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The menstrual cycle

The menstrual cycle must be discussed and understood as a factor in sport research, participation, and performance.

The menstrual cycle is the monthly series of changes that a woman’s reproductive system undergoes to be prepared for a possible pregnancy. 89 When women start menstruating, how long, heavy, or painful periods are, and other impacts on health, wellbeing, training, and performance will vary between individuals, and across a woman’s life course. 90

Symptoms including pain (stomach cramps and/or breast pain), bleeding, fatigue, feelings of discomfort or anxiety relating to periods, are often cited as barriers to sport and physical activity in women and girls. 99 A high proportion of athletes and women who exercise report that their menstrual cycle has a negative impact on training and sport performance. 90, 91, 92, 93, 94, 95, 96, 97, 98

Usage of hormonal contraception is also very common. Studies suggest that about 50 per cent of female athletes are likely using hormonal contraception including to help regulate and adapt their cycles for training and competitions. 99, 100, 101

While the impact of the menstrual cycle and/or the use of hormonal contraception on sport and physical activity participation and performance is increasingly recognised, there are many gaps, including:

  • Limited research on the impact of the various hormonal phases and the use of hormonal contraceptives and performance. 93, 100, 102
  • Potential higher injury risks during different phases of the menstrual cycle and/or in the presence of menstrual dysfunction. 103, 104
  • Knowledge of the menstrual cycle, risk factors for dysfunction, and the impact it and/or hormonal contraceptives can have on performance, especially for athletes and coaches. 97, 98, 100, 105, 106
  • Impact on different cultural, demographic, and sport-specific groups, especially those where menstruation remains a ‘taboo’ subject, para-athletes, and those from aesthetic sports. 95, 107

For women and girls to be fully engaged in sport, it is important for the menstrual cycle to be actively discussed and considered as a factor in research, training, participation, and performance. 100

Resources and reading

  • Move over menstrual cycle: Ovulation monitoring is the new gold standard to monitor REDs in female athletes, opens in a new tab, Jessalyn O’Donnell, SIRCuit, (23 January 2023). Low energy availability (LEA) arises when there is not enough energy (calories) consumed to support critical body functions as well as extra physical activity, such as training. Relative Energy Deficiency in Sport (REDs) is a result of longstanding LEA and is associated with a variety of negative health and performance outcomes. Until recently, menstrual cycle patterns were considered a key indicator of energy availability in female athletes. Menstrual cycles remain important, but ovulation is the key marker of energy availability. This SIRCuit article summarizes the relationship between LEA, REDs and ovulation, as well as answers questions about whether ovulation monitoring is right for you.
  • Patience Through Puberty, opens in a new tab, Molly Huddl, Sara Slattery, How she did it book, (10 March 2022). This section will provide some thought-provoking facts on the abysmal performance attrition and participation rates of athletes, and particularly female athletes, in running events during the transition from high-school/junior to senior elite ranks. However, it will also raise the notion that the physiology behind female development through adolescence is different to that of male athletes and that patience in long-term athlete development is often over-looked and ignored in the pursuit of short-term performance outcomes. Finally, this section will focus on how creating a positive performance environment, with proactive awareness and education on Relative Energy Deficiency in Sport is a requirement to improve female adolescent sport culture, and ultimately, female athlete retention rates and love of sport for life.
  • The Whoop Strap and Oura Ring Are Measuring the Impact of Menstruation and Pregnancy on Athletes as Women's Research and Tech Finally Rise, opens in a new tab, Joe Lemire, Sports Business Journal, (17 November 2021). Kristen Holmes played and coached field hockey at the highest level for more than two decades, earning three All-America selections at Iowa and later coaching Princeton to a national championship. Never, she says, did the subject of menstrual cycles arise in the context of training. Researchers aren’t asking those questions either, with one estimate indicating that women account for only 3% of participants in sport science analysis.
  • Sport science body to track female athletes’ hormonal changes linked to menstruation, opens in a new tab, Linda Geddes, The Guardian, (16 July 2021). The English Institute of Sport (EIS) is seeking to level the playing field through the rollout of regular saliva testing to track the rise and fall of two key drivers of these monthly changes: oestrogen and progesterone. Because of the hormones involved, the menstrual cycle underpins many aspects of a woman’s health, from her bone strength to her fertility, immune system and mental functioning. “If they don’t have a healthy menstrual cycle, it means for whatever reason, something’s not quite right,” said Dr Richard Burden, co-lead for female health at the EIS. Some women also experience symptoms related to their menstrual cycle such as low energy, pain or bloating. According to one recent study of female rugby players, 93% of them reported cycle-related symptoms, and 67% thought these affected their athletic performance.
  • Does injury incidence really change across the menstrual cycle? Highlighting a recent key study, opens in a new tab, Dr Emma Jane Lunan, BJSM blog, (5 April 2021). Part of the BJSM Knowledge translation series. This is a plain language translation of a non-BJSM article. This study aimed to assess whether the menstrual cycle phase and extended cycle length had an influence on the incidence of injuries in international footballers. This study adds further weight to the premise that monitoring athlete menstrual cycles may be useful to identify points within the cycle that athletes are at increased risk of injuries. In particular extended menstrual cycles are easily identified and it may be worthwhile modifying training during this period.
  • Tokyo-Perceptions-Study_FINAL.pdf, Australian Institute of Sport, (2021?). Survey was undertaken to understand what Australian elite female athletes think about the effect of their menstrual cycle on performance, and why? Two thirds of athletes reported that their menstrual cycle affects their performance. Athletes who experience three or more menstrual symptons were twice as likely to report feeling affected. Para-athletes and athletes in aesthetic sports were more affected than other athletes. Two thirds of athletes also called for 'more focus', including education, on the menstrual cycle and female performance in sport.
  • How periods and the pill affect athletic performance, opens in a new tab, Dan Gordon, The Conversation, (22 September 2020). The menstrual cycle, the pill and their potential impact on sporting performance have long been considered a taboo subject. Yet for most females who undertake any form of exercise or high-performance sport, there are a range of challenges that can affect their athletic performance, including from their menstrual cycle and their use of contraceptive pills. But a historic lack of scientific research in these areas still means we have very limited knowledge of the specific effect that both have on athletic performance. However, what research we do have on these subjects shows both can have an impact on athletic performance – which may be especially important for elite athletes.
  • Australian women's cricket team tracks players' periods in focus on women's health and fertility, opens in a new tab, Amanda Shalala, ABC News, (10 October 2020). The aim is to see whether players are regular, and what symptoms they might have. "If we can start to collect those types of things, hopefully down the track, we can start to look at those other facets of the menstrual cycle and how they can actually start to affect performance as well," Dr Inge says.
  • Why periods must no longer be a taboo subject in sport, opens in a new tab, Louise Lawless, The Irish Times, (25 July 2019). Athletes who incorporate menstrual cycle into preparation are reaping the benefits.
  • The menstrual cycle and female athletic performance, opens in a new tab, Johanna Ihalainen, Mid Sweden University, (2019). In a recent study, more than half of elite female athletes reported that hormonal fluctuations during their menstrual cycle negatively affected their exercise training and performance capacity.
  • Sport Science on Women, Women in Sport Science., opens in a new tab Mujika, Iñigo; Taipale, Ritva S., International Journal of Sports Physiology and Performance, Volume 14(8), pp.1013-1-14, (2019). This editorial article discusses issues on women in sport science and sex differences in responses and adaptations to training. Some interesting comments/links to research in the text include:
    • Unique to women is the ability to legally and ethically alter their hormonal profile and menstrual cycle by using exogenous hormones (hormonal contraceptives).
    • Approximately 42% of exercising women believe that their menstrual cycle has a negative impact on exercise training and performance.
    • Approximately 50% of elite athletes are currently using hormonal contraceptives, and up to 70% have used them. Unfortunately, we still do not fully understand the effects of the menstrual cycle and hormonal contraceptives on training and performance.
    • Monitoring and reporting of menstrual-cycle phase takes a little extra time and effort but could explain “interesting” results. More research should test women in different phases of the menstrual cycle to further elucidate the possible phase effects on training responses, adaptations, and performance (instead of just testing in the follicular, or “low-hormone,” phase of the menstrual cycle, when hormonal profile is “most similar” to that of men).
    • When applicable, use of accurate measurements for determination of both ovulation and nonovulatory cycles may also be important (a menstrual bleed does not necessarily indicate ovulation).
    • Users of hormonal contraceptives should be included in research in their own group to further elucidate the possible effects of exogenous hormones on training adaptations and performance, and the type and delivery methods of hormonal contraceptives should be reported.
    • It would also be of benefit for researchers to consider the potential underlying issues that might have been a reason for using hormonal contraceptives (e.g., relative energy deficiency in sport, polycystic ovary syndrome, endometriosis, etc.), as these may have influenced endogenous hormone profiles prior to taking hormonal contraceptives.
  • Menstruation is not a taboo in women’s sport, period, opens in a new tab, Kirsty Elliott-Sale, The Conversation, (12 April 2018). Menstruation is often called the “last great taboo” in women’s sport. But periods are the media’s taboo, not sportswomen’s. Our new research showed that elite athletes are not afraid to talk about their menstrual cycle and how it affects them. We also found that half of the 430 athletes we interviewed are using some kind of hormonal contraceptive, which affected their menstrual cycle.
  • Female athletes, hormonal contraception, and bone health, opens in a new tab [infographic], Emily Kraus, Clinical Assistant Professor, Standford Children's Orthopedic and Sports Medicine, Twitter, (accessed 23 March 2023).

  • Hormonal Contraception and severe asthma exacerbation: Is there a link?, opens in a new tab [audio; 10:36mins], BMJ Talk Medicine, Sound Cloud, (November 2020). In this podcast, the effect of hormonal contraception on the impact of severe asthma exacerbation in women of reproductive age is discussed. Multimedia Editor of Thorax, Rachael Moses, interviews Dr Nwaru, Associate Professor of epidemiology, Krefting Research Centre, University of Gothenburg, Sweden, author of the longest longitudinal study investigating this impact in women with established asthma.
  • Periods as barometers of hormonal health. Female athlete health Pt 1 with Dr Nicky Keay Episode #449, opens in a new tab [audio; 13:49 mins], BMJ Talk Medicine, SoundCloud, (November 2020). A dive into female athlete health with Dr Nicky Keay. Dr Keay is a Sports and Dance Endocrinologist and Honorary Fellow at the Department of Sport and Exercise Sciences at Durham University. Many of our listeners will know Nicky from some of her publications in BJSM relating to female athlete health, which we cover in two rich podcasts. For some of the resources mentioned, please see the links below, or check out the BJSM blog homepage, where they will be collated into an interactive blog.

  • The Exercising Female. Science and Its Application, opens in a new tab, 1st edition, Forsyth J., Roberts C. Routledge, (2018). Based on the latest research, and treating women as a unique population, the book seeks to critically evaluate current debates, present the science underpinning female sport and exercise performance, and inform applied practice for the exercising female. Featuring contributions from leading scientists from around the world, and adopting a multidisciplinary approach—from exercise physiology, endocrinology, and biochemistry to psychology, biomechanics, and sociology—the book includes chapters on topics such as: Exercise and the menstrual cycle, contraception, pregnancy, motherhood, and menopause.
  • Sex Hormones, Exercise and Women. Scientific and Clinical Aspects, opens in a new tab, Hackney, AC. Springer, (2016). The thematic question explored in this work is: if exercise affects reproductive hormones, conversely then could the reproductive hormones have physiological effects unrelated to reproduction that influence the capacity of women to exercise? In exploring this question, the goal is to better understand the unique physiology of women and whether female sex hormones might account for some of the variance in physiological performance between amenorrheic and eumenorrheic women, and within women across the age span as they experience menarche to menopause. Sex Hormones, Exercise and Women: Scientific and Clinical Aspects synthesizes the research by exploring the physiology and psychology behind these occurrences. This novel title will not only be of interest to researchers, exercise scientists, graduate students, and clinicians; it will also serve as a source of valuable information for female athletes and their trainers in the context of preparing for competitions.

  • Female Performance and Health Initiative (FPHI), Australian Institute of Sport, (accessed 21 March 2023). The FPHI was established in October 2019, to improve female athlete specific knowledge and systems of support. The initiative will benefit Australian athletes, coaches, parents, sporting organisations and support staff in the sport sector and will raise awareness and understanding to key female athlete performance and health considerations, including but not limited to: 
  • “I’m an Athlete. Period.”, opens in a new tabActive Inclusion, South Australian Office for Recreation, Sport and Racing, Taboo Period Products, (2023). Project has several videos and ambassadors aiming to:
    • Removing the stigma and/or taboo nature around menstruation
    • Improving awareness of the barriers related to menstruation for girls and young women involved in sport
    • Identifying champions to start conversations in clubs/sports and how barriers can be addressed
    • Empowering champions to lead conversations and promote change
    • Raise awareness and reduce aversion to the discussion of periods
    • Reduce barriers that impact female participation in sport
  • Periods, contraceptives and performance: The need for more education, opens in a new tab, University of Southern Queensland, (March 2023). The University of Southern Queensland (UniSQ) has been chosen by the Australian Institute of Sport (AIS) to lead a landmark research project to address major knowledge gaps among female athletes and those that support them about how the menstrual cycle can impact training and performance. “By the end of this project, we will have an evidence-based resource that will serve as a starting point for sporting organisations to utilise and improve upon the quality of any female athlete health education delivered.”

  • Puberty & Sport: An Invisible Stage, opens in a new tab, Women in Sport, (2018). Puberty is a confusing time of significant physical, emotional and social change for girls, which they feel unprepared to deal with due to a lack of education. During this transition to adulthood, girls can form negative attitudes towards sport due to parents being less engaged, increased studying and pressure to perform well at school, a desire for new, more mature experiences and wanting to be accepted and acceptable to peers.

  • Current evidence shows no influence of women's menstrual cycle phase on acute strength performance or adaptations to resistance exercise training, opens in a new tab, Lauren Colenso-Semple, Alysha D'Souza, Kirsty Elliott-Sale, et al., Frontiers in Sports and Active Living, Volume 5, (March 2023). the purpose of this umbrella review was to examine and critically evaluate the evidence from meta-analyses and systematic reviews on the influence of menstrual cycle phase on acute performance and chronic adaptations to resistance exercise training (RET). We observed highly variable findings among the published reviews on the ostensible effects of female sex hormones on relevant RET-induced outcomes, including strength, exercise performance, and hypertrophy. We highlight the importance of comprehensive menstrual cycle verification methods, as we noted a pattern of poor and inconsistent methodological practices in the literature. In our opinion, it is premature to conclude that short-term fluctuations in reproductive hormones appreciably influence acute exercise performance or longer-term strength or hypertrophic adaptations to RET.
  • Go with the flow – menstrual health experiences of athletes and coaches in Scottish swimming, opens in a new tab, Sarah Zipp, Molly Hyde, Sport in Society, (24 March 2023). In collaboration with Scottish Swimming, our study included semi-structured interviews with 13 coaches and 6 athletes. Both coaches and athletes felt they lacked knowledge and expressed a strong desire for menstrual health education in sport. Notably, most coaches were not confident that their knowledge would enable them to offer practical advice. Athletes indicated an openness about discussing the menstrual cycle, especially as they got older. We conclude that menstrual health education should be formally incorporated into coaching education, which will improve athlete experience.
  • The impact and experienced barriers menstruation present to football participation in amateur female footballers, opens in a new tab, Cecile Pinel, Ritan Mehta, Katrine Okholm Kryger, Journal of Sport Sciences, Volume 40(17), pp.1950-1963, (September 2022). This study (1) assessed the impact different stages of the menstrual cycle has on experienced football performance and exercise ability (2) identified the experienced barriers to football participation menstruation presents in amateur women footballers. An online survey was used. The inclusion criteria were non-professional, women currently experiencing regular menstrual cycles, ≥18 years, ≥60 min football/week in the UK. Most of the respondents were aged between 18–25 (89%), Caucasian (83%) and competing in Universities Leagues (69%). Menstruation was reported to “never” limit football playing in 17%, “sometimes” in 47%, “rarely” in 25% and “always” in 10% of respondents. The majority (73%) reported one or more barriers menstruation present to football participation. Confidence and aerobic capacity/endurance were identified to be the aspects most negatively impacted during the pre-menstrual and menstrual stages. Confidence is likely to be negatively impacted due to the barriers identified. Thus, recommendations on how to reduce these through education of players and involved staff, at the club and the FA level have been made.
  • The impact of menstruation on participation in adventurous activities, opens in a new tab, Heather Prince, Erin Annison, Sport, Education and Society, (4 April 2022). Menstruation is a ‘taboo’ subject in many cultures and its effect on women’s participation in sport and physical culture in western societies is under-researched. This study examines the effect of menstruation and premenstrual syndrome (PMS) on habitual participants in adventurous activities through the voices of women. In a survey to explore women’s lived experiences (n = 100), 89% of respondents noted that their participation is affected by menstruation/PMS. The dominant constraints to participation in adventurous activities were related to practical challenges of hygiene and waste disposal for managing menstruation. Rich qualitative data provide evidence for the negative and emotional responses of women to ‘missing out’ on adventurous activities with the majority of concerns about their performance in socio-cultural contexts related to personal anxieties. Some women commented on their belief in being a role model in professional work encouraging open discussion around menstruation and enabling more women and girls to take part in adventurous activities. Key practical recommendations are suggested in respect of provision of toilet facilities where possible and biodegradable sanitary products. Raised awareness amongst leaders and educators, particularly men is important so that they might identify strategies to manage the constraints facing women and girls and enable more inclusivity and greater participation in adventurous activities.
  • Physical Activity, Menstrual History, and Bone Microarchitecture in Female Athletes with Multiple Bone Stress Injuries, opens in a new tab, Rudolph, Sara, Caksa, Signe, Gehman, Sarah, et al., Medicine and Science in Sports and Exercise, Volume 53(10), pp.2182-2189, (October 2021). To determine differences in health and physical activity history, bone density, microarchitecture, and strength among female athletes with a history of multiple BSI, athletes with ≤1 BSI, and nonathletes. Groups did not differ according to age, body mass index, age at menarche, areal bone mineral density, or tibial bone microarchitecture. Women with multiple BSI had a higher prevalence of primary and secondary amenorrhea (P < 0.01) compared with other groups. Total hours of physical activity in middle school were similar across groups; however, women with multiple BSI performed more total hours of physical activity in high school (P = 0.05), more hours of uniaxial loading in both middle school and high school (P = 0.004, P = 0.02), and a smaller proportion of multiaxial loading activity compared with other groups. These observations suggest that participation in sports with multiaxial loading and maintaining normal menstrual status during adolescence and young adulthood may reduce the risk of multiple bone stress injuries.
  • Injury Incidence Across the Menstrual Cycle in International Footballers, opens in a new tab, Dan Martin, Kate Timmins, Charlotte Cowie, et al., Frontiers in Spors and Active Living, Volume 3, (March 2021). One hundred fifty-six injuries from 113 players were eligible for analysis. Injury incidence rates per 1,000 person-days were 31.9 in the follicular, 46.8 in the late follicular, and 35.4 in the luteal phase, resulting in injury incidence rate ratios of 1.47 (Late follicular:Follicular), 1.11 (Luteal:Follicular), and 0.76 (Luteal:Late follicular). Injury incident rate ratios showed that muscle and tendon injury rates were 88% greater in the late follicular phase compared to the follicular phase, with muscle rupture/tear/strain/cramps and tendon injuries/ruptures occurring over twice as often during the late follicular phase compared to other phases 20% of injuries were reported as occurring when athletes were “overdue” menses.
  • Prevalence and frequency of menstrual cycle symptoms are associated with availability to train and compete: a study of 6812 exercising women recruited using the Strava exercise app, opens in a new tab, Georgie Bruinvels, Esther Goldsmith, Richard Blagrove, et al., British Journal of Sports Medicine, Volume 55(8), pp.438-443, (March 2021). The most prevalent menstrual cycle symptoms were mood changes/anxiety (90.6%), tiredness/fatigue (86.2%), stomach cramps (84.2%) and breast pain/tenderness (83.1%). After controlling for body mass index, training volume and age, the MSi was associated with a greater likelihood of missing or changing training (OR=1.09 (CI 1.08 to 1.10); p≤0.05), missing a sporting event/competition (OR=1.07 (CI 1.06 to 1.08); p≤0.05), absenteeism from work/academia (OR=1.08 (CI 1.07 to 1.09); p≤0.05) and use of pain medication (OR=1.09 (CI 1.08 to 1.09); p≤0.05). Menstrual cycle symptoms are very common in exercising women, and women report that these symptoms compromise their exercise participation and work capacity. The MSi needs to be formally validated (psychometrics); at present, it provides an easy way to quantify the frequency of menstrual cycle symptoms.
  • Bidirectional Interactions between the Menstrual Cycle, Exercise Training, and Macronutrient Intake in Women: A Review, opens in a new tab, Sílvia Rocha-Rodrigues, Mónica Sousa, Patrícia Lourenço Reis, et.al., Nutrients, Volume 13(2), (2021). Women have a number of specificities that differentiate them from men. In particular, the role of sex steroid hormones and the menstrual cycle (MC) significantly impact women’s physiology. The literature has shown nonlinear relationships between MC, exercise, and nutritional intake. Notably, these relationships are bidirectional and less straightforward than one would suppose. For example, the theoretical implications of the MC’s phases on exercise performance do not always translate into relevant practical effects. There is often a disconnect between internal measures (e.g., levels of hormone concentrations) and external performance. Furthermore, it is not entirely clear how nutritional intake varies across the MC’s phases and whether these variations impact on exercise performance. Therefore, a thorough review of the existing knowledge could help in framing these complex relationships and potentially contribute to the optimization of exercise prescription and nutritional intake according to the naturally occurring phases of the MC. Throughout this review, an emerging trend is the lack of generalizability and the need to individualize interventions, since the consequences of the MC’s phases and their relationships with exercise and nutritional intake seem to vary greatly from person to person. In this sense, average data are probably not relevant and could potentially be misleading.
  • Elite female athletes' experiences and perceptions of the menstrual cycle on training and sport performance, opens in a new tab, Brown N; Knight CJ; Forrest Née Whyte LJ, Scandinavian Journal of Medicine and Science in Sports, Volume 31(1), pp.52-69, (2021). Individual semi-structured interviews were conducted with 17 elite female athletes (25.5 ± 4.7 years) from multiple sports. Results revealed athletes' experiencing a natural menstrual cycle reported physical symptoms alongside mood disturbances and reduced motivation to train. The decision to actively control the menstrual cycle was often triggered by a desire to reduce the effect on competition, to lessen anxieties about making required weight or reduce distraction to manage during competition. Athletes indicated an openness to talk about the menstrual cycle to other females, however, there was variation in the comfort athletes experienced regarding talking to male coaches. Overall, the findings highlight the need to educate elite athletes and coaches on the menstrual cycle, considering it in the same light as other physiological functions in sport to improve health, well-being, and performance. Furthermore, providing education on how to construct positive conversations, equipping individuals with the correct terminology, and confidence to talk about the menstrual cycle will reduce some reservations identified through improved knowledge and understanding.
  • What male coaches want to know about the menstrual cycle in women’s team sports: Performance, health, and communication, opens in a new tab, Anthea Clarke, Andrew Govus, Alex Donaldson, International Journal of Sports Science & Coaching, Volume 16(3), (January 2021). 18 male coaches of Australian female elite football-codes brainstormed what they wanted to know about the menstrual cycle to work more effectively with female athletes. Ideas were sorted into groups of similar ideas and rated for importance and influence. Thirty-eight unique statements emerged from the brainstorming. These were organised into five clusters/topics following multidimensional scaling and hierarchical cluster analysis: 1) How does training need to be managed; 2) How is physical performance impacted; 3) What are the medical and dietary considerations; 4) When and how should we communicate with athletes; and 5) How are athletes affected psychologically and emotionally. These findings highlight the need for a comprehensive education framework to improve the knowledge of and practices related to the menstrual cycle. This education should 1) facilitate better recognition and referral of female athletes regarding menstrual cycle dysfunction and related health concerns; 2) encourage collaboration between athletes, coaches, and medical and dietary professionals; and 3) promote effective communication between athletes and coaches about the menstrual cycle.
  • How the menstrual cycle and menstruation affect sporting performance: experiences and perceptions of elite female rugby players, opens in a new tab, Findlay RJ, Macrae EHR, Whyte IY, et al., British Journal of Sports Medicine, Volume 54(18), pp.1108-1113, (September 2020). 15 international female rugby players participated in individual semi-structured interviews (age: 24.5±6.2 years). Almost all athletes (93%) reported menstrual cycle-related symptoms. Thirty-three per cent perceived heavy menstrual bleeding and 67% considered these symptoms impaired their performances. Two-thirds of athletes self-medicated to alleviate symptoms. The four general dimensions were: (1) symptoms: physiological and psychological menstrual cycle-related symptoms such as dysmenorrhoea, flooding, reduced energy levels, worry, distraction, fluctuating emotions and reduced motivation; (2) impact: perceived impact of menstruation on different aspects of daily lives and performance including negative and neutral responses; (3) resolution: the methods/approaches in dealing with menstruation-related concerns including accepting, or adapting and managing symptoms with self-medication or expert treatment; (4) support: available support and comfortability in discussing menstrual cycle-related issues. This study highlights individual responses to menstrual ‘issues’ and emphasises the need for clinicians and support staff to undertake menstrual cycle profiling, monitoring and continue to develop awareness, openness, knowledge and understanding of the menstrual cycle.
  • Practice does not make perfect: A brief view of athletes' knowledge on the menstrual cycle and oral contraceptives, opens in a new tab, Larsen B; Morris K; Quinn K; et.al., Journal of Science and Medicine in Sport, Volume 23(8), pp.690-694, (August 2020). Australian female athletes (n=189) representing their state and/or country in their respective sport completed a questionnaire comprising questions relating to the menstrual cycle and oral contraceptives. A knowledge 'score' was calculated by allocating one point for each correct answer; the highest knowledge score that could be achieved was 14. Almost half (47.1 %) of the athletes surveyed were currently using hormonal contraception, the majority (75.3 %) of which used an oral contraceptive pill. Nevertheless, the mean knowledge score achieved by athletes on the questionnaire was 5.03±3.06, with only 8.5 % of athletes achieving a knowledge score of 10 or above. Our findings indicate that knowledge surrounding the menstrual cycle and oral contraceptives was low in most elite athletes. Further education is warranted to enable athletes to make informed decisions regarding hormonal contraception, and any educational interventions should be implemented across all athlete groups.
  • Inflammation and Oral Contraceptive Use in Female Athletes Before the Rio Olympic Games, opens in a new tab, Larsen B; Cox A; Colbey C; et.al., Frontiers in Physiology, (25 May 2020). This study investigated the association between synthetic ovarian hormone use [i.e., the oral contraceptive (OC) pill] and basal C-reactive protein (CRP), peripheral blood immune cell subsets, and circulating pro- and anti-inflammatory cytokine concentrations in elite female athletes. Elite female athletes (n = 53) selected in Rio Summer Olympic squads participated in this study; 25 were taking an OC (AthletesOC) and 28 were naturally hormonally cycling (AthletesNC). Female Olympians had substantially higher CRP concentrations, a marker of inflammation and tissue damage, before the Rio Olympic Games if they used an OC. Future research should examine the potential consequences for athlete performance/recovery so that, if necessary, practitioners can implement prevention programs.
  • Australian female athlete perceptions of the challenges associated with training and competing when menstrual symptoms are present., opens in a new tab Armour, Mike; Parry, Kelly A; Steel, Kylie; et.al., International Journal of Sports Science and Coaching, Volume 15(3), pp.316- , (2020). This study aimed to investigate the strategies used by athletes to manage menstrual symptoms and the role coaches played in this process. One hundred and twenty-four valid responses from Australian athletes 16–45, with a mean age of 29 years, were received. Period pain (82%) and pre-menstrual symptoms (83%) were commonly reported and contributed to fatigue and to perceived reductions in performance during or just prior to the period (50.0% in training, 58.7% on 'game day'). Contraceptive use was reported by 42% of athletes. Those reporting heavy menstrual bleeding (29.7%) were more likely to report increased fatigue. Over three-quarters of athletes reported neither they nor their coaches altered training due to the menstrual cycle. Most athletes (76%) did not discuss menstruation with their coaches. Given the perceived negative impact on performance and potential risks with contraceptive usage during adolescence, coaches, trainers and athletes need to have a more open dialogue around the menstrual cycle.
  • Changes in Self-Reported Physical Fitness, Performance, and Side Effects Across the Phases of the Menstrual Cycle Among Competitive Endurance Athletes, opens in a new tab, Solli, Guro S.; Sandbakk, Silvana B.; et.al., International Journal of Sports Physiology and Performance, Volume 15(9), pp.1324-1333, (2020). To investigate changes in self-reported physical fitness, performance, and side effects across the menstrual cycle (MC) phases among competitive endurance athletes and to describe their knowledge and communication with coaches about the MC. The responses of 140 participants (older than 18 y) competing in biathlon or cross-country skiing at the (inter)national level were analyzed. About 50% and 71% of participants reported improved and reduced fitness, respectively, during specific MC phases, while 42% and 49% reported improved and reduced performance, respectively. Most athletes reported their worst fitness (47%) and performance (30%) and the highest number of side effects during bleeding (compared with all other phases). The phase following bleeding was considered the best phase for perceived fitness (24%) and performance (18%). Only 8% of participants reported having sufficient knowledge about the MC in relation to training, and 27% of participants communicated about it with their coach.
  • Dysmenorrhea and Heavy Menstrual Bleeding in Elite Female Athletes: Quality of Life and Perceived Stress, opens in a new tab, Silvia Vannuccini, Flavia Fondelli, Sara Clemenza, et al., Reproductive Sciences, Volume 27, pp.888-894, (2020). In female athletes, the incidence of menstrual disorders is variable, and their impact on perceived stress and quality of life (QoL) is poorly known. A cross-sectional survey was conducted in nulliparous elite athletes of reproductive age, and the study population included 112 cases. A group of women not practising regular sport activities (n = 103) was used as control. Athletes had a significantly higher incidence of irregular periods and heavy menstrual bleeding (HMB) and a lower incidence of dysmenorrhea than controls. Furthermore, athletes had a better physical QoL but higher PPS level and a worse mental QoL than controls. HMB was associated with lower mental scores and higher PSS scores than those observed in athletes with normal bleeding. No difference was found in different sports regarding gynecological health, PSS level, and QoL. An increased incidence of HMB should be considered in elite athletes with increased PSS and impaired QoL.
  • The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis, opens in a new tab, Kelly Lee McNulty, Kirsty Jayne Elliott-Sale, Eimear Dolan, et al., Sports Medicine, Volume 50, pp.1813-1827, (2020). The results from this systematic review and meta-analysis indicate that exercise performance might be trivially reduced during the early follicular phase of the MC, compared to all other phases. Due to the trivial effect size, the large between-study variation and the number of poor-quality studies included in this review, general guidelines on exercise performance across the MC cannot be formed; rather, it is recommended that a personalised approach should be taken based on each individual's response to exercise performance across the MC.
  • The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis, opens in a new tab, Kirsty Elliott-Sale, Kelly McNulty, Paul Ansdell, et al., Sports Medicine, Volume 50, pp.1785-1812, (2020). OCP use might result in slightly inferior exercise performance on average when compared to naturally menstruating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and variable across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle.
  • Methodological Recommendations for Menstrual Cycle Research in Sports and Exercise, opens in a new tab, Janse De Jonge, X; Thompson, B; Han, A, Medicine and Science in Sports and Exercise, Volume 51(12), pp.2610-2617, (2019). The aim of this review is to provide methodological recommendations for menstrual cycle research in exercise science and sports medicine based on a review of recent literature. Potential changes over the menstrual cycle are likely related to hormone fluctuations; however, only 44% of the selected studies measured the actual concentrations of the female steroid hormones estrogen and progesterone. It was shown that the likely inclusion of participants with anovulatory or luteal phase-deficient cycles in combination with small participant numbers has affected results in recent menstrual cycle research and, consequently, our understanding of this area. To improve the quality of future menstrual cycle research, it is recommended that a combination of three methods is used to verify menstrual cycle phase: the calendar-based counting method combined with urinary luteinizing hormone surge testing and the measurement of serum estrogen and progesterone concentrations at the time of testing. A strict luteal phase verification limit of >16 nmol·L for progesterone should be set. It is also recommended that future research should focus on the inclusion of the late follicular estrogen peak. It is envisaged that these methodological recommendations will assist in clarifying some of the disagreement around the effects of the menstrual cycle on exercise performance and other aspects of exercise science and sports medicine.
  • Period Prevalence and Perceived Side Effects of Hormonal Contraceptive Use and the Menstrual Cycle in Elite Athletes, opens in a new tab, Daniel Martin, Craig Sale, Simon Cooper, et al., International Journal of Sports Physiology and Performance, Volume 13(7), pp.926-932, (2018). 430 elite female athletes completed a questionnaire to assess the period prevalence of HC use, the reasons for initiation and discontinuation of HCs, and the side effects experienced by HC and non-HC users. Of athletes studied, 49.5% were currently using HCs and 69.8% had used HCs at some point. Combined oral contraceptives were most commonly used (68.1%), with 30.0% using progestin-only contraceptives (implant = 13.1%, injection = 3.7%, and intrauterine system = 2.8%). Perceived negative side effects were more common with progestin-only HC use (39.1%) compared with combined-HC use (17.8%; P = .001) and were most prevalent in implant users (53.6%; P = .004). HC users reported perceived positive side effects relating to their ability to predict and/or manipulate the timing, frequency, and amount of menstrual bleeding. Non-HC users had a menstrual cycle length of 29 (5) d and 77.4% reported negative side effects during their menstrual cycle, primarily during days 1–2 of menstruation (81.6%). Approximately half of elite athletes used HCs, and progestin-only contraceptive users reported greater incidences of negative side effects, especially with the implant. Because of the high interindividual variability in reported side effects, athletes and practitioners should maintain an open dialogue to pursue the best interests of the athlete.
  • Use of Oral Contraceptives to Manipulate Menstruation in Young, Physically Active Women, opens in a new tab, Schaumberg, Mia A.; Emmerton, Lynne M.; Jenkins, David G.; et.al., International Journal of Sports Physiology and Performance, Volume 13(1), pp.82- (2018). Menstruation and menstrual symptoms are commonly cited barriers to physical activity in women. The delay or avoidance of menstruation through extended oral-contraceptive (OC) regimens may mitigate these barriers, yet information on menstrual- manipulation practices in young physically active women is sparse. The majority (74%) of OC users reported having deliberately manipulated menstruation at least once during the previous year, with 29% reporting having done so at least 4 times. Prevalence of menstrual manipulation (at least once in the previous year) was not different between competitive athletes, sub-elite recreationally active women, and recreationally active women (77% vs 74% vs 72%). The most cited reasons for manipulating menstruation were special events or holidays (rated by 75% as important/very important), convenience (54%), and sport competition (54%). Menstrual manipulation through extended OC regimens is common practice in recreationally and competitively active young women, for a range of reasons relating to convenience that are not limited to physical activity. This strategy may help reduce hormone-related barriers to exercise participation, thereby positively affecting participation and performance.

  • FitrWoman, opens in a new tab. Free mobile app that helps track your menstrual cycle and provides personalised training and nutritional suggestions tailored to the changing hormone levels throughout your cycle. A subscription option also available called FitrCoach which allows athletes to share their data with their coach to help monitor real-time status and plan training and optimise performance throughout the athletes' menstrual cycle.
  • Menstrual Cycle Tracking, opens in a new tab, (accessed 21 March 2023). Hormonal changes during the menstrual cycle impacts mood, energy levels, risk of ACL injuries and female athlete’s ability to train and perform. AthleteMonitoring.com helps you monitor menstrual phases, symptoms, load, mitigate risk, and safely maximize athletic potential.
  • NETBALLHer, opens in a new tab, England Netball, (accessed 16 June 2023). Working with female health experts, The Well HQ, England Netball is aiming to re-write the rules and reimagine best practice around the female body’s life stages. NETBALL Her provides information on key topics such as Pelvic Health; Menopause; the Menstrual Cycle; Bras & Kit; Nutrition; Pre & Post Natal; Injury; and Puberty. More resources, myth busting articles, relatable videos, and Her Latest Stories, all rooted in netball, at every level of the game are added regularly.
  • Balanced Female Health, opens in a new tab, Sport New Zealand, (May 2023). A resource for adults supporting young people in community sport. Developed by health professionals working in the sport sector, this resource covers changes throughout female puberty, the menstrual cycle, and factors that impact the physical health and mental wellbeing of all young people.

Access to resources Where possible, direct links to full-text and online resources are provided. However, where links are not available, you may be able to access documents directly by searching our licenced full-text databases (note: user access restrictions apply). Alternatively, you can ask your institutional, university, or local library for assistance—or purchase documents directly from the publisher. You may also find the information you’re seeking by searching Google Scholar, opens in a new tab.

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