 月经。她到底是什么，又能如何指导我们的生活。
🩸注：正常月经周期 24-38天，以28天为例：1-5天 经期；1-13天 卵泡期（包括经期，本期节目里为简化经期和卵泡期分开叙述）；14-28天 黄体期。
【时间轴】
01:05 Enhanced Games 嗑睾酮的女运动员们，还好吗？
04:13 想当职业运动员，就逃不开闭经？
07:41 月经，不止生育，还是女性的生命体征
13:24 从细胞层面看经期，子宫到底在发生什么？
18:15 成人后唯一的无疤痕修复：子宫内膜
23:56 月经的炎症反应，从局部到全身
35:35 卵泡期 vs 黄体期：能量需求和代谢差异
43:41 免疫骨骼心血管，结论待定
45:13 不同月经周期，两种压力反应模式
48:58 卵泡期更适合高强度运动？
54:10 断食，适合女性吗
55:46 代谢研究里月经周期的盲点
63:38 经前综合征，如何应对？
68:14 更敏感，是雌性的生存优势
69:10 女性是活得更久，但也病得更久
70:02 女性在现代医学研究中，长期被系统性忽视
76:34 希望下一代女性，能看到的世界
感谢 专研高品质舒适感的她研社对本节目的支持。她研社，舒适刚刚好。【她研社均衡力】卫生巾，弱酸面层和人体健康肌肤pH值相近，有效抑制有害菌，干爽不漏不敏痒。复制下方淘口令 上天猫/淘宝获取节目专属优惠券 获取更多产品信息~
97💲kzBCgl6lYsl🔐 https://s.tb.cn/h.RwcqfRu MF937 小宇宙专属她研社79元任选3组2
📃 本期播客提到的文献素材传送门：
第一部分：运动员月经稀发/闭经
运动员月经稀发/闭经比例： https://pubmed.ncbi.nlm.nih.gov/30644600/ ：“Forty-four percent of premenopausal females had oligomenorrhea/amenorrhea.”
舞蹈员和长跑运动员闭经比例： https://www.ccjm.org/content/85/4/313 ：“In small studies, the prevalence of secondary amenorrhea was as high as 69% in dancers and 65% in long-distance runners.”
职业运动员闭经常态化： https://pmc.ncbi.nlm.nih.gov/articles/PMC8609260/ ：“According to the participants, the five main reasons for not reporting the amenorrhea were: (1) normalizing of the subject, (2) the absence of menstruation is not perceived as a problem by the athletes themselves, (3) experienced shame and taboo, (4) prioritisation of sports performance, and (5) denial.”
IOC 声明能量摄入与消耗失衡会导致包括闭经在内的生殖失调： https://stillmed.olympics.com/media/Documents/Athletes/Medical-Scientific/Consensus-Statements/REDs/BJSM-IOC-consensus-statement-on-Relative-Energy-Deficiency-in-Sport-REDs.pdf ：“A syndrome of impaired physiological and/or psychological functioning experienced by female and male athletes that is caused by exposure to problematic (prolonged and/or severe) low energy availability. The detrimental outcomes include, but are not limited to, decreases in energy metabolism, reproductive function, musculoskeletal health…”
月经应作为重要生命体征： https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/12/menstruation-in-girls-and-adolescents-using-the-menstrual-cycle-as-a-vital-sign，https://pubmed.ncbi.nlm.nih.gov/39906529/ ：“The menstrual cycle is a vital sign from menarche through menopause, an underutilized but powerful tool for understanding gynecological and general health.”
月经不规律与疾病的关联性： https://academic.oup.com/jcem/article-abstract/87/5/2013/2846638?redirectedFrom=fulltext ：“Compared with women reporting a history of very regular menstrual cycles, women reporting usually irregular or very irregular cycles had an increased risk for nonfatal or fatal CHD [age-adjusted relative risks (RR), 1.25 and 1.67, respectively; 95% confidence intervals (CI), 1.07–1.47 and 1.35–2.06, respectively].”， https://pmc.ncbi.nlm.nih.gov/articles/PMC12671990/ （超多疾病，不一一详细列出了）
古代神话和传说里对月经的态度： https://www.sciencedirect.com/science/article/abs/pii/S1521693416301250（有正面和负面）
第二部分 经期
经期子宫内免疫细胞的逐步参与： https://journals.physiology.org/doi/full/10.1152/physrev.00031.2019 ：Section VIII 及 Figure 5 记录了细胞凋亡先于内膜脱落发生的时序："endometrial apoptosis was extensive before the onset of breakdown, shedding, and bleeding"；Section VIII 下半段、Section IX 及 Figure 6 描述了中性粒细胞的大规模招募及其通过MMPs推动组织分解的机制："Neutrophils contain high levels of MMPs, and endometrial neutrophils may activate MMPs in situ, thereby contributing to endometrial breakdown"；巨噬细胞吞噬凋亡细胞后发生表型转变并释放IL-10、TGF-β等抗炎因子（即胞葬触发的促炎→抗炎转换）见于Section VIII，巨噬细胞的来源与定位动态见于Section IX；无疤痕修复的机制分布在 Introduction、Section X 和Section XI-C中 。
经期巨噬细胞功能转化： https://pmc.ncbi.nlm.nih.gov/articles/PMC10691302/ ：“After the acute endometrial shedding, exudated inflammatory cells can upregulate cytokine levels, mainly in elevated levels of TNF-α and IL-1. Following this, M1 macrophages accumulate in the wound, releasing TNF-α, IL-1, and IL-6. Cytokines involved in wound healing activate the NF-κB signaling pathway.”
在经期的免疫细胞修复功能： **https://www.frontiersin.org/journals/reproductive-health/articles/10.3389/frph.2021.779979/full ："analysis of this fluid is likely to be of value not only for treating endometrial bleeding problems but also in providing potential new therapies for poorly repairing wounds"
经血内物质可以帮助组织修复： https://faseb.onlinelibrary.wiley.com/doi/10.1096/fj.201800086R ：“Functionally, they promote repair of endometrial and keratinocyte wounds by promoting migration.”， “MF (4%) brought about complete repair/100% healing of the wounded HaCaT keratinocyte cell line monolayer within 24 h of addition, compared with only 40% repair in the presence of 4% PB plasma”
经血内干细胞可帮助疾病治疗： https://pmc.ncbi.nlm.nih.gov/articles/PMC7656201/ ：“Human menstrual blood-derived mesenchymal stem cells (MenSCs) have shown great potential in regenerative medicine.”，相关临床实验： https://clinicaltrials.gov/study/NCT01483248#study-plan ， https://clinicaltrials.gov/study/NCT07131150
经期外周血炎症水平增高： https://mednexus.org/doi/10.4103/2096-2924.232878 ：“The expression of inflammatory indexes, such as platelets (PLT), lymphocytes (Lym), the percentage of Lym (Lym%), neutrophils (Neu), the percantage of Neu (Neu%), neutrophil-to-lymphocyte ratio (NLR), interleukin-6 (IL-6), and cancer antigen 125 (CA125), reached the highest level during the menstrual period.”, ”The expression levels of IL-8, IL-1β, and IL-6 during the menstrual period and luteal phase were significantly higher than those in follicular phase.”
痛经患者外周血炎症水平更高： https://pmc.ncbi.nlm.nih.gov/articles/PMC3563666/ ：“Functional annotation revealed an excessive inflammatory response and insufficient TGF-β superfamily member signals with anti-inflammatory consequences, which may directly contribute to menstrual pain.”
omega3 和健康饮食能缓解痛经： https://onlinelibrary.wiley.com/doi/full/10.1111/1747-0080.12835 ：“Findings suggest that daily supplementation of 300–1800 mg omega-3 long chain polyunsaturated fatty acids over 2–3 months are generally well tolerated and reduces pain and analgesic use in women with dysmenorrhoea.”， https://link.springer.com/article/10.1007/s00228-021-03263-1 ：“the highest effectiveness of treatment was seen at low doses of n-3 PUFAs, and with increasing daily intake, the effectiveness of treatment with n-3 PUFAs decreased.“ https://karger.com/goi/article-abstract/84/3/209/153726/Nutrition-as-a-Potential-Factor-of-Primary?redirectedFrom=fulltext ：“The increased consumption of fruits and vegetables as the sources of vitamins and minerals, as well as fish and milk and dairy products have positive associations with less menstrual pain.”， https://pmc.ncbi.nlm.nih.gov/articles/PMC5963185/ ：“subjects in the second and third tertiles of “snacks” pattern had a 4.23 (95% CI =
1.32–13.58, P = 0.01) and 3.41 (95% CI = 1.10–10.50, P = 0.03) times, respectively, higher chance to experience moderate to severe dysmenorrhea in comparison with subjects in the first tertile.”
运动特别是力量训练可以缓解痛经： https://pmc.ncbi.nlm.nih.gov/articles/PMC11896821/ ：“The majority of the studies on strength training interventions concentrated on the uterine region, emphasizing core training and isometric training. These uterine-specific exercise interventions facilitate the delivery of essential oxygen and nutrients to the uterine muscles and tissues, enhance blood circulation, and support repair processes. These also lower congestion and inflammation while optimizing the uterine microenvironment. This may provide a higher advantage than other therapies.”
热敷缓解痛经： https://pmc.ncbi.nlm.nih.gov/articles/PMC12876241/ ：“applied heat increases pelvic blood flow, which may help to dissipate and reduce the concentration of prostaglandins, thereby relieving ischemia and muscle cramps”
全球贫血和缺铁数据： https://ourworldindata.org/billions-people-suffer-anemia-cheap-ways-reduce
第三部分 卵泡期
卵泡期能量需求较少： https://pmc.ncbi.nlm.nih.gov/articles/PMC7357764/ ：“Overall, there was a small but significant effect favoring increased RMR in the luteal phase (ES = 0.33; 95% CI = 0.17, 0.49, p < 0.001).” https://academic.oup.com/nutritionreviews/article/81/7/869/6823870 ：“ Overall, energy intake appears to be lower in the follicular phase compared with the luteal phase, with a particular decrease in the days leading up to and including ovulation.”
卵泡期血糖调节能力更强： https://pmc.ncbi.nlm.nih.gov/articles/PMC10513929/ ：“Our study therefore highlights that brain insulin action improves peripheral insulin sensitivity also in women but only during the follicular phase.”
多囊患者胰岛素抵抗概率增高，妊娠风险，心血管疾病概率也增高： https://pmc.ncbi.nlm.nih.gov/articles/PMC9832677/ ：”IR and compensatory hyperinsulinaemia (HI) are present in 65–95% of women with PCOS, including the vast majority of overweight and obese women and more than half of women of normal weight.“， “Women with PCOS and IR have a significantly increased risk of adverse pregnancy outcomes and chronic diseases, such as type 2 diabetes mellitus (T2DM), cardiovascular disease, and metabolic syndrome, which seriously affect the physical and mental health of women of childbearing age, increasing their social burden”
柳叶刀建议更名多囊卵巢综合征为多内分泌代谢性卵巢综合征： https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(26)00717-8/fulltext
卵泡期免疫功能变化，骨代谢变化，心血管功能变化证据不强： https://pubmed.ncbi.nlm.nih.gov/37309068/， https://link.springer.com/article/10.1007/s00223-026-01482-1， https://journals.physiology.org/doi/full/10.1152/ajpheart.00341.2020
卵泡期皮质醇基础量更高，对急性刺激反应相对更温和 https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2020.00311/full ： “In line with our hypothesis, our meta-analysis found that women in the follicular phase had higher cortisol levels than women in the luteal phase, with an overall Hedges' g of 0.13 (p < 0.01) for the random effects model.”， https://www.sciencedirect.com/science/article/abs/pii/S0149763423001811 ：“Three studies provided sufficient data for the meta-analysis and showed a significant, small-sized effect, indicating higher cortisol reactivity in the luteal than in the follicular cycle phase.”
卵泡期更倾向消耗碳水化合物，黄体期更常用脂肪和蛋白质： https://academic.oup.com/nutritionreviews/article/81/7/869/6823870 ：“Rates of carbohydrate and fat oxidation vary across the cycle, with greater glycogen storage at rest, and a stronger preference for fat utilization during exercise, in the luteal phase compared with the follicular phase.”， https://journals.physiology.org/doi/abs/10.1152/ajpendo.1994.267.3.E422 ：“This study shows small changes in protein metabolism during the menstrual cycle in women, with an increase in oxidative leucine metabolism during the luteal phase…fluctuations in protein metabolism and thyroid hormones throughout the menstrual cycle are causally related.”
特里尔社会压力测试流程： https://pmc.ncbi.nlm.nih.gov/articles/PMC3227197/
高强度训练在卵泡期效果更好： https://pmc.ncbi.nlm.nih.gov/articles/PMC12538072/#abs0025 ：“High-frequency SIT during the follicular phase preserved mitochondrial function and enhanced tissue remodeling, while luteal phase-based training suppressed mitochondrial pathways and reduced cardiorespiratory fitness.”
120人的根据月经不同周期调整训练的 IMPACT 研究： https://pmc.ncbi.nlm.nih.gov/articles/PMC10823667/
第四部分 黄体期
黄体期能量摄入及饮食推荐： https://www.mdpi.com/2072-6643/16/12/1911 ：“Researchers at the Mayo Clinic emphasize the importance of not only the composition of the diet but also eating smaller and more frequent meals to alleviate PMS symptoms such as bloating and feelings of fullness. Similarly, the ACOG stressed the importance of meal frequency, suggesting the consumption of six small meals instead of three larger meals. This dietary pattern may help to maintain stable blood glucose levels and potentially reduce PMS symptoms.” https://pmc.ncbi.nlm.nih.gov/articles/PMC8566643/ ：“Consuming a high carbohydrate snack 3–4 h before exercise can mitigate these effects during the luteal phase”， “Carbohydrate loading in the mid-luteal phase, however, has shown no change or small (13%) increase in muscle glycogen with a potential for improved performance”, “Because of increased progesterone levels in the luteal phase, the protein requirement may be higher due to higher rates of protein
catabolism” https://www.frontiersin.org/journals/nutrition/articles/10.3389/fnut.2023.1079417/full ：“It has been suggested that caloric intake, as well as preferential carbohydrate selection, during the premenstrual period is more significant in women with PMS, who are considered to be more sensitive to cyclical hormonal or neurotransmitter fluctuations.”
肥胖女性和肥胖成人断食好处对比： https://pmc.ncbi.nlm.nih.gov/articles/PMC12479299/ ， https://pmc.ncbi.nlm.nih.gov/articles/PMC12309044/
断食研究者女性更难坚持： https://pmc.ncbi.nlm.nih.gov/articles/PMC6816332/ ：“It remains to be established why we experienced a gender difference (82% of dropouts were female).”
断食的优势与月经周期波动幅度相当： HOMA-IR（胰岛素抵抗指数）**断食改善：**−0.31（Miao et al., PMC8970877）至 −0.60（Lu et al., PMC12363089）**月经周期波动：**卵泡中期1.35 → 黄体早期1.59，差值+0.24（Yeung et al., BioCycle Study, PMC2999972） LDL胆固醇 断食改善：−5.44 mg/dL（Wang et al., PMC12309044）**月经周期波动：**综合多项研究范围为4–10%（Mumford et al., PMID 14764796）总胆固醇 断食改善：−6.31 mg/dL（Wang et al., PMC12309044）**月经周期波动：**综合多项研究的范围为4–10%（Mumford et al., PMID 14764796）还有炎症 CRP（C反应蛋白，炎症标志物）**断食改善：**−0.024 mg/dL，即−0.24 mg/L（Wang X et al., PMID 32947129）**月经周期波动：**卵泡早期（月经期第2–5天）1.8 mg/L vs 黄体期0.7 mg/L，差值1.1 mg/L，p<0.001（Gursoy et al., PMC4701164）
断食时间推荐在卵泡期： https://pmc.ncbi.nlm.nih.gov/articles/PMC13210042/ ：“These cyclical changes provide a physiological basis for the observation that women may tolerate longer fasting windows more easily during the early-to-mid-follicular phase, whereas the luteal phase may be associated with greater difficulty adhering to restrictive eating schedules.”
针对 PMS 和 PMDD 疗法简介： https://pmc.ncbi.nlm.nih.gov/articles/PMC9790166/#s0003 ， https://pubmed.ncbi.nlm.nih.gov/18852497/ ：“cognit