Sexual and Reproductive Health Issues among Recreational Female Hikers at High Altitude: A Scoping Review
SRH among Female Hikers
Vol. 21 No. 2 : 2026 (589-610)
Abstract
Hiking offers well-documented cardiovascular, psychological and sleep benefits and is increasingly popular among women. However, strenuous conditions at high altitude introduce unique challenges to female physiology, particularly their sexual and reproductive health (SRH). This scoping review explores the SRH issues experienced by recreational female hikers especially at high altitude. It was conducted according to Joanna Briggs Institute methodology for scoping reviews and was reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A systematic search was performed across PubMed, Scopus and Web of Science, using keywords and synonyms related to females, reproductive health, hiking and high altitude. Inclusion criteria encompassed studies addressing SRH issues faced by female hikers. Fifteen studies met these criteria. Reported issues clustered into six topics: menstrual disturbances and hormonal dysregulation; nutrition–menstrual interactions; pregnancy at high altitude; contraceptive considerations; the association between menstruation and acute mountain sickness; and other challenges, including sexual harassment and menstruation-related participation barriers. Most studies were small and observational, with more than half published before 2005, limiting the certainty of the evidence. Despite the growing participation of women in hiking and mountaineering, substantial gaps remain in understanding the short-term effects of high-altitude exposure on female SRH. This review highlights the necessity for targeted research to address these knowledge gaps and to develop evidence-based guidelines for female hikers. Ensuring safe participation in high-altitude activities will allow women to realise these benefits without compromising reproductive health.
Keywords :
Female hikers; high altitude; sexual and reproductive health,
Correspondance Address
*Correspondence: drrose@ukm.edu.my
References
Andjelkovic, M., Paal, P., Kriemler, S., Mateikaite-Pipiriene, K., Rosier, A., Beidleman, B.A., Derstine, M., Pichler Hefti, J., Hillebrandt, D., Horakova, L., Jean, D., Keyes, L.E. 2024. Nutrition in women at high altitude: A scoping review-UIAA Medical Commission Recommendations. High Alt Med Biol 25(1): 9-15. https://doi.org/10.1089/ham.2023.004
Artal, R., Fortunato, V., Welton, A., Constantino, N., Khodiguian, N., Villalobos, L., Wiswell, R. 1995. A comparison of cardiopulmonary adaptations to exercise in pregnancy at sea level and altitude. Am J Obstet Gynecol 172(4): 1170-80. https://doi.org/10.1016/0002-9378(95)91475-7
Botta, R.A., Fitzgerald, L. 2020. Gendered experiences in the backcountry. J Outdoor Recreat Educ Leadersh 12(1): 27-40. https://doi.org/10.18666/JOREL-2020-V12-I1-9924
Boulware, D.R. 2004. Gender differences among long-distance backpackers: A prospective study of women Appalachian trail backpackers. Wilderness Environ Med 15(3): 175-80. https://doi.org/10.1580/1080-6032(2004)15[175:gdalba]2.0.co;2
Braun, B., Butterfield, G.E., Dominick, S.B., Zamudio, S., McCullough, R.G., Rock, P.B., Moore, L.G. 1998. Women at altitude: Changes in carbohydrate metabolism at 4,300-m elevation and across the menstrual cycle. J Appl Physiol 85(5): 1966-73. https://doi.org/10.1152/jappl.1998.85.5.1966
Buecker, S., Simacek, T., Ingwersen, B., Terwiel, S., Simonsmeier, B.A. 2021. Physical activity and subjective well-being in healthy individuals: Ameta-analytic review. Health Psychol Rev 15(4): 574-92. https://doi.org/10.1080/17437199.2020.1760728
Callaghan, A., Vrentas, J. 2024. For women mountain climbers, dangers go beyond avalanches and storms. The New York Times. New York.: https://www.nytimes.com/2024/05/31/sports/mountaineering-sexual-harassment-abuse-nims-purja.html [Accessed on 19 January 2025].
Citherlet, T., Raberin, A., Manferdelli, G., Pialoux, V., Millet, G.P. 2024. Menstrual cycle does not impact the hypoxic ventilatory response and acute mountain sickness prediction. Sci Rep 14(1): 26087. https://doi.org/10.1038/s41598-024-76404-y
Crowley, R. 2018. Thru-hiking and why people do it. Master Thesis. Atlanta (GA): Georgia State University.
Dolinting, E.E., Yusof, A., Soon, C.C. 2013. Understanding sport tourists’ motives and perceptions of Sabah, Malaysia as a sport tourist destination. J Phys Educ Sport 13(4): 547-56. https://doi.org/10.7752/jpes.2013.04086
Dragoman, M.V., Tepper, N.K., Fu, R., Curtis, K.M., Chou, R., Gaffield, M.E. 2018. A systematic review and meta-analysis of venous thrombosis risk among users of combined oral contraception. Int J Gynecol Obstet 141(3): 287-94. https://doi.org/10.1002/ijgo.12455
Gaillard, S., Dellasanta, P., Loutan, L., Kayser, B. 2004. Awareness, prevalence, medication use, and risk factors of acute mountain sickness in tourists trekking around the Annapurnas in Nepal: A 12-year follow-up. High Alt Med Biol 5(4): 410-9. https://doi.org/10.1089/ham.2004.5.410
Gardner, L., Keyes, L.E., Phillips, C., Small, E., Adhikari, T., Barott, N., Zafren, K., Maharjan, R., Marvel, J. 2024. Women at altitude: Menstrual-cycle phase, menopause, and exogenous progesterone are not associated with acute mountain sickness. High Alt Med Biol 25(2): 107-12. https://doi.org/10.1089/ham.2023.0100
Grant, I.D., Giussani, D.A., Aiken, C.E. 2021. Blood pressure and hypertensive disorders of pregnancy at high altitude: A systematic review and meta-analysis. Am J Obstet Gynecol MFM 3(5): 100400. https://doi.org/10.1016/j.ajogmf.2021.100400
Grant, I.D., Giussani, D.A., Aiken, C.E. 2022. Fetal growth and spontaneous preterm birth in high-altitude pregnancy: A systematic review, meta-analysis, and meta-regression. Int J Gynecol Obstet 157(2): 221-9. https://doi.org/10.1002/ijgo.13779
Hamlett, M. 2020. The scariest encounters women have on the Appalachian trail are with men. Daily Beast. https://www.thedailybeast.com/the-scariest-encounters-women-have-on-the-appalachian-trail-are-with-men/ [Accessed on 19 January 2025]
Harris, C.W., Shields, J.L., Hannon, J.P. 1966. Acute altitude sickness in females. Aerosp Med 37(11): 1163–7.
Hillebrandt, D., Meijer, H.. 2009. Consensus statement of the UIAA medical commission Vol: 14. Contraception and period control at altitude. The International Mountaineering and Climbing Federation.
Horakova, L., Kriemler, S., Študent, V., Pichler Hefti, J., Hillebrandt, D., Jean, D., Mateikaitė-Pipirienė, K., Paal, P., Rosier, A., Andjelkovic, M., Beidlemann, B., Derstine, M.. Keyes, L.E. 2024. Hormonal contraception and menstrual cycle control at high altitude: A scoping review-UIAA medical commission recommendations. High Alt Med Biol 25(4): 255-65. https://doi.org/10.1089/ham.2024.0021
Howard, I., Goldenberg, M. 2020. Women thru-hiker experiences on the pacific crest trail: gender influences, factors of success, and personal outcomes. J Outdoor Recreat Educ Leadersh 12(1): 41-61. https://doi.org/10.18666/JOREL-2020-V12-I1-9959
Huey, R.B., Carroll, C., Salisbury, R., Wang, J.-L. 2020. Mountaineers on Mount Everest: Effects of age, sex, experience, and crowding on rates of success and death. PLoS One 15(8): e0236919. https://doi.org/10.1371/journal.pone.0236919
Jean, D., Moore, L.G. 2012. Travel to high altitude during pregnancy: Frequently asked questions and recommendations for clinicians. High Alt Med Biol 13(2): 73-81. https://doi.org/10.1089/ham.2012.1021
Joy, E., Van Baak, K., Dec, K.L., Semakula, B., Cardin, A.D., Lemery, J., Wortley, G.C., Yaron, M., Madden, C. 2015. Wilderness preparticipation evaluation and considerations for special populations. Wilderness Environ Med 26(4 suppl): 76-91. https://doi.org10.1016/j.wem.2015.09.010
Keyes, L.E. 2015. Hormonal Contraceptives and Travel to High Altitude. High Alt Med Biol 16(1): 7–10. https://doi.org/10.1089/ham.2014.1111
Keyes, L.E., Hackett, P.H., Luks, A.M. 2016. Outdoor activity and high altitude exposure during pregnancy: A survey of 459 pregnancies. Wilderness Environ Med 27(2): 227-35. https://doi.org/10.1016/j.wem.2016.02.010
Keyes, L.E., Sanders, L. 2023. Pregnancy and exercise in mountain travelers. Curr Sports Med Rep 22(3): 78–81. https://doi.org/10.1249/JSR.0000000000001044
Kilgour, L. 2007. Gender, spatiality and fear: Young women’s experiences of outdoor physical activity. Ann Leis Res 10(2): 215-33. https://doi.org/10.1080/11745398.2007.9686762
Kredlow, M.A., Capozzoli, M.C., Hearon, B.A., Calkins, A.W., Otto, M.W. 2015. The effects of physical activity on sleep: A meta-analytic review. J Behav Med 38(3): 427-49. https://doi.org/10.1007/s10865-015-9617-6
León-Velarde, F., Rivera-Chira, M., Tapia, R., Huicho, L., Monge-C, C. 2001. Relationship of ovarian hormones to hypoxemia in women residents of 4,300 m. Am J Physiol Integr Comp Physiol 280(2): R488-93. https://doi.org/10.1152/ajpregu.2001.280.2.R488
Manning, J.W., Montes, J., Stone, T.M., Rietjens, R.W., Young, J.C., DeBeliso, M., Navalta, J.W. 2015. Cardiovascular and perceived exertion responses to leisure trail hiking. J Outdoor Recreat Educ Leadersh 7(2): 83-92. https://doi.org/10.18666/JOREL-2015-V7-I2-7005
Mawson, J.T., Braun, B., Rock, P.B., Moore, L.G., Mazzeo, R., Butterfield, G.E. 2000. Women at altitude: energy requirement at 4,300 m. J Appl Physiol 88(1): 272-81. https://doi.org/10.1152/jappl.2000.88.1.272
Mikkonen, R.S., Ihalainen, J.K., Davis-Wilson, H.C., Hackney, A.C. 2023. The hypothalamic–pituitary–ovarian axis, menstrual and oral contraceptive cycles: Regulation and function in the context of exercise and sport. In: Hackney, A.C. (eds). Sex hormones, exercise and women. Springer, Cham; 1–24.
Mountjoy, M., Sundgot-Borgen, J.K., Burke, L.M., Ackerman, K.E., Blauwet, C., Constantini, N., Lebrun, C., Lundy, B., Melin, A.K., Meyer, N.L., Sherman, R.T., Tenforde, A.S., Torstveit, M.K., Budgett, R. 2018. IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. Br J Sports Med 52(11): 687-97. https://doi.org/10.1123/IJSNEM.2018-0136
Niedermeier, M., Grafetstätter, C., Hartl, A., Kopp, M. 2017. A randomized crossover trial on acute stress-related physiological responses to mountain hiking. Int J Environ Res Public Heal 14(8): 905. https://doi.org/10.3390/ijerph14080905
Peters, M.D., Godfrey, C., McInerney, P., Munn, Z., Tricco, A.C., Khalil, H. 2024. Scoping reviews. JBI Manual for Evidence Synthesis. JBI.
Pinckard, K., Baskin, K.K., Stanford, K.I. 2019. Effects of exercise to improve cardiovascular health. Front Cardiovasc Med 6: 1-12. https://doi.org/10.3389/fcvm.2019.00069
Prince, H.E., Annison, E. 2023. The impact of menstruation on participation in adventurous activities. Sport Educ Soc 28(7): 811-23. https://doi.org/10.1080/13573322.2022.2059756
Richalet, J.P., Lhuissier, F., Jean, D. 2020. Ventilatory response to hypoxia and tolerance to high altitude in women: Influence of menstrual cycle, oral contraception, and menopause. High Alt Med Biol 21(1): 12-9. https://doi.org/10.1089/ham.2019.0063
Roach, R.C., Lawley, J.S., Hackett, P.H. 2017. High-altitude physiology. In Auerbach, P.S., Cushing, T.A., Harris, N.S. (eds.). Auerbach’s Wilderness Medicine. 7th Ed. Philadelphia: Elsevier.
Rock, P.B., Muza, S.R., Fulco, C.S., Braun, B., Zamudio, S., McCullough, R.E., McCullough, R.G., Cymerman, A., Wolfel, E.E., Kambis, K.W., Mazzeo, R., Butterfield, G.E., Moore, L.G. 2001. Women at altitude: Effect of menstrual-cycle phase on acute mountain sickness during deployment to high altitude terrain. Natick (MA): U.S. Army Research Institute of Environmental Medicine.
Ryterska, K., Kordek, A., Załęska, P. 2021. Has Menstruation disappeared? Functional hypothalamic amenorrhea-What is this story about? Nutrients 13(8): 2827. https://doi.org/10.3390/nu13082827
Salisbury, R., Hawley, E., Bierling, B. 2021. The Himalaya by the numbers. A statistical analysis of mountaineering in the Nepal Himalaya, 1950-2019. Ann Arbor, Michigan
Shaw, S., Ghosh, D., Kumar, U., Panjwani, U., Kumar, B. 2018. Impact of high altitude on key determinants of female reproductive health: Areview. Int J Biometeorol 62(11): 2045-55. https://doi.org/10.1007/s00484-018-1609-0
Thompson Coon, J., Boddy, K., Stein, K., Whear, R., Barton, J., Depledge, M.H. 2011. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ Sci Technol 45(5): 1761-72.
Tricco, A.C., Lillie, E., Zarin, W., O’Brien, K.K., Colquhoun, H., Levac, D., Moher, D., Peters, M.D.J., Horsley, T., Weeks, L., Hempel, S., Akl, E.A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M.G., Garritty, C., Lewin, S., Godfrey, C.M., Macdonald, M.T., Langlois, E. V., Soares-Weiser, K., Moriarty, J., Clifford, T., Tunçalp, Ö., Straus, S.E. 2018. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med 169(7): 467-73. https://doi.org/10.7326/M18-0850
United Nations Population Fund. 2022. Sexual and reproductive health. https://www.unfpa.org/sexual-reproductive-health [Accessed on 19 January 2025].
Verratti, V., Ietta, F., Paulesu, L., Romagnoli, R., Ceccarelli, I., Doria, C., Fanò Illic, G., Di Giulio, C., Aloisi, A.M. 2017. Physiological effects of high-altitude trekking on gonadal, thyroid hormones and macrophage migration inhibitory factor (MIF) responses in young lowlander women. Physiol Rep 5(20): e13400. https://doi.org/10.14814/phy2.13400
Warren, K., Risinger, S., Loeffler, T. 2018. Challenges faced by women outdoor leaders. In Gray, T. & Mitten, D. (eds.). Palgrave Studies in Gender and Education, Palgrave Macmillan, Cham; 247-58.
Whittington, A., Aspelmeier, J., Raymond, J. 2024. Attitudes and beliefs of men’s and women’s experiences thru-hiking the Appalachian trail. J Outdoor Recreat Educ Leadersh 16(4): 63-75. https://doi.org/10.18666/JOREL-2024-12440
