The 13th episode of the ‘Climbing, accidents, prevention’ column by physiotherapists Claudia Mario and Luca Lancellotti analyzes the menstrual cycle in athletes. In collaboration with Doctor Gynecologist Valeria Bernardi.
The menstrual cycle is still unfortunately often a taboo topic among athletes and some coaches. Recent studies, on the other hand, have begun to investigate the possible effects it can have both on performance and on the risk of injury. Why is the menstrual cycle potentially able to influence these aspects?
The menstrual cycle is the result of the simultaneous action of several hormones (hypothalamic, pituitary and ovarian), the main ones of which are estrogen and progesterone. They are responsible for changes not only in the female reproductive system but also in many other tissues and systems of the body (cardiovascular, respiratory, metabolic system, etc.). In addition, they are often held responsible for changes in psychological and behavioral status, as well as coordination skills, concentration and much more.
The menstrual cycle is divided into two main phases: follicular phase and luteal phase. The first part of the follicular phase corresponds to the actual menstrual cycle and ends with ovulation, which precedes the luteal phase. In the alternation of these phases, there is an important variation in hormone levels and some studies have shown how sports performance can be partly influenced by the menstrual cycle.
The menstrual cycle often causes physical, affective and behavioral symptoms that develop especially during the luteal phase and then disappear a few days after the onset of menstruation. Many female athletes report that physical symptoms such as back pain and cramps are the leading cause of lost or impaired workouts. But the feeling of lethargy, distraction and lack of motivation also affect the ability of athletes to train regularly.
Knowing your own menstrual cycle and the effects it determines for each woman is another step that can help the athlete to optimize his psychophysical preparation. A regular menstrual cycle is of fundamental importance for a woman’s health.
It is useless to hide that the menstrual cycle is often experienced as a nuisance, which interferes with the ability to train and compete without the thought of menstrual losses or pains. Discomfort that can sometimes be eliminated by using oral contraceptives. But be careful! Hormonal regulation is essential for a woman’s entire body.
The absence of menstruation (amenorrhea), a rather common situation in athletes who undergo frequent and intense training, is a serious alarm bell. Amenorrhea can have very serious and irreversible consequences, such as osteoporosis, and should ALWAYS be investigated with your gynecologist. In this case there are no do-it-yourself searches on google or advice from friends, but it is necessary to rely on serious and competent specialists.
The intake of oral contraceptives masks the lack of menstruation, making it an insidious problem by many athletes too underestimated or ignored, what is called “Functional Hypothalamic Amenorrhea” FHA (functional hypothalamic amenorrhea). The absence of menstruation is one of the symptoms of female athletic triad, most recently included in the symptoms of RED’s (relative energy deficiency in sport). The female athletic triad is a syndrome that includes changes in menstrual function, bone density and nutritional status. Each component of the triad includes a spectrum of more or less severe signs and symptoms that each athlete can exhibit, which outline a different severity of the situation.
At the heart of the problem there is an incorrect supply of nutrients. If during sporting practice the muscles run out of energy reserves available, the body is forced to withdraw energy from other physical processes, progressively establishing problems affecting other organs. Female athletes who undergo very intense training regimes for long periods have a higher risk of developing amenorrhea. However, when strenuous exercise is supported by adequate nutritional intake, in a non-stressful environment, it does not typically cause amenorrhea. Conversely, intense workouts that are not adequately compensated for by an adequate nutritional plan increase the risk of menstrual dysfunction.
The primary goal of female athletic triad treatment is to increase energy availability by increasing caloric intake and / or reducing energy expenditure. Nutrition counseling and diet monitoring are sufficient to solve the problem in most female athletes. However, when it comes to real eating disorders, psychological support for the athlete is essential. There are no pharmacological treatments capable of restoring bone loss and metabolic abnormalities that irreversibly compromise health and performance in athletes with functional hypothalamic amenorrhea (FHA).
Menstrual cycle and performance
What role do menstrual hormones play in sports performance? Is there a way to optimize the training program in relation to the menstrual cycle? Some very recent studies have tried to establish whether there is a relationship between the phases of the menstrual cycle and athletic performance. From a theoretical point of view, estrogenic hormones are able to influence the use of metabolic substrates such as glycogen which becomes available to the muscle cell more quickly. They also have an antioxidant effect, which could decrease the inflammatory response and protect the muscle cell from damage resulting from training. Estrogen is also able to positively influence the capacity for voluntary muscle activation, and decreases involuntary inhibition, making the athlete faster and more powerful. Consequently, the rise in estrogen levels that occurs during the final follicular phase could potentially affect sports performance. While the data need to be confirmed and further studies based on a more rigorous methodology are needed, performance appears to be slightly better around 6-10 days into menstruation. It is important to emphasize that the menstrual cycle is very individual. Each woman experiences it differently and experiences different symptoms. It becomes very difficult to generalize for all the advice we can give. Rather, we would like to encourage you to observe your cycle, keep track of how you feel and try to understand if there is a recurrence in moments when you are more energetic or not. Based on your personal feeling it can be interesting to modify the training. For example, athletes who experience severe PMS, associated with severe cramps, heavy flow, or other unwell situations, may arrange the unloading week to coincide with their period. On the contrary, after about a week it might be advisable to do strength and power sessions, while keeping the duration SHORT!
Risk of accidents and menstruation
Is there a correlation between the phases of the menstrual cycle and the risk of injury? An article published in 2021 by the British Journal of Sport Medicine investigated the incidence of soft tissue injuries (such as muscles, tendons and ligaments) in female soccer players. In the final follicular phase (ovulation) the risk was 32-47% higher than in the other phases of the cycle. It is interesting to note that this same phase is often experienced by athletes as a moment of particular energy, in which they feel, and often are, actually stronger. This positive effect is likely due to the high level of estrogen associated with the low level of progesterone. We can therefore assume that the athlete is inclined to push his limit, running some more risks. But at the same time it cannot be ruled out that hormonal activity influences the body by predisposing the woman to get injured. Hence the need to optimize the training program in order to take advantage of this window of particular strength and motivation, reducing the risk of injuries. For example, high intensity but short duration sessions can be preferred. Avoiding training in a state of physical fatigue decreases the risk of injury, so it is a good idea to stop the session when you still feel strong, rather than running out of energy. This is just one example of how to modulate your training program. In addition, there are several free applications that can help you keep track of your menstrual cycle and the symptoms associated with each phase. A couple of examples are Clue and Fit4woman.
However, we remind you that if you take oral contraceptives any lack of menstruation will be masked. The Female Athletics Triad we talked about above is an insidious enemy for young athletes! This pathology exposes you to the risk of developing major injuries and undermines your health in the short and long term, with sometimes irreversible consequences.
If you have any doubts about it, talk to your gynecologist.
Thanks to Doctor Gynecologist Valeria Bernardi for her precious contribution!
by Claudia Mario and Luca Lancellotti
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Info: claudiamario.it, studioerre.bs.it
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