The role of menstrual cycle phase-based resistance training for women post anterior cruciate ligament reconstruction: a scoping review

Figures & data

Figure 1. PRISMA flow diagram.

Prisma diagram illustrating the systematic review and meta-analysis process and the final number of studies (14 final studies).

Table 1. Study characteristics of primary studies and reviews that met inclusion criteria.

Author, Year, Location	Study Design & Duration	Population	Study Design/Review Aim	Comparison	MC Verification	Results	Conclusions
Reis et al. 1995 [18] Germany	Non-randomized controlled trial. 8 weeks	N = 7 students. Training status not noted. Non-injured. Age: 24 ± 3.5 years	Lower limb unilateral knee extension RT every second day in the FP. Rest or x1/week in LP.	Opposite leg carried out lower limb unilateral knee extension RT every third day throughout the MC (regular training).	BBT, ovulation kits, & blood serum analysis. N = 1 excluded by blood analysis.	20% increase maximum knee extension strength difference in FP-based RT group.	FP based RT is superior for strength development.
Sung et al. 2014 [17] Germany	Randomised controlled trial. 12 weeks	N = 20 untrained students. Non-injured. Age: 25.9 ± 4.5 years	8 lower limb unilateral leg press RT sessions in FP & 2 in LP per MC.	Opposite lower limb completed 8 lower limb unilateral leg press RT sessions in LP & 2 in FP per cycle.	Calendar tracking, BBT, & blood serum analysis N = 4 excluded by BBT analysis	29% increased maximum knee extension strength in FP-based RT group. FP-based RT group also showed a higher increase in muscle CSA than LT. Increase in fibre diameter of type II fibres and in cell nuclei-to-fibre ratio only after FP-based RT.	FP based RT is superior for strength development & muscle CSA.
Wikström-Frisén et al. 2017 [25] Sweden	Randomised Controlled trial 16 weeks	N = 59 N = 32 using OCP, N = 27 no OCP. x3/week > 2 months RT experience. Non-injured. Age: 25 ± 4 years	Group 1: Leg press and leg curl RT x5/week in FP. 1x/week in LP. Group 2: Leg press and leg curl RT 5 days/week in LP. x1/week in FP.	Control group: Leg press and leg curl RT 3 days/week during MC.	Calendar tracking Exclusion if cycle >35 days. n = 2 excluded.	Increased squat jump and muscle strength for FP based RT compared to LP. Control group greater strength compared to LP based RT. Increased LBM in FP group only.	High volume FP based RT is superior to optimize results compared to LP-based RT. FP based RT also resulted in larger LBM compared to regular training.
Wikström-Frisén et al. 2016 [26] Sweden	Randomised Controlled trial 16 weeks	N = 59 N = 32 using OCP N = 27 no OCP x3/week > 2 months RT experience. Non-injured. Age: 25 ± 4 years	Group 1: Leg press and leg curl RT x5/week in FP. 1x/week in LP. Group 2: Leg press and leg curl RT 5 days/week in LP. x1/week in FP.	Control group: Leg press and leg curl RT 3 days/week during MC.	Calendar tracking. Exclusion if cycle >35 days. n = 2 excluded.	No negative impact on sex and growth hormones, body fat, bone mineral density in either group. Participants’ preferred FP based RT.	FP based RT was not associated with negative hormonal consequences & is well accepted by participants.
Sakamaki-Sunaga et al. 2016 [27] Japan	Non-randomized controlled trial 12 weeks	N = 14 Untrained, uninjured. Age: 21 ± 2 years	Upper limb unilateral dumbbell curls RT 3 days/week in FP, and 1 day/week in LP.	Opposite arm unilateral dumbbell curls RT 3 days/week in LP and 1 day/week in FP.	BBT. No exclusion criteria.	No difference in maximum voluntary contraction or muscle CSA.	No difference between FP and LP based RT adaptations.
Sung and Kim. 2019 [28] Korea	Non-randomized controlled Trial 12 weeks	N = 36 sedentary or recreationally active. Non-injured. Age:25 ± 7 years	Intervention group: Leg extension RT x8 times in FP and x2 times in LP.	Control group: Leg extension RT x8 times in LP and x2 times in FP.	BBT. No exclusion criteria.	Max leg extension strength increased for FP and LP based RT groups. Sig greater max isometric force increase for LP based RT for underweight group.	LP based RT can influence muscle strength results for underweight women.
Zainab et al. 2021 [29] India	Randomised controlled trial 12 weeks	N = 150 students with primary dysmenorrhea. Training status not noted. Age= 18–22 years	Group A: N = 75. Performed RT (10 core exercises) daily in FP	Group B: N = 75 Performed RT (10 core exercises) daily in LP	No MC verification. No exclusion criteria.	Group A had decreased WALIDD score, & increased QoL more than Group B	Completing core RT during the FP is more effective as compared to LP based RT.
Vargas-Molina et al. 2022 [30] Spain	Pilot Study 8 weeks	N = 14. 2 years of RT experience. Non injured. Age: 26.6 ± 3.0 years	Group 1: N = 7 Strength training during the FP, hypertrophy training during ovulation, muscular endurance during LP, and recovery during the premenstrual phase.	Group 2: N = 7 Undulating training divided into 4 phases per month: strength, hypertrophy, muscular endurance, and recovery.	Urinary ovulation testing	Strength increases were observed for both groups, with bench press favouring Group 1. Only Group 1 showed differences in CMJ. A significant increase in LBM was observed for Group 2, however absolute changes favoured Group 1.	The MC tailored program benefited bench press and CMJ performance. Limited by small sample. Future studies should seek to investigate the topic employing a larger sample.
Knowles et al. 2019 [31]	Narrative Review	No inclusion criteria	Overview the current research regarding RT performance and muscle adaptation in women, focused on hormonal variables that may influence RT outcomes.	N/A	N/A	Muscle adaptation may be optimized by emphasizing FP based RT, or with combined strength/power training through the MC.	Current evidence suggests possible RT practices that could optimize performance outcomes in women, although further research is warranted.
Thompson et al. 2020 [19]	Systematic Review	N = 17 included studies (n = 418 women) Age: 18–38 years.	Identify and critically appraise current studies on the effect of the MC and OCP on responses to RT.	N/A	N/A	Conflicting findings, small participant numbers & methodological issues.	Results appear to suggest that female hormones may affect RT responses.
Randell et al. 2021 [32]	Narrative Review	No inclusion criteria	Discuss research addressing other major topics relating to women soccer players.	N/A	N/A	Greater responses to training have been observed in studies when higher frequency RT was performed in the FP compared to the LP or compared to regular training	Phase-based RT is a promising area to maximize responses. Further research is required before implementation, noting the logistical challenges of personalizing loads in squads.
Hansen et al. 2018 [33]	Narrative Review	No inclusion criteria	Aim: Review the literature regarding the effect of female hormones on muscle and tendon collagen protein turnover and mass.	N/A	N/A	Future trials are needed to clarify the effects of the oestrogens on muscle biology under different conditions, e.g. phase of MC.	The number of studies within the area is still limited.
Gharahdaghi et al. 2020 [34]	Narrative Review	No inclusion criteria	Aim: Provide an update on advances in RT induced hormonal responses and their impact on muscle adaptation.	N/A	N/A	RT in late FP appears to result in increased fibre type II CSA, nuclei to fibre ratio and muscle mass, compared to RT during LP. This has not been confirmed.	Future trials are needed to clarify the effects of the oestrogens on muscle biology under different conditions, e.g. phase of MC.
Oosthuyse et al. 2023 [35]	Invited Review	No inclusion criteria	Aim: Outline recent advances in ovarian hormone molecular signaling that elucidates the mechanisms for menstrual phase variability in exercise metabolism.	N/A	N/A	Progesterone increases protein catabolism during the LP by indeterminate mechanisms. Satellite cell function supported by estrogen-targeted gene expression is countered by progesterone, which explains greater muscle strengthening from FP-based RT.	Causative effects are provided by the review. The review also highlights research opportunities and evidence-based relevance for women athletes, including FP-based RT.

MC: Menstrual Cycle. OCP: Oral Contraceptive Pill. LP: Luteal Phase. FP: Follicular Phase RT: Resistance training BBT: Basal Body Temperature. LH: Luteinising Hormone. N/A: Not Applicable. N=: Number of Participants 1RM: 1 Repetition Maximum Test. LBM: Lean body mass. CMJ: Counter Movement Jump. WALIDD: Working ability, Location, Intensity, Days of Pain, Dysmenorrhea score. QoL: Quality of Life.

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