Facts & Figures

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Author & pictures: Dr. Emma Ross

APPLYING THE FEMALE FILTER

When six women collapsed after the 800-metre race at the 1928 Amsterdam Olympics, the International Olympic Committee banned women from running any distance over 200m. It was thought that any greater distance ‘makes too great a call on feminine strength’. In 2019 Brigid Kosgei broke the long-standing women’s marathon world record by running 26.2 miles in 2 hrs 14 min 4 sec. Incredible performances like this continue to remind us that women can perform far beyond any limits that were originally bestowed upon them by that 1928 committee. As women continue to pursue peak performance, whether that be in sport and exercise or beyond, we have to think differently about what it takes to allow them to fulfil their potential, because it won’t always be the same things that have worked for the men.

However, at the moment in sport, female athletes usually train and are coached in a way that doesn’t always consider the ‘female’ part of being a female athlete. The support that is applied to their performance (nutrition, physiology, psychology, etc.) is usually based on research that has been done on men (Costello, Bieuzen, & Bleakley, 2014), or what has been seen to be successful with male athletes. However women are very different from men. Women have periods and menstrual cycles, they may use hormonal contraception, they have breasts, they are far more likely to have pelvic floor dysfunction, they have a much higher risk of injury, and they manage emotions and derive confidence differently from men. I believe we need to get better at looking at fitness and performance with a female filter, considering all these female specific factors so that as active women we can truly get the best out of ourselves, whatever our ambitions are in sport, from personal achievements to podium performance.

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MASTERING THE MENSTRUAL CYCLE

The menstrual cycle is a biological rhythm that defines the reproductive years of women. From the onset of periods during puberty (the average age for starting periods in the UK is 13 yrs) a woman’s body cycles through hormonal changes which prepare her for a potential pregnancy. If pregnancy doesn’t occur during that cycle, the whole process repeats again, and again, until periods and the cycle stop, at the menopause (at about 51 yrs). This cycle of hormonal fluctuation is called the menstrual cycle. In sport we have become accomplished at tuning into and taking advantage of the effects of hormones to inform our practises around priming, training adaptation, nutrition and recovery, but we have failed to really tune in, understand and capitalise on the menstrual cycle hormones in the same way.

Like all hormones, which are chemical messengers, the hormones of the menstrual cycle, oestrogen and progesterone, can have widespread effects throughout the body, from altering metabolism, mood, immune function, body temperature, sleep and cognitive function to name a few. Importantly, their influence on female health and performance can be beneficial, in both the short and long term. However their imbalance or the nature of their rapid fluctuations can produce symptoms which can be challenging for athletes.

The fluctuating levels of these hormones across the whole cycle, create four parts of the cycle where sex hormone levels and ratios are distinctly different from one another (see fig 1). The menstrual cycle is typically described as a 28 day cycle (although only 13% of women actually have a 28 day cycle and anywhere between 23 and 35 days, and up to 40 days in teens, is considered normal (Bull, et al., 2019)). The first day of the cycle is the first day of the period. During the period, both hormones are at their lowest levels, after which oestrogen starts to rise to its peak in the late follicular phase. In the second half of the cycle both hormones rise, with progesterone peaking in the mid luteal phase, before both hormones drop down to low levels again if this cycle has not resulted in pregnancy.

THE MENSTRUAL CYCLE

Figure 1: A typical menstrual cycle, showing fluctuations of oestrogen and progesterone, and the four points where hormone levels, and/or ratio of oestrogen and progesterone are distinctly different. Published with Permission from The WellHQ

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The hormonal fluctuations and their influence on a woman’s physiology affects how women feel physically and emotionally, and for athletes this means wellbeing, training, recovery, and performance may be affected in different ways at these different times. These experiences can differ tremendously amongst women, and not all influences of the menstrual cycle are negative. For example, oestrogen can increase the levels of the mood-enhancing neurotransmitter serotonin (Rybaczyk, et al., 2005). Thus in the late follicular phase, mood, motivation and energy levels may be increased. In terms of performance, oestrogen creates what we might call an ‘anabolic’ environment – that is one where muscle repair and growth is supported, through influences on antioxidative processes, cell membrane stability and satellite cell proliferation (Mangan, Bombardier, Mitchell, Quadrilatero, & Tiidus, 2014). Because of this physiological environment, researchers have sought to explore whether performing more resistance training in this first half of the cycle increased strength gains compared to regularly spaced training throughout the cycle. These researchers ‘compressed’ strength training sessions in the first two weeks of the cycle, performing it on every other day, and then only two strength training sessions in the second half of the cycle. Compared to regularly performing the same amount of strength training across the cycle, participants saw a 33% increase in strength training with their menstrual cycle phase, compared to a 14% increase in strength when then trained in a more traditional programme (Reis, Frick, & Schmidtbleicher, 1995), and a 40% increase versus 28% when strength training was compressed in the first half of the cycle versus the second half of the cycle, respectively (Sung, et al., 2014). Working with individual athletes makes training mapped to the menstrual cycle a feasible and accessible approach to programming training. However it isn’t always pragmatic when training in squads. Training with the menstrual cycle in mind doesn’t have to include training that is synchronised to the cycle. It could be ensuring that each player increases her understanding of how she feels across her cycle, which then allows her to develop strategies to capitalise or cope with her physical and emotional state at that time. This may sound simple, but since 88% (Bruinvels, Goldsmith, & Blagrove, 2020) of women say that their cycle symptoms make performance worse at some point in their cycle, yet only 20-30% of them talk

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to their coach about it (Brown, Knight, & Forrest (née Whyte), Scand J Med Sci Sports., 2021), but tuning in to the menstrual cycle, discussing it in relation to how it impacts one’s ability to perform and then acting upon that to maximise performance on any given day affords female players so much opportunity.

The range of more challenging symptoms that can be experienced across the cycle is vast, from gastrointestinal issues, brain fog, migraines, bloating, abdominal pain, joint inflammation, anxiety, depression, and emotional sensitivity (Martin, C, Cooper, & Elliott-Sale, 2018). Most symptoms are reported during the premenstrual phase, as a result of the rapid withdrawal of both sex hormones at the end of the cycle, and during the period, when the smooth muscle of the uterus contracts to expel it’s lining through the vagina, as a bleed. Importantly, research has shown that determinants of performance, such as VO2max, speed and power are not affected across the menstrual cycle (McNulty, et al., 2020). However, the symptoms that a woman experiences can impact her ability to tap into her performance potential on any given day of the cycle. When females are being negatively impacted by their cycle symptoms, there are numerous strategies that can be explored to alleviate these symptoms which range from diet, lifestyle, exercise, rest and recovery and stress management to pharmacological interventions (Panay, 2011). It’s important to remember that every women’s experience of her cycle will be unique, which means there is no one blueprint of what a menstrual cycle looks or feels like. However, a healthy cycle should always contain a period and ovulation, and its symptoms be mild and manageable.

This makes menstrual cycle monitoring a powerful tool for athletes, coaches and support staff. It allows an athlete to capture her own experience of the cycle, and how it influences her in the context of her life and her sport. At the very least it can help explain why some days feel better than others; at best it can produce patterns that can be anticipated, exploited, or overcome to optimise training, recovery and performance. Physical and emotional changes should also be monitored across the cycle, as well as sleep, muscle soreness, motivation to train and any injury or illness. Monitoring the cycle requires recording the first day of the period, which indicates day one of the cycle, and over time, tracks cycle length. Athletes should note how heavy their flow is during their period, which can help identify heavy menstrual bleeding which can cause symptoms of fatigue and increase susceptibility to anaemia (Bruinvels, Burden, Brown, Richards, & Pedlar, 2016).

Monitoring does not have to be costly or complicated. Athletes can use a calendar/diary and pen, through to more sophisticated digital health trackers. They should monitor for at least three months to allow meaningful conclusions about their cycle patterns to be made. It is worth noting that it’s never useful to instruct athletes to monitor their cycle, instead they must first see the value in it, often through education, and then find a system of recording that suits them. Monitoring empowers athletes to be architects of their own health and wellbeing – not only to tap into the powers and pitfalls of their cycle, but to recognise when the cycle is unhealthy. The period is a vital sign of health, and loss of periods (amenorrhea) needs to be investigated. In athletes this is commonly a sign of under-fuelling or low energy availability, and it increases the risk of injury and illness and long-term poor health. (Mountjoy, Sundgot-Borgen, & Burke, 2014) (Mountjoy M. , 2018 ). This situation is known as Relative Energy Deficiency in Sport (RED-S). Although amenorrhea is prevalent in female athletes, with the figure higher for those in endurance or weight managed sports (Logue, et al., 2020 ), RED-S still remains poorly recognised by health professionals, coaches and athletes (Curry, Logan, & Ackerman, 2015).

So, my final word is on creating a culture in your sport, your club, your team, where girls and women feel comfortable discussing things like the menstrual cycle; where female specific factors are considered as an important part of their health, wellbeing and performance. That requires that we get rid of the silence, secrecy and judgement that seems to surround some of these topics. Instead create a space where we can discuss athletes’ bodies and what they might be doing at any given time, how it’s affecting them, and how they can use its strengths and overcome it’s challenges. Walking into these conversations, creating these spaces for girls and women to share and discuss these topics is not always easy, but when we do, with support, empathy, and encouragement, that’s when the magic happens. That’s when athletes will show up, take chances, and fulfil their potential.

About the author: Dr Emma Ross was, until recently, the Head of Physiology at the English Institute of Sport, supporting practitioners working across Olympic and Paralympic sports and leading the EIS Female Athlete Programme. This programme aimed to empower coaches, athletes and sports practitioners to better understand the exercising female, and how to capitalise on her physiology and psychology in the context of sport. Emma recently co-founded The WellHQ, to continue this mission to tackle the taboo’s, educate and empower people in sport and beyond, about topics such as periods and the menstrual cycle, breast health, pelvic floor health and what it takes for girls and women to thrive in sport, in health and in life.

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REFERENCES

1. Brown, N., Knight, C., & Forrest (née Whyte), L. (2021).

Scand J Med Sci Sports. Elite female athletes’ experiences and perceptions of the menstrual cycle on training and sport performance., 31, 52– 69.

2. Bruinvels, G., Burden, R., Brown, N., Richards, & Pedlar,

C. (2016). The Prevalence and Impact of Heavy Menstrual

Bleeding (Menorrhagia) in Elite and Non-Elite Athletes.

PloS one, 11(2), e0149881.

3. Bruinvels, G., Goldsmith, E., & Blagrove, R. e. (2020).

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. British Journal of Sports Medicine, online first.

4. Bull, J. R., Rowland, S. P., Scherwitzl, E. B., Scherwitzl, R.,

Danielsson, K. G., & Harper, J. (2019). Real-world menstrual cycle characteristics of more than 600,000 menstrual cycles. Npi Digital Medicine, 2(83).

5. Costello, J., Bieuzen, F., & Bleakley, C. (2014). Where are all the female particpants in sport and exercise medicine research? European JOurnal of Sports Science, 847-851.

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8. Mangan, G., Bombardier, E., Mitchell, A., Quadrilatero, J., & Tiidus, P. (2014). Oestrogen-dependent satellite cell activation and proliferation following a running exercise occurs via the PI3K signalling pathway and not IGF-1. .

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14. Reis, E., Frick, U., & Schmidtbleicher, D. (1995). Frequency variations of strength training sessions triggered by the phases of the menstrual cycle. Int J Sports Med., 16(8), 545–550.

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DR. EMMA ROSS

Dr. Emma Ross (43) describes herself: “I’m on a mission.” She wants to empower women throughout their lifespan, with the knowledge and wisdom they need to achieve health, happiness and high performance, whether in work, sport, family or life.

She was Head of Physiology at the English Institute of Sport (EIS) where she developed and led the SmartHER campaign to improve support of female athletes. The campaign supports coaches, athletes and sports practitioners to gain a better understanding of the exercising female. Emma founded her own company “The Well HQ”, to continue her mission to tackle the taboos, and to educate and empower people in sport and beyond, about the menstrual cycle, breast health, pelvic floor health and what it takes for girls and women to thrive. Ross has a first class degree in Sports Science, a Master in Sport and Exercise Physiology and a PhD in Exercise Neurophysiology. She taught as a University lecturer for over 10 years. She has over 20 years of experience of teaching and researching human physiology, and a decade of working in high performance sport supporting some of the world’s best athletes.

She now lives in Sussex, UK with her family. She’s a mother of two children (5 and 9 years old).