Perceived impact of the menstrual cycle and hormonal contraceptives on physical exercise and performance in 1,086 athletes from 57 sports

Linda Ekenros, Philip von Rosen, Guro Strøm Solli, Øyvind Sandbakk, Hans-Christer Holmberg, Angelica Lindén Hirschberg, Cecilia Fridén, Linda Ekenros, Philip von Rosen, Guro Strøm Solli, Øyvind Sandbakk, Hans-Christer Holmberg, Angelica Lindén Hirschberg, Cecilia Fridén

Abstract

Female athletes train and compete under the potential influence of hormonal fluctuations during the menstrual cycle or during use of various hormonal contraceptives. Dysmenorrhea and premenstrual symptoms are common in the general population, as well as side effects of hormonal contraceptives. More detailed knowledge concerning prevalence and perceived impact of these symptoms on training and performance in different sports is required. The aim of the study was to 1) characterize perceptions of training and performance during the menstrual cycle phases and by hormonal contraceptive use in a large population of female athletes; 2) explore whether symptoms experienced are related to perceived performance; and 3) examine potential differences in these factors between athletes at different levels of performance. The study was based on self-reported data from 1,086 athletes from 57 sports at different performance levels via a web-based questionnaire. Thirty-seven percent (n = 407) of the athletes did not use hormonal contraceptives. In this group, menstrual cycle related symptoms were common across all athlete levels, particularly dysmenorrhea (74%, n = 300) and premenstrual symptoms (78%, n = 318), which also influenced perceived performance of aerobic fitness, muscle strength, mental sharpness, balance, and sleep quality. Sixty-three percent (n = 679) of the athletes used various hormonal contraceptives and 40% (n = 272) perceived a variety of side-effects. Physical performance was experienced equally independent of time-point of the pill-chart except for the period of inactive pills, which was associated with more negative impact. Nonetheless, only 18% (n = 191) of the athletes considered menstrual cycle or hormonal contraceptive issues when planning their training or competitions. These results indicate that greater focus is needed to identify and effectively treat different menstrual cycle and hormonal contraceptive related symptoms on an individual level.

Keywords: amenorrhea; dysmenorrhea; hormones and athletes; premenstrual symptom; sex hormone.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Ekenros, von Rosen, Solli, Sandbakk, Holmberg, Hirschberg and Fridén.

Figures

FIGURE 1
FIGURE 1
Division of the respondent athletes into users and non-users of hormonal contraceptives (HC users). Each box indicates the number (n) of respondents as well as the percentage (%) of the total number. EE = ethinyl estradiol; IUS = intrauterine system; OCs = oral contraceptives.
FIGURE 2
FIGURE 2
Premenstrual symptoms reported by the non-users (n = 407) of hormonal contraceptives. Physical symptoms in light green and mental symptoms in green. Breast tenderness was the most frequent reported physical symptom (43%, n = 172) and irritability the most frequent reported mental symptom (54%, n = 214).
FIGURE 3
FIGURE 3
The perceived impact (positive, negative or no change) of (A) Overall physical performance, (B) Muscle strength, (C) Aerobic fitness, (D) Mental sharpness, (E) Balance and (F) Sleep quality, during different phases of the menstrual cycle (n = 299 in each phase). A proportion of 6%–24% of the athletes answered “I do not know” on perceived impact for the different modalities, respectively (data not shown).
FIGURE 4
FIGURE 4
Side effects experienced by the athletes using hormonal contraceptives, in percentage. In (A) side effect of hormonal contraceptives containing progestins alone (49%, n = 299) and hormonal contraceptives containing a combination of progestins and ethinyl estradiol (51%; n = 316). A total of 615 (91%) users of hormonal contraceptives answered this question. In (B) side effects of combined oral contraceptives, divided into estrogen dominant oral contraceptives (18%; n = 56) and progestin dominant oral contraceptives (51%; n = 156). The oral contraceptives of non-specific dominance (31%; n = 95) (data not shown).
FIGURE 5
FIGURE 5
The perceived impact (positive, negative or no change) of (A) Overall physical performance, (B) Muscle strength, (C) Aerobic fitness, (D) Mental sharpness, (E) Balance, and (F) Sleep quality, during different time points in the pill chart of combined hormonal contraceptives. First and third pill week (n = 307) and at the time point for inactive pills (n = 163). A proportion of 18%–46% of the athletes answered “I do not know” on perceived impact for the different modalities, respectively (data not shown).

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