PhD Pinboard: Understanding Menstrual Health in Elite Women's Football
- Guest
- May 14
- 12 min read
This PhD Pinboard article by Georgia Brown tackles the complex, previously under-researched question of how the menstrual cycle affects elite female footballers' performance, recovery, and sleep.
I’m Georgia Brown – a Sport Scientist currently working with San Diego Wave FC, and formerly with the Australian Women’s National Football Team, the Matildas.
My PhD focuses on menstrual health in football (soccer) players, as well as whether different phases of the menstrual cycle and menstrual associated symptoms impact match performance, recovery, and sleep.
This research matters because many female athletes report that their menstrual cycle negatively affects how they feel and perform (1, 2), yet there’s still a lack of robust scientific evidence to guide support practices.
With the growth in professionalism of women’s football, and the increasing match demands (3, 4), optimizing player performance and recovery is of critical importance. To best support elite female footballers, we need to understand if and how the menstrual cycle influences physical performance, recovery, and sleep so we can effectively tailor strategies to help female footballers perform and recover across their menstrual cycle.
What drew me to this research?
I was offered a unique opportunity to complete an embedded PhD with Football Australia, alongside a sport scientist role with the youth national teams. I had the freedom to choose any research topic—and with my strong interest in physiology, and a passion for working with female athletes, I was drawn to exploring the menstrual cycle.
The menstrual cycle is controlled by fluctuating concentrations of oestrogen and progesterone (see Figure 1). These hormones regulate reproductive function, but also affect key physiological processes that may impact athletic performance and recovery (5, 6, 7, 8). The idea that fluctuating levels of oestrogen and progesterone could affect performance and recovery intrigued me!
It also made sense to me – several friends and teammates growing up had expressed difficulties training and competing at certain times during their menstrual cycle, largely due to symptoms experienced around menstruation. However, there was no conclusive research to support or deny these perspectives (9, 10).
Now, I had the opportunity to explore the influence of the menstrual cycle in a sport I grew up playing, watching, loving, and now working in.
The PhD Journey and Challenges
Like most PhDs, mine was definitely a journey.
The focus of the research evolved over time. Initially, menstrual health itself was not a major consideration, but I quickly learned how essential it is. For example, having a regular menstrual cycle is a key marker of female health and sometimes referred to as the “fifth vital sign” (11, 12). Disruptions to the menstrual cycle are often linked to low energy availability (LEA) in athletes, which has serious implications for both health and performance (13).
So, before we could even ask whether menstrual cycle phases and symptoms impact performance and recovery, we had to explore the menstrual health football players in Australia… plus we wanted to hear, rather than assume, their perspective on the menstrual cycle’s impact!
Conducting quality menstrual cycle research has been a challenge. We aimed to track the same players over multiple menstrual cycles to identify patterns in performance, recovery, and sleep between phases and with regards to symptoms. Exploring differences between menstrual phases requires regular hormonal testing, as the phases are defined by their hormonal profile (see Figure 1 above) – i.e., associating changes in performance or recovery with a specific phase due to differing hormonal profiles.
As we worked with four clubs across Australia during the domestic league season we could not meet the best practice recommendations which often involve blood samples (6), though we built upon previous research in football by including two urinary hormonal tests – luteinizing hormone (LH: predicts timing of ovulation), and Pregnanediol Glucuronide (PdG: metabolite of progesterone).
We faced many limitations common in this type of research including many players presenting with abnormal cycles (e.g., long menstrual cycles, abnormal hormonal profiles), several players dropping out after the second cycle of monitoring, player selection for matches was out of our control, and aligning the timing of phases with the timings of matches all greatly reduced our sample size.
Despite all that, the work has been incredibly rewarding. It has given me a deeper appreciation for the complexity of female physiology and the importance of research that directly supports the health and performance of women in sport.
Key Findings
Menstrual health and perceived menstrual effects
For my first study (14), we surveyed 199 players across Australia's domestic leagues and national teams to better understand menstrual health, symptomatology and perceived menstrual effects in elite and professional football. The findings were:
Cases of amenorrhea were low (just one case of primary, and 2% secondary), but oligomenorrhoea — infrequent or irregular periods — was more common, affecting 19% of players.
Almost all players (97%) reported experiencing menstrual symptoms, underscoring how widespread the issue is, even in high-performance environments.
40% of players perceived the menstrual cycle to disrupt their training and competition.
Players with heavier menstrual bleeding, pelvic pain, and increasing number of menstrual symptoms were more likely to report their period affected their training and competition.
Influence of menstrual phase and symptoms
In three follow-up studies (14-16), we tracked players across 1 to 4 menstrual cycles. Players recorded menstruation days and conducted urinary hormone testing, which helped us identify menstrual status and break the cycle into three key phases: early-follicular (menstruation), late-follicular and luteal (see Figure 2).
At the same time, we measured a range of performance and recovery metrics during competitive matches. Here's what we looked at:
Physical match performance (via match GPS): total distance, high-speed running, very-high-speed running, accelerations, decelerations, and peak speed. (2)
Recovery (via perceptual questionnaires): including the Hooper Index (fatigue, soreness, stress, sleep, total wellness) and Perceived Recovery Status (PRS). (15)
Sleep (via actigraphy): sleep duration, sleep efficiency, wake time, sleep latency, and more - because sleep is important for both performance preparation and post-match recovery. (16)
What did we find? First of all, looking at the influence of menstrual phase:
Players tended to cover more relative total and high-speed running distance during the late-follicular phase compared to other phases , though results varied widely between and within some individuals (see Figures 2 and 3).
Interestingly, menstrual phase didn’t relate to daily perceptual responses on match day or in the days after.
However, when we zoomed in on recovery timelines, a more complex picture emerged. During the early-follicular phase, players showed impaired recovery (fatigue, soreness, wellness) from the day following a match to two days following a match. Additionally, fatigue and PRS did not return to pre-match levels two days following a match during the late-follicular phase.
Sleep was not influenced by menstrual phase.
And how did menstrual symptoms influence performance and recovery? Higher menstrual symptom severity was linked to:
A lower number of accelerations performed during a match, though the reduction was small, equating to approximately 5 less accelerations over a 90min match for a player reporting the average menstrual symptom severity.
Longer sleep duration and later wake times, particularly in players reporting lower back pain or mood changes/anxiety. This may seem counterintuitive, but we postulate that perhaps players are utilizing sleep to help manage menstrual symptoms.
Other key findings
One of the noteworthy findings across these studies was that many players experienced subtle menstrual disturbances i.e., abnormal hormonal profiles despite a regular cycle length resulting in luteal phase defect or anovulation. These often remain undetected by surveys/screenings (i.e. as in the first study) or tracking cycle length alone, and require hormonal testing.
Also, although almost all players in the first study reported symptoms, the number and severity of those symptoms during the longitudinal monitoring were relatively low. It is of note however, that we did have a much smaller sample size in the longitudinal study.
How can we apply these findings in practice?
The menstrual cycle is gaining increasing attention in elite sport and research. Understanding how the menstrual cycle may affect players can help coaches and support staff fine-tune performance, recovery, and well-being. Whilst the body of research surrounding the menstrual cycle in sport is growing, it is still limited and there are few papers specifically in football.
Here are some practical, evidence-based strategies so far to integrate menstrual cycle knowledge into your performance planning.
1. Start with Simple Menstrual Monitoring
You don’t need complex systems to track basic menstrual health characteristics. Simple questionnaires and daily calendar-based tracking can help players log their cycles, symptoms, and how they’re feeling/performing/recovery at different points of their cycle - giving you a clearer picture over time and the ability to detect major menstrual health issues e.g., oligomenorrhea and amenorrhea.
2. Tailor Symptom Support
Menstrual symptoms vary widely between players. An individualised approach, supported by a multidisciplinary team, can help manage symptoms effectively.
3. Understand the Limits of Calendar-based Tracking + Balance Accuracy and Practicality
Use of calendar-based tracking only (i.e., no hormonal testing) means accurate identification of most menstrual phases is not possible. Combining calendar-based tracking with urinary hormone tests (e.g., LH and PdG) provides a more accurate method of menstrual phase determination. However, I would not recommend long-term use of these tools in practice due to the cost and burden to players.
4. Applicability of Menstrual Phase Based Monitoring
Be aware that due to the number of players using hormonal contraceptives and experiencing abnormal menstrual cycles (e.g., anovulation, luteal phase defect, oligomenorrhea, amenorrhea), menstrual phase-related changes in performance and recovery may be applicable to less than half a team’s squad.
5. Individualised Tracking of Match Running Across Menstrual Phases
Monitoring physical match metrics across an individual’s menstrual cycle may help you spot trends between phases. Total distance and high-speed running may be greatest during the late-follicular phase – though our findings are based off a small sample size and large variability was present! As such, individualised monitoring is recommended.
6. Tracking Match Running in Relation to Menstrual Symptoms
Severe symptoms may impact physical match performance, especially accelerations. Monitoring and managing menstrual symptoms may help reduce disruptions to physical performance, though more research is needed!
7. No Need to Consider Menstrual Phase with Respect to Perceptual Responses or Sleep
Menstrual phase doesn’t appear to be associated with perceived fatigue, soreness or stress, nor objective or subjective sleep around matches. These findings are echoed by several other studies (17, 18).
8. Monitoring Menstrual Phase May Improve Interpretation of Perceptual Recovery Timelines
Tracking menstrual phase may improve your understanding of how each player perceptually recovers following matches, though variable influence of menstrual phase prevents any general phase-based recommendations.
9. Support Players with Severe Menstrual Symptoms
If a player reports frequent or severe symptoms, strategies like proactive symptom management or promoting longer sleep may help protect recovery and performance.
Final Reflections
Completing my PhD while working in the industry as a sport scientist for female footballers gave me a unique and valuable perspective - one that bridges the gap between research and real-world practice. It taught me the importance of balancing evidence-based insights with the realities of day-to-day performance environments.
The menstrual cycle in sport is a hot topic right now - and rightly so. Whilst exploring menstrual phase effects is exciting, we’re not yet at the stage where we can say "we expect you to perform / recover / sleep better or worse during x, y or z phase", for example. For now, an individualised approach to monitoring menstrual cycle phases is recommended, while also recognising the practical challenges of doing so accurately.
That said, I’ve seen the clear benefits of monitoring and managing menstrual health and symptoms in practice. This aspect is not only more feasible but also more applicable - regardless of whether an athlete uses hormonal contraception or experiences menstrual irregularities.
Although I’ve paused my own research in this area for now, there’s a wealth of exciting work being done in the field of menstrual health and female athlete performance. Keep an eye out - there’s more to come!
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Frequently Asked Questions (FAQs)
What is the menstrual cycle and why does it matter in sport?
The menstrual cycle prepares the body for pregnancy via cyclical hormonal fluctuations (i.e., oestrogen and progesterone) and when this does not occur, results in a bleeding phase (i.e., menstruation) approximately every 28 days. An irregular, prolonged, or absent menstrual cycles can be a sign of low energy availability, which is associated with several health and performance consequences. Additionally, many athletes report their menstrual cycle negatively impacts their performance.
What are the key menstrual health issues in elite female footballers?
Key menstrual health concerns in elite female footballers include:
Absent periods (no menstruation by age 15 or missing periods for over 3 months)
Irregular or infrequent/prolonged cycles (longer than 45 days)
Oligomenorrhea (infrequent periods)
Amenorrhea (absence of periods)
Heavy menstrual bleeding
Other menstrual symptoms (e.g., cramps, fatigue, and mood changes)
How can the menstrual cycle affect athletic performance, recovery, and sleep?
The menstrual cycle can influence athletic performance, recovery, and sleep through three key mechanisms:
• Menstrual health (strong evidence of impact)
• Menstrual symptoms (can impair performance and disrupt sleep but individual responses vary and current objective evidence is scarce)
• Menstrual phase effects (inconclusive though research is growing)
What are the challenges of researching the menstrual cycle in elite sport?
Accurately studying the menstrual cycle requires hormone testing (via urine, blood, or saliva samples) - methods that are often costly, impractical, and burdensome. Cycle-to-cycle variability in menstrual characteristics (e.g., length, hormone levels, phase timing) also means testing is required across multiple cycles. Many athletes also present with subtle menstrual disturbances, meaning that despite initial screening for “normal” cycles, their hormonal profiles may not align with standard menstrual phase criteria—further reducing the usable sample size.
How can coaches and support staff help players manage menstrual symptoms and optimise performance?
Encourage players to track their menstrual cycle and symptoms over multiple cycles to identify individual patterns. Recognising repeated symptoms, rather than one-off issues, is key to distinguishing true menstrual-related effects and implementing proactive symptom management. It’s also important to avoid over-attributing every symptom to the menstrual cycle; for example, a single headache during menstruation could stem from dehydration or stress rather than hormones. Leveraging a multi-disciplinary team to implement nutrition, recovery, sleep, load management and medical care can help develop tailored strategies to manage symptoms and optimise performance throughout the cycle.
References
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3. Culvin A. Football as work: the lived realities of professional women footballers in England. Managing Sport and Leisure. 2021:1-14.
4. Williams J, Pope S, Cleland J. ‘Genuinely in love with the game’ football fan experiences and perceptions of women’s football in England. Sport in Society. 2022:1-17.
5. Oosthuyse T, Strauss JA, Hackney AC. Understanding the female athlete: molecular mechanisms underpinning menstrual phase differences in exercise metabolism. European Journal of Applied Physiology. 2023;123(3):423-50.
6. Janse de Jonge XA. Effects of the menstrual cycle on exercise performance. Sports Med. 2003;33(11):833-51.
7. D'Souza AC, Wageh M, Williams JS, Colenso-Semple LM, McCarthy DG, McKay AKA, et al. Menstrual cycle hormones and oral contraceptives: a multimethod systems physiology-based review of their impact on key aspects of female physiology. Journal of Applied Physiology. 2023;135(6):1284-99.
8. Bernstein C, Behringer M. Mechanisms Underlying Menstrual Cycle Effects on Exercise Performance: A Scoping Review. Women Sport Phys Act J. 2023;31(2):129-46.
9. McNulty KL, Elliott-Sale KJ, Dolan E, Swinton PA, Ansdell P, Goodall S, et al. The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis. Sports Med. 2020;50(10):1813-27.
10. Elliott-Sale KJ, McNulty KL, Ansdell P, Goodall S, Hicks KM, Thomas K, et al. The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis. Sports Med. 2020;50(10):1785-812.
11. Attia GM, Alharbi OA, Aljohani RM. The Impact of Irregular Menstruation on Health: A Review of the Literature. Cureus. 2023;15(11):e49146.
12. ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstetrics & Gynecology. 2015;126(6):e143-e6.
13. Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, et al. 2023 International Olympic Committee's (IOC) consensus statement on Relative Energy Deficiency in Sport (REDs). Br J Sports Med. 2023;57(17):1073-97.
17. Abbott W, Exall Z, Walsh L, Clifford T. Menstrual Cycle and Situational Match Variables: Effects on Well-Being in Professional Female Soccer Players. Research Quarterly for Exercise and Sport. 2024;95(3):1-9.
18. Scott D, Bruinvels G, Norris D, Lovell R. The Dose-Response in Elite Soccer: Preliminary Insights From Menstrual-Cycle Tracking During the FIFA Women's World Cup 2019. Int J Sports Physiol Perform. 2024;19(4):331-9.
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