Can period-related symptoms predict menstrual manipulation among Australian female cyclists?

ABSTRACT

This study explored the extent of menstrual manipulation and its associated impact on period-related symptoms and training disruptions in Australian Female Cyclists. 205 female cyclists, from recreational to elite level, participated in an online “Female Cyclist Questionnaire (FCQ)”. The FCQ utilised a series of validated questionnaires to obtain demographic information and menstrual function of the respondents, and to investigate their menstrual manipulation habits and perceptions on how their period-related symptoms affected their well-being, mood, energy and training tolerance. More than 80% of the cyclists reported that their period-related symptoms impacted upon training and 41% made training adjustments based on these symptoms. Two-thirds of respondents thought their training should be phase-controlled yet only half discussed their hormonal cycles with their coaches. Menstrual manipulation was predicted by reduced “workout tolerance” in these cyclists (odds ratio = 0.632). Half of the respondents reported compromised ability to tolerate high-intensity interval training with period-related symptoms. Period pain, increased irritability, lower energy levels and more sugar cravings were commonly reported but did not predict menstrual manipulation. The data indicated that period-related symptoms are present in Australian female cyclists across all levels of participation. However, the perceived impact to training and subsequent behavioural changes varied among individuals.

KEYWORDS:

• Women
• contraception
• menstruation
• training
• sports

Introduction

Circa-mensal hormonal fluctuations can result in menstrual cycle (MC) signs and symptoms that impact sports participation and performance (M. Schaumberg et al., 2013). Indeed, research among a large international sample of physically active women revealed that 81.1% reported experiencing at least one MC-related symptom “often” which negatively impacted their exercise participation and work capacity (Bruinvels et al., 2021). Within Australia, up to two-thirds of female athletes, from recreational to elite levels, perceived their performance to be reduced by their MC during training and competitions (Armour et al., 2020; McNamara et al., 2022). Period pain and pre-menstrual symptoms were reported to be the most frequent and debilitating MC symptoms.

Hormonal contraceptives (HC) can change menstrual bleeding patterns and alleviate MC symptoms, to the benefit of an athlete (Martin et al., 2018). The reported prevalence of HC use, particularly oral contraceptives (OC), is therefore unsurprisingly comparable and/or greater in elite and competitively active female Australian athletes of childbearing age (42–58%; (Armour et al., 2020; McNamara et al., 2022)) compared to the general population (43.2%; (Skiba et al., 2019)). Menstrual manipulation for sports is, however, not limited to high-level athletes. Up to a quarter of non-elite, physically active Australian women previously reported using OC to avoid menstruation for the purpose of physical activity, exercise, sport or competition (M. A. Schaumberg et al., 2018). Yet recent meta-analyses indicated that despite the reported perceptions of MC symptoms on training and performance, only a trivial effect of MC phase was observed on exercise performance (Carmichael et al., 2021; McNulty et al., 2020). Furthermore, even if OC use can help maintain performance consistency, there is a possibility that the exercise performance of OC users are, on average, slightly inferior when compared to their naturally menstruating counterparts (Elliott-Sale et al., 2020). It was, however, also acknowledged within the same review that group-level effects across studies reviewed tended to be trivial and variable, precluding recommendations on OC use based on performance impacts. The withdrawal bleed, which occurs during the seven-day break from exogenous hormone consumption in the OC cycle, has also frequently been mistaken as a real menstrual bleed (Sims et al., 2023). This results in the possibility of masking underlying health issues related to low energy availability resulting in risk of overtraining (Solli et al., 2020). It has therefore been suggested that female athletes should instead perceive healthy menstrual function as an indicator of their good health (Holtzman & Ackerman, 2021; Oleka, 2020) and an increase in readiness to train and compete (Wells et al., 2020).

The current research regarding MC manipulation in female athletes is enlightening (Armour et al., 2020; Findlay et al., 2020; Martin et al., 2018; McNamara et al., 2022; Oxfeldt et al., 2020), yet the diverse range of athletes used in these studies may limit their application to some sports. For instance, endurance athletes, specifically cyclists, have to undertake large training volumes (van Erp et al., 2019) that may restrict the ability to manipulate their exercise schedules around the discomfort associated with their MC. For female professional cyclists in particular, it is not uncommon to race year-round (Sanders et al., 2019). Accordingly, a consistent training volume throughout the year is required to ensure their readiness to compete. It is therefore likely that professional cyclists resort to MC manipulation to facilitate training consistency. This issue is also not confined to professional cyclists, as the nature of endurance sport and the rapid loss of adaptation from detraining (Mujika & Padilla, 2001) is a key consideration to rationalise consistently high training volumes for female cyclists of all skill levels (Oviedo-Caro et al., 2020). The heavy training and competition schedules imposed on female cyclists are likely to promote concerns surrounding energy balance (Barreto et al., 2021), which can be influenced by ovarian hormone concentrations (Helm et al., 2021; Henry et al., 2003). As such, it is essential to understand MC manipulation within this population to provide the best possible guidance for female cyclists and their support staff to optimise health and maximise performance.

The purpose of this study was to examine menstrual manipulation practices within female cyclists to better understand this population of endurance athletes. To achieve our aim, the objectives of this study were to: gain insight into the extent of menstrual manipulation in Australian cyclists across different sport performance levels, evaluate the cyclists’ perceptions of the impact of period symptoms on their ability to train, investigate if the occurrence of period symptoms predicted menstrual manipulation among cyclists and explore some of the environmental factors that could impact a female cyclist’s readiness to engage in phase-controlled training paradigms.

Methods

Participant criteria and recruitment

Females, aged 18 and above, who were involved in cycling at any level and across any discipline, and were Australians and/or resided in Australia, were invited to participate in an online “Female Cyclist questionnaire (FCQ)”. Recruitment involved, primarily, targeted emails and a promoted social media campaign through which individuals were provided a link to the survey. The research team also coordinated with National/State governing bodies, coaching and support staff, event organisers and individual athletes to disseminate the hyperlink to as many individuals to achieve the largest sample possible. Data was collected between July and November 2020.

Ethics approval

All participants provided informed consent prior to completing the questionnaire. No personal identifiable information was collected, and the survey results returned to the database were anonymous. The study represented a collaboration with Cycling Australia and was approved by the University’s Human Research Ethics Committee.

Questionnaire survey

An online survey was created on the Qualtrics platform (Qualtrics LTD, Seattle, WA) and was designed to take approximately 10 to 15 minutes to complete. Logic was applied to the survey to ensure that the correct follow-up questions were asked.

First, demographic information, namely the participant’s age and sporting background, was collected. Then, participants completed the “menstrual function and use of contraceptives” section of the Low Energy Availability in Females Questionnaire (LEAF-Q) to assess for their menstrual function (such as bleeding pattern related to exercise) and menstrual manipulation (such as the use of HC). The complete 25-item LEAF-Q is a brief and validated screening tool (78% sensitivity and 90% specificity) that classifies current energy availability, reproductive function and bone health to identify female athletes at risk of the female triad through their self-reported symptoms of gastrointestinal illnesses, injuries and reproductive function (Melin et al., 2014). The following section comprised an adaptation of the 21-item Australian Cycling Team Questionnaire (ACT-Q) to investigate how participants perceived their MC-related symptoms affected their well-being, trainability, mood and energy. This section also included questions to examine some of the environmental factors that shape their receptibility to MC phase-controlled training programmes. Environmental factors included discussion with coaches and support staff, knowledge around MC and menstrual manipulation, and interest in furthering education on MC-related health and performance. Responses were indicated on a 4-point Likert-type scale, with 1 = “never”, 2 = “sometimes”, 3 = “most of the time” and 4 = “always”. Participants used free-text answers to elaborate on their choices. The full questionnaire can be found in the Supplementary Material.

Data analysis

The raw data was exported from Qualtrics directly to Microsoft Excel and IBM SPSS Statistics.

Participants were categorised into three groups based on their menstrual manipulation practice to conduct a stratified analysis. The first group consisted of cyclists who did not engage in menstrual manipulation and thus, were experiencing their natural menstrual cycles (MC). This MC group included participants who experienced irregular menstrual cycles. The second group consisted of cyclists who currently use oral contraceptives (OC) to manipulate the menstrual cycle. The third group consisted of cyclists who currently use alternative contraceptives (AC) to manipulate the menstrual cycle such as hormonal coil/ring/patches and copper intra-uterine devices. Descriptive statistics were used to report demographic information, level of sport involvement, previous and current OC use and perceptions of menstrual manipulation. Categorical variables were expressed as total numbers (n) and frequencies (%); while continuous variables were presented as Mean $\pm$ SD. One-way ANOVAs with Bonferroni post-hoc analyses were used to explore differences between groups. Content analysis was conducted on responses to open-ended questions by two independent researchers (refer to the first and last author). Differences between the researchers were discussed and a consensus was reached. Following this, a frequency analysis was performed. A logistic regression was conducted to investigate the probability of menstrual manipulation based on self-reported menstrual symptoms. The odds ratio (OR) for each variable and its accompanying 95% confidence interval (CI) were calculated. An alpha value of .05 was used for all statistical tests. Missing data were not replaced. Finally, the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used to confirm all desired elements for conducting online survey studies were achieved in this study (See Supplementary Material).

Results

Proportion of menstrual manipulation across sports performance levels

The FCQ received 303 responses with 98 excluded for missing data. 205 participants aged 33.5 ± 10.2 years were included in our analysis and their demographics and menstrual characteristics are presented in Tables 1 and 2 respectively. As shown in Table 1, 39% of elite, 48% of sub-elite and 42% of recreational cyclists engaged in menstrual manipulation (that is, were OC or AC users). No significant difference in proportion was observed between the three performance levels. Table 2 detailed the menstrual characteristics of the respondents, of whom 114 did not manipulate their menstrual cycle (MC). Further, 51 respondents used OC to manipulate their menstruation, 40 used AC to manipulate their menstrual cycle. Table 3 illustrates the proportion of menstrual manipulation among participants across performance levels. OC was the most common form of menstrual manipulation (56%), and almost half of the OC users (47%) were on an extended regime wherein active pills are consumed for two or more cycles, skipping the sugar pill within each 28-day cycle. Hormonal implants made up the most frequent form of AC (48%). 90% of AC users reported to be previous OC users. As for the MC respondents, 74% reported having a regular menstrual cycle, with almost three quarters (73%) having previously used OC.

Table 1. Demographic of Australian Female Cyclists.

Demographic	Elite		Sub-elite		Recreational		Total
	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Age (years)*^	29.1	8.4	30.9	10.3	38.3	8.7	33.5	10.2
Height (m)	1.68	0.84	1.67	0.61	1.67	0.62	1.67	0.65
Body mass (kg)*^	61.0	13.6	60.6	6.6	67.2	11.2	63.2	10.2
Years cycling at current level	3.9	2.1	5.0	3.8	5.0	5.8	4.8	4.5
No. of cycling sessions per week*^~	8.0	2.6	6.4	1.9	4.1	2.0	5.7	2.5
Total weekly cycling time (hours)*^~	16.4	5.4	13.4	5.0	7.1	4.4	11.4	5.9
Menstrual manipulation (%)	39		48		42		44
	n = 28		n = 98		n = 79		n = 205

Elite refers to a cyclist who participates in international competitions including world cups, world championships and world tour cycling events. Sub-elite refers to a cyclist who participates in domestic competitions such as state championships, national championships and national series cycling events. The n value indicates the number of respondents per categorical variable.

p<.05 recreational vs. elite.

p<.05 recreational vs. sub-elite.

~p<0.05 sub-elite vs. elite.

Table 2. Menstrual characteristics of Australian female cyclists.

		n=205
Age at menarche	<11	29
	12 to 14	141
	>15	32
	do not know	1
	(missing)	2
		MC	OC	AC
		n=114	n=51	n=40
Regular periods	yes	84	35	17
(menstruation/withdrawal bleed)	no	29	7	21
	do not know	0	7	1
	(missing)	1	2	1
Heavy period flow	yes	37	11	13
	no	45	24	4
	(missing/NA)	3/29	9/7	2/21
Period length	1 to 2 days	1	2	0
	3 to 4 days	42	18	9
	5 to 6 days	31	13	6
	7 to 8 days	7	2	0
	>9	1	0	2
	(missing/NA)	3/29	9/7	2/21
No of periods in the last year	12 or more	35	9	7
	9 to 11	34	16	8
	6 to 8	12	7	1
	3 to 5	0	3	0
	0 to 2	1	0	1
	(missing/NA)	3/29	9/7	2/21
Period change with exercise	Yes	44	18	23
	No	67	31	16
	(missing)	3	2	1

Abbreviations. MC, menstrual cycle; OC, oral contraceptive; AC, alternative contraceptive (i.e., those using non-OC forms of contraceptives).

The n value indicates the number of respondents per categorical variable.

Table 3. Menstrual manipulation per sports performance level.

Elite (n = 28)
No (MC)				Yes (OC)				Yes (AC)
n = 17 (61%)				n = 5 (18%)				n = 6 (21%)
Previous OC Use	Yes	65%	11	Extended OC regime	Yes	60%	3	Previous OC Use	Yes	83%	5
	No	35%	6		No	40%	2		No	17%	1
Sub-Elite
No (MC)				Yes (OC)				Yes (AC)
n = 51 (52%)				n = 31 (32%)				n = 16 (16%)
Previous OC Use	Yes	73%	37	Extended OC regime	Yes	40%	12	Previous OC Use	Yes	88%	14
	No	27%	14		No	60%	18		No	12%	2
Recreationally Active
No				Yes (OC)				Yes (AC)
n = 46 (58%)				n = 15 (19%)				n = 18 (23%)
Previous OC Use	Yes	76%	35	Extended OC regime	Yes	60%	9	Previous OC Use	Yes	94%	17
	No	24%	11		No	40%	6		No	6%	1
Total
No (MC)				Yes (OC)				Yes (AC)
n = 114 (56%)				n = 51 (25%)				n = 40 (20%)
Previous OC Use	Yes	73%	83	Extended OC regime	Yes	47%	24	Previous OC Use	Yes	90%	36
	No	27%	31		No	53%	27		No	10%	4

Abbreviations: OC, oral contraceptive; AC, alternative contraceptive (i.e., those using non-OC forms of contraceptives); MC, menstrual cycle (i.e., not using menstrual manipulation).

Extended OC regime refers to taking active pills for two or more cycles, skipping the sugar pill within each 28-day cycle. The n value indicates the number of respondents per categorical variable and categorical variables are summarised as percentage (count).

Perceptions of the impact of period symptoms on their cycling training

The perceived effects of the period on training and performance are presented in Table 4. We herein clarify that “period” in this study refers to the menstrual bleed of naturally cycling females and withdrawal bleed of OC/AC users respectively. Of all respondents, 90% reported experiencing at least one period-related symptom. 18% reported that their period symptoms did not impact their training. Less than seven percent reported a positive impact of their period symptoms (such as an increased sense of well-being and/or performance and an improved tolerance to workouts). The rest of the respondents perceived their cycling training to be negatively impacted by at least one of their period symptoms. Period pains typically occurred a few days before (40%) and during (59%) the participants’ menstrual/withdrawal bleed. However, approximately a quarter of all respondents did not perceive period pain to impact their training (27%). Contrastingly, 26% reported skipping training sessions due to period pain. 39% of all respondents reported changes in tolerance to high-intensity interval training (HIT), while 19% reported changes in tolerance to endurance sessions. 16% of all respondents reported issues with temperature regulation. The most commonly experienced change in mood state was increased irritability (57%), which was also the most commonly reported period symptom. Respondents also frequently reported lower energy levels (33%) and more sugar cravings (32%).

Table 4. Perceived Effects of Period on Training and Performance.

Impact of period pain on training	MC		OC/AC		Total
	n	%	n	%	n	%
No effect	28	32	14	20	42	27
Skipping training sessions	18	21	22	32	40	26
Causes fatigue	15	17	11	16	26	17
Causes discomfort	20	23	6	9	26	17
Causes pain	11	13	10	14	21	13
Requires modifications to training	9	10	12	17	20	13
Ignored effect	15	17	2	3	17	11
Demotivated for training	4	5	11	16	15	10
Reduced quality of training	9	10	4	6	13	8
Takes medication	7	8	6	9	13	8
Causes decreases in performance	6	7	3	4	9	6
Increases sense of well-being	1	1	0	0	4	3
Differs per period	2	2	3	4	5	3
Decreases sense of well-being but increases performance	2	2	0	0	2	1
Causes increases in performance	2	2	0	0	2	1
N	87		69		156
Changes in tolerance to workout
High-intensity interval training	46	42	27	35	73	39
No effect	21	19	19	24	40	21
Temperature regulation	17	16	13	17	30	16
Endurance	16	15	12	15	28	15
Fatigue	14	13	6	8	20	11
Energy	10	9	3	4	13	7
Power	9	8	4	5	13	7
Gym	4	4	7	9	11	6
Better tolerance	8	7	3	4	11	6
Motivation	5	5	6	8	11	6
Recovery	6	6	3	4	9	5
Sleep	3	3	1	1	4	2
Others	2	2	1	1	3	2
Altitude	2	2	1	1	3	2
N	109		78		187
Changes in mood states
Irritable	73	68	33	42	106	57
Emotional	24	22	22	28	46	25
Tired	18	17	15	19	33	18
Depressed	21	20	12	15	33	18
No change	10	9	10	13	20	11
Unmotivated	3	3	8	10	11	6
Sensitive	3	3	7	9	10	5
Anxious	3	3	6	8	9	5
Irrational	1	1	1	1	2	1
Asocial	1	1	1	1	2	1
N	107		78		185
Changes in energy levels and food cravings
Low energy	42	40	19	24	61	33
Craving sugar	38	36	21	27	59	32
No change	19	18	24	31	43	23
Hunger/cravings (unspecified)	21	20	14	18	35	19
Craving carbs	17	16	6	8	23	13
Craving salt	9	8	1	1	10	5
Craving junk food	3	3	2	3	5	3
Variable energy	0	0	3	4	3	2
Craving spicy	0	0	1	1	1	1
Craving fat	1	1	0	0	1	1
N	106		78		184

Abbreviations. MC, menstrual cycle (i.e., not using menstrual manipulation); OC, oral contraceptive; AC, alternative contraceptive (i.e., those using non-OC forms of contraceptives).

The n value indicates the number of respondents per categorical variable. The N value indicates the total number of respondents per categorical variable.

When comparing the perceived effects of period on training and performance, a trend was noted that was indicative of a greater proportion of OC/AC users who reported skipping training sessions and being demotivated for training due to their withdrawal bleed when compared with their naturally cycling counterparts (from their menstrual bleed). OC/AC users also reported less period-related discomfort and reductions in energy levels. Additionally, there was an observed trend for a greater proportion of naturally cycling respondents reporting “no effect” of period pain on training. It is, however, important to note that no statistical tests for differences were conducted due to the manner in which the data was collected and the low statistical power to conduct these tests.

Predicting menstrual manipulation based on period-related symptoms

Logistic regression was conducted to examine if the frequency of experiencing period-related symptoms such as pain, mood swings, energy fluctuations and changes in workout tolerance could predict whether the cyclists engaged in menstrual manipulation (OC/AC use). As shown in Table 5, the model predicted 60.3% of the responses correctly. Menstrual manipulation was more accurately predicted by our model compared to no manipulation (i.e., naturally cycling females). Table 6 shows that only period-related changes in workout tolerance significantly predicted whether the participants engaged in menstrual manipulation (p = 0.023). Respondents who reported more frequent changes in workout tolerance were 37% less likely to manipulate their MC compared to those who did not (odds ratio = 0.632, 95% CI 0.426 to 0.938).

Table 5. The observed and the predicted frequencies for menstrual manipulation by logistic regression with the cut-off of 0.50.

	Predicted
Observed	Yes	No	% Correct
Yes	80	26	75.5
No	47	31	39.7
Overall % Correct			60.3

Sensitivity = 75.5%. Specificity = 39.7%. False positive = 47/(47+80) = 37%. False negative = 26/(26+31) = 46%.

Table 6. Predictor coefficients for the model predicting menstrual manipulation.

					95% CI for Odds Ratio
Predictor	$\mathit{\beta }$ (S.E.)	Wald’s x^2	df	Sig., p	Lower	Odds Ratio	Upper
Tolerance	−0.458 (0.201)	5.185	1	0.023	0.426	0.632	0.938
Mood	0.113 (0.205)	0.305	1	0.581	0.750	1.120	1.673
Energy	−0.070 (0.167)	0.174	1	0.676	0.672	0.933	1.294
Pain	−0.165 (0.171)	0.937	1	0.333	0.607	0.848	1.185
Constant	1.052 (0.521)	4.084	1	0.043		2.865

R² = .070 (Hosmer & Lemeshow), .064 (Cox & Snell), .086 (Nagelkerke). Model x²(1) = 12.11, p = 0.017.

Current training practices and menstrual knowledge of the female cyclists

Almost two-thirds of the participants (64%) indicated that they thought their training programme should consider their MC. However, only half of the participants (51%) reported discussing their cycles with coaching staff. Respondents also revealed that they were more likely to discuss their MC with female coaches and/or management. Less than a third of the athletes’ management and coaching staff were reported as female (21.6% and 31.5% respectively). Only 41% of the participants reported making training adjustments based on MC symptoms.

Of the menstruating females, 43% reported experiencing changes in their menstruation when they increased their exercise intensity, frequency or duration, and 57% of these respondents were concerned that their menstrual health was being impacted by exercise. Almost half of all respondents (47%) were concerned about the effect sports had on their health and fertility, and over half of these individuals (54%) indicated that there was insufficient information available to make informed decisions for both their health and performance. 69% of the participants in this study indicated a desire to increase their knowledge in this area.

Discussion

Proportion of menstrual manipulation in our cycling cohort

In our sample of Australian female cyclists, 44% indicated manipulating their MC, a finding similar to that of the general population of Australian women of childbearing age (43%) (Skiba et al., 2019). This finding, while consistent with a recent convenience sample of 120 Australian athletes across a number of sports and skill levels (Armour et al., 2020), was somewhat unexpected. Indeed, M. A. Schaumberg et al. (2018) previously reported a 60% prevalence rate of menstrual manipulation among physically active Australian women. Furthermore, the use of OC is purported to go beyond basic birth control (Fisher et al., 2018). It is partially influenced by the activity level of a woman and the negative impacts that MC has on exercise participation and performance (Bruinvels et al., 2016, 2021). With the high levels of physical activity observed in our cohort (Table 1), it was expected that the proportion of menstrual manipulation would be higher when compared to the general population. In addition to these all-of-cohort findings, our data indicates that elite level cyclists were least likely to manipulate their MC (38%). This finding is lower than previously reported among elite athletes (47 to 58%; (Martin et al., 2018; McNamara et al., 2022)) and may be a consequence of the large amount of team sports athletes surveyed within these studies. In individual sports such as cycling, coaches and athletes have more opportunities to tailor training programmes to suit their individual needs (Clarke et al., 2021; Findlay et al., 2020) and this could reduce the need for elite female cyclists to manipulate their MC to accommodate their training (Martin et al., 2018).

Of the non-OC users in this study, some two-thirds indicated previous OC use for menstrual manipulation. This finding is of interest as it may represent a shift in female athletes’ opinions on the importance of normal menstruation for health. Indeed, the trend towards normal menstruation has been noted anecdotally within elite Australian female cyclists. It has been suggested that this trend is possibly due to an increased knowledge and evolving perception towards a regular MC as an indicator of good health and training status. Nevertheless, physical and emotional symptoms associated with OC use such as weight gain, headaches/migraines and poor mood, and practical reasons such as no longer sexually active/not needed (Martin et al., 2018) should not be ruled out as important factors driving this change in OC use.

The perceived impact of period symptoms on the cyclists’ training and performance

Consistent with previous research among exercising women (Bruinvels et al., 2021), period pain and period-related symptoms were reported by most of our cohort, with three-quarters reporting that period pain impacted their training. Our findings exceed the 50 to 65.6% previously reported in Australian athletes (Armour et al., 2020; McNamara et al., 2022) and may partly be attributed to the single sport emphasis for our study. Cyclists are physically constrained to a small range of repetitive movement patterns, which could accentuate sensations of fatigue and discomfort. Furthermore, there is increased labial sensitivity at the saddle contact point, particularly when bleeding, which further amplifies the impact of pain on training. Indeed, our findings revealed the most prevalent reasons for negative impacts of period pain on training was due to an increase in sensations of fatigue and discomfort. Yet only a quarter of our respondents reported skipping a training session due to pain. This suggests that the cyclists could have normalised period pain and thought of it as an unacceptable excuse to abstain from training (Findlay et al., 2020).

More than three-quarters of our respondents also reported changes in tolerance to workouts, with HIT sessions (39% of total respondents) being the most common. These findings are consistent with previous works indicating that athletes perceive distinct changes to their aerobic performance, muscle strength, mental sharpness and balance at different phases of the MC and time points on the OC pill chart (Thompson et al., 2021). Interestingly, a recent review of 51 published studies found that physical performance is not affected by the fluctuations in female sex-steroids and that any reduction is trivial at best (McNulty et al., 2020). Furthermore, short-duration high-intensity efforts should be more readily tolerated than longer duration physical efforts from a mechanistic and/or physiological standpoint as the influence of menstrual status is only exaggerated in a low energy availability state (Casazza et al., 2004). When considered in concert, there appears to be a discrepancy between the female athletes’ perceptions of the impact of their period on performance compared with its actual impact. It could be that negative affective mood states surrounding the period, which were experienced by almost all our respondents and consistently reported by exercising women in previous literature regardless of skill levels and sport disciplines (Brown et al., 2021; Bruinvels et al., 2021), influenced self-efficacy beliefs that exaggerated negative perceptual responses to exercise during training. However, this association between affective and perceptual responses to exercises were abolished during performance tests and in competition as interoceptive cues such as afferent feedback from exercising and respiratory muscles start to dominate (Wrightson et al., 2019).

Given that perceptions of period-related symptoms were found to impact the likelihood of adjusting training, it is important to understand this relationship further. Specifically, HIT is essential to improve key indices of endurance performance and unwarranted adjustments and/or removal of these training sessions may have substantial influence on future readiness to perform in competition. As aforementioned, the difference in mindset between completing high-intensity training efforts and performing during maximal tests/competitions should not be undermined. Additionally, tolerance to HIT may not be linked directly to CHO use, energy availability and/or other “common” influencers of performance (Hoffmann et al., 2021). It is possible that period-related discomfort and other issues associated with the period are confounders that could impact tolerance. For example, HIT is consistent with a high metabolic load and for many, HIT sessions are completed on an indoor ergometer so that training efforts can be structured and completed with precision. Temperature regulation, which was an issue for 16% of our respondents, could be one of the mitigating factors in the reported reduction in HIT tolerance. Therefore, mitigation strategies for HIT sessions need to be developed as it is crucial that the training programme is adapted to reflect the high-intensity racing demands inherent of female cycling races (van Erp et al., 2019).

Some period symptoms predict menstrual manipulation among cyclists

Findings from the logical regression indicated that period pain, changes in workout tolerance, mood states and energy levels, as a collective, could predict the use of menstrual manipulation. However, in this model, the frequency of cyclical changes in workout tolerance was the only significant predictive factor of menstrual manipulation habits, whereby the likelihood of menstrual manipulation is lower when more changes to workout tolerance was reported. This could be interpreted as the naturally cycling respondents experienced greater changes in workout tolerance when compared with OC/AC users. This interpretation would be consistent with the review by Elliott-Sale et al. (2020), which concluded that OC use contributed to performance consistency across the hormonal cycle.

However, there was a trend for a greater proportion of our OC/AC respondents (when compared with those naturally cycling) to skip training sessions and/or be demotivated for training. Furthermore, a greater proportion of naturally cycling respondents reported that period pain had no effect on training. These observations were surprising as previous literature suggested that contraceptive use not only helped maintain performance consistency, but also relieved period symptoms (Martin et al., 2018). An explanation for this could be that our cohort of OC/AC respondents inherently had lower tolerance to period-related symptoms or experienced greater symptoms. Possibly, they chose to menstrual manipulate to decrease the occurrence of period-related discomfort and reductions in energy levels that would further reduce their ability to complete workouts. Furthermore, it is also possible that some OC/AC respondents had misinterpreted our survey question whereby they responded to the perceived effects of the period based on their previous experiences of menstruation. Consequently, we recommend future research to further investigate the association between period symptoms and tolerance to period-related symptoms in athletes who use OC, AC, or did not engage in menstrual manipulation.

In summary, although no direct cause-effect relationships can be drawn from these findings, our predictive model suggests that the likelihood of female cyclists practicing menstrual manipulation is less when they are able to tolerate greater period-related workout changes.

Environmental factors that could impact the cyclists’ readiness to engage in phase-controlled training paradigms

With the high prevalence of period-related symptoms (Table 4) and their perceived negative impacts on performance, female cyclists could benefit from phase-controlled training programmes. However, several external factors exist which likely influence an athlete’s decision to engage in this style of training. Within this cohort, only half of the respondents discussed their cycles with coaching staff, a finding that may be somewhat exaggerated due to the large number of recreational cyclists in our sample. This finding was despite two-thirds believing that training paradigms should be phase-controlled and 58% already tracking their hormonal cycle. Respondents further identified “gender concern”, specifically cycling coaches and/or management being predominantly male, to magnify problems associated with necessary communication. This finding is consistent with previous literature (Armour et al., 2020; Brown et al., 2021) which indicated that female athletes were not convinced that the men understood the common and persistent physical and emotional symptoms associated with hormonal fluctuations. This issue was further highlighted by Australian female Olympians calling for education specifically for their male coaches (McNamara et al., 2022). It becomes imperative to increase conversations surrounding the MC not only to enhance athlete-coach relationships but also, positively impact the athlete’s training and competitive performance (Brown et al., 2021).

Our respondents also appeared to lack knowledge of MC and basic female physiology as only a quarter rated their knowledge as “good” and less than half felt that they were empowered with sufficient knowledge to make informed decisions regarding their health and performance. These statistics are concerning from a health perspective as a quarter of the menstruating respondents reported not having a regular MC and almost half of the OC users were utilising an extended OC regimen. Indeed, menstrual disturbances are linked to low energy availability, decreased performance (Holtzman & Ackerman, 2021) and subsequent long term health consequences (Oleka, 2020). While extended OC use helps to ease the frequency and severity of hormone-related symptomology (Seval et al., 2011) and is perceived to improve trainability (Martin et al., 2018), the longer-term health consequences of such practice are currently unknown. Furthermore, menstrual manipulation is likely to mask underlying health issues related to low energy availability resulting in a greater risk of overtraining (Solli et al., 2020).

Education and communication regarding MC, health and training are increasingly facilitated at the elite level (Australian Government, A. S. C., 2019). However, findings from this study highlight that these need to be extended across all skill levels as the recreational level cyclists in our sample were less likely to engage in conversations about MC but were more likely to use OC. Cycling has the third highest participation rate (9.5%; almost a million) in Australian for women over 15 years old (Australian Government, A. S. C., 2022), thus undertaking a campaign to expand education on this topic would have a substantial impact. Given that some 69% of respondents expressed a desire to improve their knowledge on the interplay between MC, health and exercise performance, this should be a priority within the cycling community.

Practical applications

The study findings emphasise the importance of considering the affective needs of naturally cycling and contraceptive-using female cyclists, and their unique physical and behavioural experiences with period-related symptoms. Due to the between-individual variability in severity of both symptomology and perceived impact on training and performance, female cyclists may be advised to monitor their cycle for the purpose of self-awareness and development of positive management strategies (Brown et al., 2021). Continued education is warranted for cyclists of all levels and should also be directed at their coaching and support staff to improve communication channels such that training benefits can be maximised. The internet continues to be a platform for educational resources and the cycling community (as a collective) should be navigated to legitimate websites and applications. The best approach to enhancing the athlete-coach relationship surrounding concerns of the MC has yet to be determined but may include a mediated dialogue between the athlete and coach.

Limitations

We acknowledge that our cohort study contained a convenience sample of Australian female cyclists, and the modest sample size precluded statistical analyses of the perceived effects of period on training and performance between the three groups (MC, OC and AC). Another limitation of this study is the potential of recall bias in relation to the severity of period-related symptoms and associated changes to training based on the hormonal phase during which the participant completed the survey. We also did not assess for MC-related disorders such as endometriosis and RED-S etc., which could have emphasised or minimised menstrual-related symptoms respectively (Taim et al., 2023). Future research is recommended to take a prospective approach including a diary tracking the experience of period-related signs and symptoms and any potential training adjustments the cyclists make in relation to these signs and symptoms.

Conclusion

Our study suggests that Australian female cyclists are becoming less likely to use OC. It also confirms the presence of period-related symptoms and consequent perceived training impairments in most of our respondents. However, the affective needs surrounding period-related concerns are unique in its frequency and severity and the female cyclist should be empowered to monitor their own unique symptoms and communicate their concerns to their support network. Given the impact of perceptions of period-related symptoms on menstrual manipulation and cycling training, it is important that dialogue and education of athletes surrounding the MC and use of contraceptive not only include its biology, physical adaptation and potential impact on performance, but also the anecdotal and lived experiences of female athletes. Cycling is uniquely primed for improved athlete-coach communication surrounding potential “period”-ised training adaptations due to interpersonal coaching relationships unique to individual sports. It is critical that resources be directed to female cyclists of all performance levels to reduce menstrual stigma and enhance both participation rates and sport enjoyment.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental material

Supplemental data for this article can be accessed online https://doi.org/10.1080/02640414.2024.2334485

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.