“I won’t play or train if it’s a heavy day.”

Posted on by BMJ
Researching the menstrual cycle and its impact on the enjoyment of sport and exercise

The hot topic of the menstrual cycle and menstruation continues to be recognised as a significant factor to consider in sport and exercise research. Indeed, the British Association of Sport and Exercise Sciences (BASES) has called for more high quality, evidence-based, peer-reviewed papers on this topic [1]. Recently, two systematic reviews and meta-analysis papers highlighted the large between-study variation and the number of poor methodological quality studies that have so far been conducted in this area [2,3]. Subsequently, guidelines suggest that practitioners should take an individualised approach to support athletes who menstruate, and that, since every person’s experience with their menstrual cycle is different, should be prepared that there may “never be a universal blueprint that practitioners can exclusively use towards training and performance’ [1].

Understanding Experiences

World Rugby Player of Year 2019, Emily Scarratt, recently spoke out about the importance of tracking the menstrual cycle around training and performance:

The focus here is on importance in providing insights into marginal performance gains and health-related issues such as amenorrhea, and there certainly exists a paucity in this area. However, competitive sport at a community-level rarely sees research on these topics, yet the vast majority of people who play sport do so at the grassroots level. This leads to the question: what of menstrual cycle experiences at the community-level?

Amenorrhea (a chronic loss of menstruation) tends to be the most discussed topic in terms of menstrual disruption, since it’s onset could potentially be related to ‘Relative Energy Deficiency in Sport’ [5]. However, the most recent qualitative study among international rugby players found no individual identified with amenorrhea, yet 33% reported heavy menstrual bleeding [5] as an issue, raising the question: could this be a common problem in this context? 

The Impact of Heavy Menstrual Bleeding

Heavy menstrual bleeding (HMB) is the menstrual blood loss of  ≥80ml a month [6]. This is difficult to diagnose in a clinical setting though, and fails to include the impairment HMB may cause on quality of life including social life, relationships, work, and sports participation [7,8]. HMB can also increase levels of fatigue and perceived stress, especially in the context of iron deficiency [9-13]. Despite this, Bruinvels et al.’s study [14] found that only a minority of women who exercise seek medical advice regarding HMB, implying that either they are unaware of the consequences, or that they are too embarrassed, or that they feel it is unnecessary, perhaps as they have learnt/are able to cope with it. Better understanding HMB in a rugby context is imperative for deeper understanding of the knowledge, lived experiences, and perceptions of HMB.

New Research into Heavy Menstrual Bleeding

I am currently undertaking a Master of Research (MRes) project at the University of Bath, with the aim of determining how common HMB is in 15-a-side women rugby union players in England. The MRes project is looking at self-reported HMB prevalence in women rugby union players in England, and comparing this to the perceived disruption to rugby training and performance, and other factors such as seeking of medical advice, and reported history of anaemia. This will be the first research project to determine the prevalence of HMB in a women’s rugby sporting context, establishing the groundwork to later understand why this may be a problem in this population, and what can be put in place to help. This research will also provide useful, practical insights for other low-resource sports settings beyond the elite level. A link to the survey can be found here https://bathreg.onlinesurveys.ac.uk/womens-health-questionnaire 

Why More Research Matters

Ultimately, the more research investigating menstruation and the menstrual cycle in sport, the closer we will get to providing a better understanding of the impact on – and practical advice for – sport and exercise settings. Whilst there may “never be a universal blueprint that practitioners can exclusively use towards training and performance’ [1], research in this area is progressively moving towards a much-needed cultural change, providing more nuanced, kinder, inclusive outcomes, and breaking down taboos surrounding menstruation in a sport and exercise context.

Author Name & Affiliations

Megan Watts @meganlwatts, University of Bath MRes Health and Wellbeing student

Dr Sheree Bekker @shereebekker, University of Bath, Assistant Professor (Lecturer), Dept. for Health

Megan @meganlwatts is halfway through her MRes degree, conducting the project entitled “The Prevalence and Experiences of Heavy Menstrual Bleeding among Women Rugby Players in England: a sequential explanatory mixed-methods study”. Megan has aspirations to undertake a PhD to continue her work exploring women’s health in a sporting context, one that she hopes would be collaborative in nature, placing player welfare at the forefront of her research.

Competing Interests

None

References

  1. Elliot-Sale K, Ross E, Burden R, Hicks K. The BASES Expert Statement on Conducting and Implementing Female-Athlete Based Research. First published in The Sport and Exercise Scientist, Issue 65, Autumn 2020. Published by the British Association of Sport and Exercise Sciences, 2020. https://www.bases.org.uk/imgs/0000_bas_tses___autumn_2020_online_pg6_7237.pdf (accessed 09 Sept 2020).
  2. McNulty KL, Elliot-Sale K, Dolan E, et al. The effects of menstrual cycle phase on exercise performance in eumenorrheic women: a systematic review and meta-analyses. Sports Med (2020). https://doi.org/10.1007/s40279-020-01319-3
  3. Elliott-Sale, K.J., McNulty, K.L., Ansdell, P. et al. The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis. Sports Med (2020). https://doi.org/10.1007/s40279-020-01317-5
  4. England Rugby. World Rugby Player of the Year @Emily Scarratt discusses the importance of nutrition for female athletes. 2020. https://twitter.com/englandrugby/status/1194351660367171586?s=12 (accessed on 10/09/2020)
  5. Findlay RJ, Macrae EHR, Whyte IY, et al. How the menstrual cycle and menstruation affect sporting performance: experiences and perceptions of elite female rugby players. British Journal of Sports Medicine 2020;54:1108-1113.
  6. Heavy periods. London: NHS; c2018. https://www.nhs.uk/conditions/heavy-periods/ (accessed on 09 Sept 2020).
  7. Bitzer J, Serrani M, Lahav A. Women’s attitudes towards heavy menstrual bleeding, and their impact on quality of life. Open Access J Contraception. 2013 Apr;4:21-8.
  8. Karlsson TS, Marions LB, Edlund MG. Heavy menstrual bleeding significantly affects quality of life. Acta obstetricia et gynecologica Scandinavica. 2014 Jan;93(1):52-7.
  9. Shankar M, Chi C, Kadir RA. Review of quality of life: menorrhagia in women with or without inherited bleeding disorders. Haemophilia. 2008 Jan;14(1):15-20.
  10. Gokyildiz S, Aslan E, Beji NK, Mecdi M. The effects of menorrhagia on women’s quality of life: a case-control study. ISRN obstetrics and gynecology. 2013 Jul 8;2013.
  11. Vannuccini S, Fondelli F, Clemenza S et al. Dysmenorrhea and Heavy Menstrual Bleeding in Elite Female Athletes: Quality of Life and Perceived Stress. Reproductive Sciences. 2020 Mar;27(3):888-94.
  12. Pedlar CR, Brugnara C, Bruinvels G, Burden R. Iron balance and iron supplementation for the female athlete: a practical approach. European journal of sport science. 2018 Feb 7;18(2):295-305.
  13. Napolitano M, Dolce A, Celenza G et al. Iron-dependent erythropoiesis in women with excessive menstrual blood losses and women with normal menses. Annals of hematology. 2014 Apr 1;93(4):557-63.
  14. Bruinvels G, Burden RJ, Cushway T et al. The Impact of Heavy Menstrual Bleeding (Menorrhagia) and Iron Status in Exercising Females. British Journal of Sports Medicine. 2017 Feb 1;51(4):304-.

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