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Considerations for coaches training female athletes

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PROFESSIONAL STRENGTH & CONDITIONING / WWW.UKSCA.ORG.UK
ISSUE 55 / DECEMBER 2019
Introduction
There is a rapidly growing need to better
understand the modern female athlete,
with the Women’s Super League and
Championship having now gone full- and
part-time – as well as women’s rugby union
and cricket also gaining full-time status. As
the level of female sporting performance
and professionalism increases, so too must
our understanding of how to optimise a
female’s athletic performance. Strength
and conditioning (S&C) coaches working
with young athletes often say ‘children
are not mini adults’, thus highlighting the
anatomical and physiological differences
between adults and children, and the need
to tailor training programmes accordingly.
With this in mind, should female athletes
be trained in the same manner as male
athletes, given that there are anatomical,
physiological and endocrine differences
between the sexes? Female athletes are
not smaller male athletes and this should
be considered as one of the key training
considerations.54
From a performance perspective it is clear
that men and women differ in muscle
mass and strength,53,56,65,143 anaerobic
power and capacity,57,88 muscle cross
sectional area, maximal aerobic capacity
and performance.3,23,24,35,67,69,127 A female’s
absolute whole-body strength (1RM), upper
body strength and lower limb strength is
60-63.5%, 55% and 72% respectively of a
man’s.73,126,128 However, when absolute values
are compared relative to body weight,
fat-mass and muscle cross sectional area,
a woman’s lower body strength is similar
to that of a man’s; the upper body strength
of a woman, though, is still somewhat less.
Considerations for coaches
training female athletes
OVERVIEW
Like their male counterparts, female athletes want to become fitter, faster and
stronger, meaning that there is a requirement for researchers, practitioners and
coaches to better understand the female athlete. Most training programmes/
interventions are based upon research on men: women have been considered
physiologically too variable, with the menstrual cycle deemed to be a barrier for
inclusion with potential interference to results.10 There are many physiological
and psychological differences between the sexes, and indeed between women
themselves (eg, oral contraceptive users versus non-users). Therefore, in order
to truly individualise and optimise training, these differences must be considered
during the planning and implementation of strength and conditioning plans.
Coaches need to understand female-specific issues such as: the menstrual cycle,
breast health, female psychology and trends in female injuries in order to be able
truly to promote the health and well-being of female athletes; this means, in turn,
that they can train sportswomen in their own right and not group them with men.
By Guy Pitchers, Canterbury Christ Church University and
Kirsty Elliott-Sale, Nottingham Trent University
TRAINING FEMALE ATHLETES
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Research data show that muscle hypertrophy
is similar between sexes, as are muscle
synthesis rates post exercise and rate of gain
of CSA per day.28,35,69,146 Strength training
programmes for females should be based
on the same principles as males – namely
multi-muscle, multi-joint and high intensity
movements and exercises – as females
respond to strength training in the same way
that men do.19,140 Previous data suggest that
training experiences, access to specialised
training and the fact that female athletes
enter sport less conditioned, all account for
inital sex differences in strength.77,132 These
strength differences are eliminated when
appropriate training is undertaken.74 Triplett
and Stone140 concluded that resistance
training is the primary determinant of
muscle mass and its distubution around the
body.
Menstrual cycle
Menstruation occurs when the endometrium
wall is sloughed off and discharged.
This happens around 9-10 times a year
(approximately every 24–35 days) and on
average ~457 times, until the menopause
(cessation of menstrual cycle) occurs.22
In the US, the average age for menarche
(the onset of the menstrual cycle) is 12.7 ± 1.3
years; however, it is important to note that,
as the hypothalamic-pituitary-gonadal axis
is yet to be fully established from its pre-
pubertal state, cycles are often anovulatory
(ie, no egg matures) and irregular for several
years.7,92 The menstrual cycle comprises of
three phases: menses (or menstruation),
follicular and luteal. The cycle contains
varying amounts of two endogenous
hormones: oestrogen which is low during
the menses, high during the follicular phase
and moderate during the luteal phase; and
progesterone, which is low during menses
and follicular phase, but high during luteal
phase (see Figure 1).
During menstruation (also known as a
period), blood and tissue is discharged
for between 2-7 days; the shedding of the
endometrial wall is important as it removes
any unfertilised eggs. Typically, the blood
and tissue discharged is not significant
enough in volume to affect exercise
performance.70 Within the follicular phase,
the uterine lining is reconstructed under
the influence of oestrogen; during this time
an egg will slowly mature until ovulation,
which subsequently starts the luteal
phase. In this final stage, progesterone will
prepare the endometrium for implantation:
however, if no egg is fertilised, oestrogen
and progesterone decline sharply and a new
cycle begins.
The follicular phase has been associated
with an increase in endurance, insulin
sensitivity and pain tolerance.52,116 Julian et
al72 showed that performance of the Yo-Yo
test was considerably higher in the early
follicular phase (3,288 ± 800m), compared to
the mid luteal phase (2,833 ± 896m); a trend
towards significance was observed (p = 0.07),
but other research has shown that hormonal
changes during the menstrual cycle do not
influence anaerobic performance.149 Sung
et al135 investigated the effects of strength
training in 20 untrained eumenorrheic
women (women with normal periods) over
TRAINING FEMALE ATHLETES
Figure 1. Example of a 28-day menstrual cycle46
OVARIAN CYCLEHORMONE LEVELS
Growing
follicle
Corpus
luteum
HORMONE: Progesterone Oestrogen LH FSH
OVULATION
VU
LATI
O
0714 21 28
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ISSUE 55 / DECEMBER 2019
three consecutive cycles. Subjects completed
four training sessions a week, where one leg
was mainly trained in the follicular phase and
the other in the luteal phase. Their results
demonstrated that the leg trained in the
follicular phase was significantly larger in
absolute maximal isometric force compared
to the luteal dominant leg (188 ± 98 vs 267 ±
101N). Furthermore, follicular phase strength
training saw a significant increase in muscle
diameter and type II muscle fibre diameter.
Another study showed that handgrip
was highest in the follicular phase when
oestrogen concentrations were high and
progesterone concentrations were low;107,110
however, research exists which contradicts
these findings.39,55 Elliott et al39 assessed
isometric strength in seven eumenorrheic
females in the early follicular and mid-luteal
phase: the results indicated that cyclical
variation in endogenous reprodcutive
hormones did not affect muscle strength.
Currently, findings are not consistent
enough to draw clear conclusions about
the effects of the menstrual cycle phase on
aerobic and anaerobic performance.
There is still some confusion regarding the
menstrual cycle and performance; famous
cases include Paula Radcliffe, who set a
world record during her period, and England
Lionesses midfielder Jordan Nobbs, who
suffered from premenstrual symptoms
prior to her injury. Many limitations occur
within research as poor methodologies, self-
reporting of menstrual cycle, low sample
sizes and inter- and intra-variability of
menstrual cycles all leave more questions
than answers.152 Historically, it was
believed that women should avoid exercise
to maintain fertility and that exercise
was too ‘stressful’ for women; menstrual
disturbances were noted following running
up to 10 miles a day in untrained women.13
The menstrual cycle is often seen as a
taboo in female athletes; a naïve S&C coach
may be unwilling to consider the potential
impacts that a eumenorrheic menstrual
cycle could have on physical performance
and wellness. The menstrual cycle is
important for sexual function, fertility,
bone health, cognitive function and mood.92
The impact of menstrual dysfunction
(amenorrhea, anovulation, luteal phase
defect, and oligomenorrhea), which is seen
in roughly 50% of exercising adults and
54% of female adolescent athletes who
regularly participate in sport, is often
overlooked.30,68,145 It is important to
emphasise that abnormalities in a female’s
menstrual cycle should not be assumed to
be associated with exercise until
psychological and/or physiological causes
are ruled out.100
Further research on how the ovarian
hormones affect sporting performance
is required if coaches are to provide the
best training stimulus to achieve optimal
adaptation.10,26 It is likely that recording and
tracking a player’s cycle will have a positive
impact on performance and start the all-
important conversations on menstrual
health.
Female Athlete Triad and Relative
Energy Deficiency in Sport
The single biggest challenge for athletes,
especially female athletes, is to avoid low
energy availability due to its known effects
on menstrual function and bone health –
as evidenced by the Female Athlete Triad
(which describes the synergist relationship
between energy availability, menstrual
function and bone health).100 Relative Energy
Deficiency in Sport (RED-S) is a condition
caused by low energy availability, which
impairs many bodily processes, such as
menstrual function, musculoskeletal health,
gastrointestinal function, cardiovascular
function and growth and development.93
As a result of these changes to physical
functioning, many aspects of sports
performance may also be negatively affected.
Likewise, there may be psychological
effects that either cause RED-S or are the
result of RED-S. The International Olympic
Committee (IOC) created this broader and
more comprehensive syndrome in 2014, to
supersede the previous term – ie, the Female
Athlete Triad – for the condition.31
RED-S can affect the physical functioning,
health and performance of not just females,
but also males, non-Caucasians and athletes
with a disability. At present, some, but
not all, of the proposed effects of RED-S
have limited evidence to support them, as
the RED-S model is in its early stages of
development. Bone and reproductive health
are the most evidence-based systems in this
model, given their established history as
part of the Female Athlete Triad, which was
first recognised as a disorder in the 1990s.99
In addition, evidence on the endocrine
changes resulting from RED-S is emerging.42
The original RED-S consensus paper was
published in 2014 and since then there have
been several updates and additions.94,95,96
Moutjoy et al96 proposed a set of criteria for
assessing RED-S and guiding athletes and
coaches regarding return to play following
RED-S. Female athletes, unlike males, have
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a unique early warning detection system
for low energy availability as menstrual
function is one of the first physiological
systems to be sacrificed when energy
availability is restricted. As such, it is vitally
important to monitor menstrual function in
female athletes.
Hormonal contraceptives
Although menstrual cycle hormones are
endogenous (naturally occurring within
the body), oral contraceptives provide
exogenous (external synthetic) oestrogens
and progestins. These exogenous hormones
downregulate endogenous oestrogen and
progesterone due to negative feedback on
the hypothalamic-pituitary ovarian axis
(see Figure 2 for a comparison of the two).
Currently, there is a wide range of hormonal
contraceptives available, including oral
contraceptives (combined, progestin-only),
injections, implants, vaginal rings, patches
and intra-uterine systems. Oral contraceptive
use is high in the general population and in
athletes,21,12,86,138 with 49.5% of athletes based
within the UK currently using some type of
hormonal contraceptive and 69.8% having
used a hormonal contraceptive at some
point in their career.86
The menstrual cycle is usually standardised
to a 28-day cycle, and oral contraceptives are
designed to mimic that same cycle length.
Typically, individuals are required to take
one pill a day for 21 days, followed by seven
consecutive placebo pills or pill-free days.
During the seven pill-free days of a combined
monophasic oral contraceptive regimen,
women often experience a withdrawal bleed,
which should not be confused with a period,
as these are not the same thing.
Oral contraceptive use has been shown
to have positive and negative symptoms
in athletes: Martin et al86 showed benefits,
such as improved skin, reduced bleeding
and reduced period pain, and negative
effects such as weight gain and irregular
periods. Schaumberg et al123 showed that
the majority (74%) of athletes intentionally
manipulated their oral contraceptive use
to avoid their withdrawal bleed, with 29%
manipulating this at least four times a
year. It is of course an athlete’s personal
choice to use hormonal contraceptives
for contraceptive purposes. However,
athletes should consider the potential
implications of hormonal contraceptive use
on their training, performance and health
if they are not using their contraceptive
for contraception purposes – ie, they may
be using it to treat medical conditions like
dysmenorrhoea, menorrhagia and acne.43
Figure 3 is a guide of good practice for
practitioners to be aware of when working
with female athletes.
EUMENORRHEIC MENSTRUAL CYCLE
DAYS 1-5
Low levels of progesterone
and oestrogen stimulate the
hypothalamus to secrete GnRH
Pituitary gland releases LH and FSH
and the ovary matures follicles in
response to FSH
DAYS 6-10
Dominant follicle develops
Oestradiol levels increase faster than
progesterone
Endometrium thickens due to
oestrogen
DAYS 11-14
Oestrogen suppresses
FSH production
High oestrogen induces LH
surge = ovulation
Cervical mucose viscosity changes
DAYS 15-22
Follicle releases ovum
Ruptured follicle is corpus luteum
and is a source of progesterone, this
signals hypothalamus to reduce LH
and FSH production
Progesterone causes thickening of
endometrium for implantation of
embryo
DAYS 23-28
Option 1: Sperm and ovum result in
the formation of embryo
Option 2: No fertilisation,
corpus luteum deteriorates and
progesterone synthesis stops; uterine
lining will slowly start to break down
ORAL CONTRACEPTIVE (COMBINED)
DAYS 1-10
Oestrogen in pill suppresses
production of FSH
No follicle development or increase
in uterine lining
DAYS 11-21
Low levels of progestin signal to
hypothalamus and pituitary to
prevent LH surge
No stimulus for endometrial lining
thickening and mucose production
remains thick
DAYS 22-28
Placebo pills enable a withdrawal
bleed of some uterine lining
Figure 2. Comparison between oral contraceptive (combined) and non-hormonal
menstrual cycle
GnRH – Gonadotropin-releasing hormone; FSH – Follicle stimulating hormone;
LH – Luteinising hormone
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Figure 3.
Pyramid of good practice
NHC = Non-hormonal contraceptive;
HC = Hormonal contraceptive
Data recording: age of menarche, current
cycle length, and NHC/HC user
Encourage athletes to record and track own cycle with subjective
comments on well-being and performance
Create a climate where athletes are able to openly discuss
menstrual health
Ensure smear test
completed in over-25s
Indirect tracking of cycles in
NHC athletes
Coherent procedures to deal with
menstrual concerns
Athlete education in menstrual health,
pros/cons of HC methods
Training is
reflective of
current
NHC/HC state
Direct tracking of
individual cycles
The impact of oral contraceptives on
sporting performance is difficult to
interpret due to many factors: the lack
of standardisation of oral contraceptives
used in research studies (high and low
dose users); failure to control the type of
oral contraceptive used (progestin only,
combined etc) by the participants; inter- and
intra-individual variation in endogenous
hormones; and an increase in the occurrence
of type II errors (accepting a false null
hypothesis).41 Research has not shown a
change in strength and short-term high
intensity performance between pill-taking
and pill-free days;18,38,40,58,82,109,122,134 however,
several studies used non-active participants
and none used high level athletes.40,82,109,122
However, when it comes to endurance
performance, the results are varied. Rechichi
and Dawson113 showed no effect of oral
contraceptive use on a 200m swim time trial,
although they showed that blood lactate
levels were reduced and pH increased
during the withdrawal (pill-free) phase.
Conversely, Lebrun et al78 demonstrated,
with highly trained athletes in a randomised,
double blind, placebo-controlled study, that
absolute and relative changes in V̇O2max from
follicular to triphasic oral contraceptive
use decreased by 4.7%, whereas a +1.5%
improvement was demonstrated in the
placebo group. There was, however, a large
individual variability within the results
and no significant differences found in
anaerobic speed test, aerobic endurance
(time to fatigue at 90% of V̇O2max), and
isokinetic strength. Rechichi and Dawson112
showed that reactive strength from 45 cm
box in team sport athletes was significantly
lower in the late-withdrawal phase (158 ± 29
cm s-1) than in the pill consumption phase
(178 ± 48 cm s-1). Redman and Weatherby114
found significant alterations in peak power
output (433 ± 5 vs 449 ± 6 watts) and 1000m
rowing ergometer time (227 ± 1 vs 231 ± 1
seconds) during the withdrawal phase, when
exogenous hormones were absent. These
studies highlight the lack of consensus
in this area, due to the aforementioned
methodological differences. Future research
needs to address these issues and should
employ more robust techniques where
identical oral contraceptives are used and
endogenous hormone blood sample are
taken in well-trained athletes.
Monitoring the menstrual cycle
When a S&C coach is planning a pro-
gramme, a key consideration should always
be to consider the individual. It is advisable
to record each athlete’s menstrual history,
including age at menarche, contraception
usage, time of last period and frequency of
periods.89 Although a general consensus
is that monitoring the menstrual cycle
is important, how to collect valid and
reliable data is yet to be established.
Furthermore, education amongst athletes
requires improvement: only 16% of athletes
surveyed could identify both oestrogen and
progesterone as female ovarian hormones
that fluctuate throughout the menstrual
cycle and only 18% knew that amenorrhea
meant the absence of menstruation.44
Hamilton60 used a 31-day cycle training
approach during his time at GB Women’s
Hockey (see Table 1 on next page).
Although this table shows the application
of theoretical research in an applied
setting, practitioners need to be mindful
that this model cannot simply be applied
to all female athletes and would need to
exclude hormonal contraceptive users and
individuals with menstrual dysfunction;
it would also need to be adjusted to the
individual’s cycle length (that may also vary
between months). Menstrual cycle tracking
can be direct or indirect. Direct methods
include blood, urine, saliva, ultrasounds of
follicular development and biopsies of the
endometrial.121 Although these methods
would remove doubt of menstrual health,
they are typically expensive, invasive
and time-intensive. Indirect methods
include body temperature, ovulation
tests, use of questionnaires and apps;
these methods would be quicker and
more practical but some caution
is still required. An app is easy
and assessable for athletes and
coaches, but users need to be
mindful that apps are unable
to exclude certain menstrual
dysfunctions such as
anovulation (menstrual
bleeding occurs but
ovulation does not)
and luteal phase
defects (short
duration and/
or insufficient
progesterone).
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Table 1. Adapted from Hamilton60
Early
follicular
(menses)
Regeneration Light Mixed early light
conditioning and
start loading gym
Speed
Conditioning
Gym and speed
Medium
Medium/
heavy
Very heavy
Medium Conditioning
heavy
Light Light mixed
Metabolic
Oestrogen,
progesterone and
testosterone low
Changes in mood resulting in
increased stress, accidents,
poor reaction times and
perception of exercise.
Immune depression
Eliminate skill and precision
training, reduce stress and training
volume
Include anaerobic and power-based
activity, lactic acid-based work and
strength training
Include high intensity, low volume,
complex tasks, anaerobic and
power-based activity, lactic
acid-based work and strength training
Include low intensity and high-volume
aerobic work. Emphasise non-weight
bearing activities and prolonged
exercise
Strength and power training
Include high intensity, low volume,
complex tasks, anaerobic and
power-based activity, lactic
acid-based work and strength training
Include low intensity and high-volume
aerobic work. Emphasize non-weight
bearing activities and prolonged
exercise. Ability to cope with stress
Recovery week. Eliminate skill and
precision training. Include simple
tasks and low stress. Reduce stress
and training volume and include
strength training
Increased glycogen storage,
fat and protein and water and
electrolyte stores
Greater protein breakdown.
Muscle endurance low. Increased
glycogen storage, increased fat
and protein. Increased water and
electrolyte stores
Increased glycogen stores in liver
and muscle tissue, decreased
glycogen stores in blood glucose.
Increase in total energy and fat
intake. Depression of blood
lactate concentration. Greatest
retention of water, sodium,
chloride and potassium
Oestrogen rising,
progesterone low
Oestrogen peak
Testosterone peak
Progesterone
rising
Oestrogen and
progesterone
peak
Oestrogen,
progesterone and
testosterone low
Mid
follicular
Late
follicular
Ovulation
Early
luteal
Mid
luteal
Late
follicular
MENSTRUAL
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
PHASE HORMONE LEVEL EFFECT ON TRAINING WEEKS
1
2
3
4
5
FOCUS INTENSITY PRIORITY SESSION SIMPLE
TERMS
PHYSIOLOGICAL AND
PSYCHOLOGICAL CHANGES
Changes in mood resulting in
increased stress, accidents,
poor reaction times and
perception of exercise.
Immune depression
Metabolic
and strength
Aerobic
and injury
prevention
Maximal
strength
and power
Aerobic
and injury
prevention
Recovery
TRAINING FEMALE ATHLETES
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Furthermore, given the high prevalence of
oral contraceptives, athletes’ ‘cycles’ are
exogenously controlled and may give a false
indication of good menstrual health. What
is most likely best practice is a combination
of both direct and indirect methods
throughout the season. Using data that
allows the coach to alter training is a little
less clear; tracking performance throughout
the cycle may help determine if the athlete
is maximising performance by being
responsive to changes that may occur
at various points of the menstrual cycle.
Barker4 suggests that females who do
not suffer too badly from premenstrual
syndrome (PMS) or experience heavy
menstrual bleeding (heavy periods) can
mostly use a traditional periodisation
approach (linear/block), whereas other
sportswomen would need to train harder
during the follicular phase and reducing
training during the luteal phase.
Injury
As female participation in sport increases,
so too will the occurrence of injuries;
females incur more stress fractures, shoulder
(subluxation and dislocation) injuries,
patella femoral pain, ankle sprains, and ACL
injuries.6,34,65,98,130,131,133,137,154
Menopause is associated with an increased
risk of musculoskeletal injury, as oestrogen
and other female hormones decline.47 It is
proposed that females experience higher
rates of concussion than male athletes, with
a smaller head size and less musculature
around the neck proposed to explain these
differences, although interpreting these data
can be difficult as both males and females
tend to under-report symptoms.29,33,45 Some
men have a greater upper limb strength,
stronger rotator cuff and periscapular
muscles, whereas some women have greater
anterior glenohumeral laxity and decreased
stiffness, which could negatively impact
shoulder subluxation and dislocation
risk.6,8,157
Interestingly, women and men use different
strategies to control the ankle joint when
standing or walking;101 furthermore,
ligamentous laxity of the ankle joint has
been shown to be greater in women, which
helps explain why women sustain ankle
sprains nearly twice as often as men.34,151
Females are at greater risk for overuse
injuries (tendinitis, bursitis, medial tibial
stress syndrome, and stress fractures).11,155
Among collegiate athletes, females had
a higher rate of overuse injury than male
athletes (25 vs 13 per 10,000 athlete
exposures (exposure was calculated by
coach directed session)).155 It is important
to remember that bone mineral density can
be affected through low energy availability,
disordered eating, menstrual dysfunction
and/or delayed menarche.45,50
Anterior knee pain has been shown to
be higher in females, with the estimated
prevalence of anterior knee pain in 18-35
year old females at 12-13%.119 Females with a
larger Q angle (angle between the anterior
superior iliac spine and midpoint of the
patella) are more prone to lateral maltracking
of the patella.45,154 However, scientific proof
supporting this anatomical theory is limited
and practitioners are better off focusing
on landing mechanics (in particular, more
trunk flexion and no valgus) and exercises
that improve gluteal muscles (single leg
squats, single leg RDLs, miniband exercises
etc). 5,45,141,154
A lot of research into injuries in female
athletes focuses on the anterior cruciate
ligament (ACL), because of the severity
of these types of injuries and the duration
of rehabilitation following injury. Female
athletes in jumping and cutting sports are
four to six times more likely to sustain a
serious knee injury compared to males.64
Risk factors for a non-contact ACL injury
include: anterior tibial shear stress from
quadriceps contraction, near full knee
extension and deceleration with a planted
foot, with the knee internally rotated
and in valgus.1,120 Research into ACL
injuries involving the menstrual cycle is
emerging: ovulation has been associated
with a reduction in knee stiffness and ACL
injury.108,153 In eumenorrheic women, knee
laxity increased from 4.7 ± 0.8mm in the
follicular phases compared to 5.3 ± 0.7mm
in the ovulatory phase,32 which is proposed
to explain increased knee injury risk given
that a 1.3mm increase in knee displacement
increases ACL injury risk four-fold.97
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The majority
of studies invest-
igating cycle phase
and injury risk
have used subject
self-recall to establish
menstrual cycle status. It
is important to note that
hormone milieu can change
substantially near ovulation,
and that follicular and luteal
phases can vary in length significantly.76,129
Tourville et al39 suggest caution regarding
the accuracy of retrospective menstrual
cycle phases classification systems, given
the high occurrence of anovulatory cycles.
The use of single hormone samples to
ascertain hormone status has been shown
to be erroneous: it is unable to determine
if hormones are rising, peaking or falling.139
More conclusive evidence is needed to
ascertain how – or indeed if – the sex
hormones alter the mechanical properties
of muscle, tendon, or ligament in vitro or in
vivo in eumenorrheic women.
It is believed that taking oral contraceptives
can reduce the risk of ACL risk by
stabilising endogenous hormones.
However, as so often with research around
exogenous hormones, the effects may or
may not differ with the administration of
different oral contraceptives (monophasic,
biphasic, triphasic and the type, potency
and androgenicity of progestins). Currently,
there is no clear evidence on the effects
of oral contraceptives on ligament/ACL
risk.1,115,120 In a review by Herzberg et
al,63 ACL injury risk was assessed across
menstrual cycle (outside of the scope of
this paper). Risk factors for ACL injuries
involve both intrinsic (player-related) and
extrinsic (environment-related) elements;
practitioners would benefit from focusing
on extrinsic factors such as improving
neuromuscular control, or by introducing
or modifiying programmes such as
the PEP (Prevent Injury and Enhance
Performance) from the Santa Monica
Sports Medicine Foundation into their
current practice.
Breast health
Education of young females requires
improvement, as more than 50% of 2,000
females, aged between 11 and 18 years
and based in the UK, have reported never
wearing a sports bra during sports, even
though breast bounce is a major breast
health concern.125 Data in elite, adult female
athletes is currently unavailable. Breast
problems can present a real barrier to
exercise participation; they also account
for a high occurrence of pain in exercising
females that is exacerbated in high intensity
sport.9,15,17,81 Running with low breast support
can lead to increased muscle activation in
the pectoralis major, anterior and medial
deltoid.90 Furthermore, low breast support is
associated with increased ground reaction
forces,147 closely aligned with a reduction
in economical running kinematics and a
lower breathing frequency.91,148 However,
conflicting research has shown that ground
reaction forces and other physiological
variables were unaffected by breast support
changes during running.117
White et al149 showed that although a high
support bra reduced breast kinematics and
decreased breast pain, it did not influence
thorax and arm kinematics. As breasts have
limited internal anatomical support, it is
recommended that external support be used
or else the athlete risks irreparable damage
and increases the likelihood of breast
ptosis (ie, sag).87,106 Multidirectional breast
displacement during running, star jumps
and horse riding has been reduced with high
support sports bras.14,102,124 Compression
bras are perceived to be suitable for < D
cup breasts, whereas encapsulation bras
offer more support to > D cup breasts.106
Further advice for choosing a ‘good’ sports
bra includes: having a wide vertical
adjustable strap; ensuring the back has
ISSUE 55 / DECEMBER 2019TRAINING FEMALE ATHLETES
27
PROFESSIONAL STRENGTH & CONDITIONING / WWW.UKSCA.ORG.UK
ISSUE 55 / DECEMBER 2019
adjustability but not elastic qualities; having
a high neckline (reaches the upper boundary
of breast tissue); being comfortable and
providing the level of support suitable for
the intensity of the exercise.16,25,156
Coaching and psychology
It should be stated that there are more
similarities than differences between the
sexes with regards to psychology; however,
the subtle differences that exist can have
a significant impact on performance.
Differences between sexes can occur in goal
orientation, sources of confidence, cohesion
and preferred coaching styles.118
Apart from performance pressures, females
face additional stressors through patronising
attitudes, gender stereotypes and unequal
treatment.59,118 The female athlete is more
likely to experience sexual harassment and/
or abuse; data from sports students (mean
age 22 years) reported that 34% of females
experienced sexually harassing behaviour
from a man and 12% from a woman, which
negatively impacted their self-esteem and
heightened their anxiety.48,49,85,118
Tailoring the coaching and support offered
to female athletes will benefit the individual
and the team.51,83,105 Personal goals and
standards instil confidence in world class
female athletes, whereas males tend to
derive confidence from interpersonal
comparison and winning.62 Female
athletes score higher in task-orientation
and lower on levels of ego orientation
and place less emphasis on winning and
competitiveness.36,61,79 Furthermore, females
have lower feelings of efficacy and lower
confidence levels.75,144 However, females
have a greater motivation to create and
maintain close relationships and a greater
need for positive communication and
belongingness, which are essential given
the importance of cohesiveness to success
in female teams.20,27,104
Norman and French103 showed that, in the
UK, the coach occupies a powerful and
often over-bearing role in the lives of high-
performance women athletes, but that a more
democratic, personalised and positive coach-
athlete relationship can prove instrumental
in improving women athletes’ experiences
of performance sport. Sportswomen are
more likely to want to explore rationales
for decisions and often want to play some
part in the decision-making process, thus
highlighting the need for a good coach/
athlete relationship and communication.105
Failure of male coaches to understand how
best to engage with female athletes has been
shown to be a key barrier to participation,
engagement, and progression.103,104
The strength and conditioning profession
is a largely male-dominated profession,
and therefore there is a likelihood that
female athletes will be supported by a male-
dominant team. It could be misperceived
that having male coaches for female athletes
is not an ideal situation, given their inability
to fully understand the female athlete:
however, research specifically investigating
attitudes towards and preferences for male
and female S&C coaches showed that female
athletes do not demonstrate a sex preference,
or negative attitudes towards a male coach.84
In contrast, males prefer working with a male
strength coach, no matter how qualified the
female coach is.84 Magnusen and Rhea84
suggest that male athletes in male-dominant
sports may need education on how gender
does not dictate expertise and that athletes
should be focused on the coach’s experience
and teaching ability, rather than on gender.
S&C coaches may have to pay particular
attention to younger female athletes, since
they are likely to have a lower perception
of their athletic ability and sometimes are
less able to perform resistance training.66,111
If they perceive S&C training to be a
masculine activity, further issues can
arise;80 as such, it would be beneficial for
the coach to dispel myths around strength
training, explain why DOMs occur and
promote the benefits of strength and
conditioning in order to increase female
athletes’ engagement with strength training
programmes.
GUY PITCHERS, MSC, PGCE, ASCC
Guy is a strength and conditioning coach at Charlton Athletic
Women’s Football Club. He is also an instructor in sport and
exercise science at Canterbury Christ Church University, where
he is also undertaking a PhD in female physiology.
DR ELLIOTT-SALE, PhD
Kirsty completed her undergraduate degree and PhD (in exercise
physiology) at Liverpool John Moores University. Her PhD
examined the effects of female reproductive hormones on muscle
strength and since then her work has mainly focused on female
athletes; she is interested specifically in the menstrual cycle, oral
contraceptives, the Female Athlete Triad and Relative Energy
Deficiency in Sport. She is an associate professor [reader] of
female physiology and head of the Musculoskeletal Physiology
Research Group at Nottingham Trent University.
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TRAINING FEMALE ATHLETES
28 PROFESSIONAL STRENGTH & CONDITIONING / WWW.UKSCA.ORG.UK
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References (cont.)
... Asides from lifestyle variations, there is growing evidence that the physiological (Pitchers & Elliot-Sale, 2019), endocrine (Park et al., 2009) and anatomical (Pitchers & Elliot-Sale, 2019) differences between men and women, could put female athletes at greater risk of certain injuries, such as anteriorcruciate ligament (ACL) injury. These are of highest prevalence in sports involving jumping or multidirectional movements, such as football (Pitchers & Elliot-Sale, 2019). ...
... Asides from lifestyle variations, there is growing evidence that the physiological (Pitchers & Elliot-Sale, 2019), endocrine (Park et al., 2009) and anatomical (Pitchers & Elliot-Sale, 2019) differences between men and women, could put female athletes at greater risk of certain injuries, such as anteriorcruciate ligament (ACL) injury. These are of highest prevalence in sports involving jumping or multidirectional movements, such as football (Pitchers & Elliot-Sale, 2019). ...
... Asides from lifestyle variations, there is growing evidence that the physiological (Pitchers & Elliot-Sale, 2019), endocrine (Park et al., 2009) and anatomical (Pitchers & Elliot-Sale, 2019) differences between men and women, could put female athletes at greater risk of certain injuries, such as anteriorcruciate ligament (ACL) injury. These are of highest prevalence in sports involving jumping or multidirectional movements, such as football (Pitchers & Elliot-Sale, 2019). Therefore, supplements known to be beneficial for ligament rehabilitation or attenuation of muscle atrophy during injury in female athletes, such as collagen or omega-3 fish oils, could benefit the return to play in female footballers. ...
Article
Full-text available
The physical demands of professional female football have intensified in recent years. Supplements are only advised in addition to a healthy, balanced diet, but may warrant a greater prevalence in the professional game to support well-being, recovery, and performance. Supplements used by players should be safe, legal, and scientifically proven to be effective. An individual approach should be taken to using supplements dependant on the needs and goals of the player. Female players should aim to improve the frequency of protein intake throughout the day, whilst tailoring doses to individual body mass. Vitamin D supplementation is vital throughout the winter months in countries with limited sun exposure, however doses should be administered based on individual blood test results. Iron is likely to be important to the well-being of female athletes throughout the season, in particular during the menses. Omega-3 and collagen may be of greater benefit to female than male athletes during recovery from soft tissue injury, whilst probiotics and creatine are beneficial throughout the season for reducing risk of illness and optimising recovery, respectively. Ergogenic supplements for football include beta-alanine, nitrate and caffeine. Caution should be taken with caffeine use due to the varying tolerance of difference athletes and sleep impairments that can follow.
... This investigation's main findings revealed no apparent performance differences between the menstruation phase and the testing results from the other three testing occasions ( Table 2). The reduction in estrogen has been shown to decrease muscle performance-related organs such as mitochondrial function, membrane microviscosity, and others [7,8]. Since estrogen is lowest during the menstruation phase [8], it was expected that T1 would decrease performance compared with T2, T3, and T4 [1]. ...
... The reduction in estrogen has been shown to decrease muscle performance-related organs such as mitochondrial function, membrane microviscosity, and others [7,8]. Since estrogen is lowest during the menstruation phase [8], it was expected that T1 would decrease performance compared with T2, T3, and T4 [1]. However, in contrast to our expectations, the results of this investigation revealed no indications of notable harm or benefits to performance between the menstruation phase and T2, T3, and T4 when examined using eumenorrhea female college students with a menstrual cycle that lasts around 26-35 days. ...
... This investigation's main findings revealed no apparent performance differences between the menstruation phase and the testing results from the other three testing occasions ( Table 2). The reduction in estrogen has been shown to decrease muscle performancerelated organs such as mitochondrial function, membrane microviscosity, and others [7,8]. Since estrogen is lowest during the menstruation phase [8], it was expected that T1 would decrease performance compared with T2, T3, and T4 [1]. ...
Article
Full-text available
Background: The purpose of the present investigation was to examine changes in strength and aerobic physical performances in young eumenorrheic female college students during the menstruation phase and different testing occasions within a menstrual cycle. Methods: A repeated measure experimental design used to investigate the variation in physical performance from different testing occasions compared to the menstruation phase. Twelve eumenorrhea female college students volunteered to participate in this study. The participants were 19.8 ± 0.8 (±SD) years old, with the body mass of 61.4 ± 11.6 kg, the height of 162.6 ± 5.1 cm, and BMI of 23.2 ± 3.8. All participants reported regular monthly menstrual cycles of 26-33 days, none of whom reported taking oral contraceptives in their entire life. None of the participants was an athlete, and their level of activity was limited to physical education classes and recreational activities. The menstrual cycles during the two cycles before testing had to be between 26 and 35 days to participate in this study. Second, there had to be no current or ongoing neuromuscular diseases or musculoskeletal injuries. Third, no one should be taking any dietary or performance-enhancing supplements that could have affected testing results during this study. The participants tested on one-repetition maximum (1RM) bench press, 1RM leg press, push-up to failure, leg press with 60% of 1RM to failure, and running 1600 m time trial. The participants were tested on four occasions based on the classical model of the menstrual cycle (i.e., 28 days; early follicular phase (menstruation phase) on day 2 (T1), late follicular phase on day 8 (T2), ovulation phase on day 14 (T3), and mid-luteal phase on day 21 (T4)). Data were analyzed using the Bayesian hierarchical model (Bayesian Estimation) with Markov Chain Monte Carlo simulation using the decision-theoretic properties of the high-density interval (HDI) + ROPE decision rule. Results: The Bayesian estimated difference from the four testing occasions neither showed that the most credible parameter values (95% HDI) were sufficiently away from the null value nor showed that the most credible parameter values are close to the null value (Rope odds ratio among all tests were spread in 12.7% < 0 < 87.3% with an effect size ranging between d = -0.01 and 0.44). Hence, no decision can be made as to whether strength and aerobic physical performances change during the menstruation phase compared to the other testing occasions within a menstrual cycle. Conclusions: It was noticed that different studies concluded different results, which make the research in menstrual cycle difficult. However, the results from this study and published studies suggest that future research should investigate and profile motivation and autonomic nervous system activity during the menstruation phase and examine the interaction effect of the three on performance compared to other testing occasions within a menstrual cycle.
... Performance-based research in women has not kept pace with the exponential rise in participation [6,7]. Indeed, it would be naive to assume that all research in men can be directly applied to women, given the anatomical, physiological and endocrinological differences between the sexes [4,[8][9][10]. As such, sportswomen will benefit from sexspecific research and guidelines, which consider the effects of women's physiology, such as the menstrual cycle (MC), on performance [8,11]. ...
... Indeed, it would be naive to assume that all research in men can be directly applied to women, given the anatomical, physiological and endocrinological differences between the sexes [4,[8][9][10]. As such, sportswomen will benefit from sexspecific research and guidelines, which consider the effects of women's physiology, such as the menstrual cycle (MC), on performance [8,11]. ...
... Experimental studies were considered for analysis if they met the following inclusion criteria: (a) published, in full, Fig. 1 Schematic displaying the hormonal fluctuations across an idealised 28-day menstrual cycle, with ovulation occurring on day 14 Adapted from Pitchers and Elliott-Sale [8] in a peer-reviewed journal, (b) had the primary or secondary objective of assessing changes in exercise performance across the MC, (c) included within-group comparisons and (d) outcome measure(s) were taken in two or more defined MC phases. As such, case studies, review articles, study protocol papers and conference abstracts were excluded. ...
Article
Full-text available
Background Concentrations of endogenous sex hormones fluctuate across the menstrual cycle (MC), which could have implications for exercise performance in women. At present, data are conflicting, with no consensus on whether exercise performance is affected by MC phase.Objective To determine the effects of the MC on exercise performance and provide evidence-based, practical, performance recommendations to eumenorrheic women.Methods This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four databases were searched for published experimental studies that investigated the effects of the MC on exercise performance, which included at least one outcome measure taken in two or more defined MC phases. All data were meta-analysed using multilevel models grounded in Bayesian principles. The initial meta-analysis pooled pairwise effect sizes comparing exercise performance during the early follicular phase with all other phases (late follicular, ovulation, early luteal, mid-luteal and late luteal) amalgamated. A more comprehensive analysis was then conducted, comparing exercise performance between all phases with direct and indirect pairwise effect sizes through a network meta-analysis. Results from the network meta-analysis were summarised by calculating the Surface Under the Cumulative Ranking curve (SUCRA). Study quality was assessed using a modified Downs and Black checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group.ResultsOf the 78 included studies, data from 51 studies were eligible for inclusion in the initial pairwise meta-analysis. The three-level hierarchical model indicated a trivial effect for both endurance- and strength-based outcomes, with reduced exercise performance observed in the early follicular phase of the MC, based on the median pooled effect size (ES0.5 = − 0.06 [95% credible interval (CrI): − 0.16 to 0.04]). Seventy-three studies had enough data to be included in the network meta-analysis. The largest effect was identified between the early follicular and the late follicular phases of the MC (ES0.5 = − 0.14 [95% CrI: − 0.26 to − 0.03]). The lowest SUCRA value, which represents the likelihood that exercise performance is poor, or among the poorest, relative to other MC phases, was obtained for the early follicular phase (30%), with values for all other phases ranging between 53 and 55%. The quality of evidence for this review was classified as “low” (42%).Conclusion The results from this systematic review and meta-analysis indicate that exercise performance might be trivially reduced during the early follicular phase of the MC, compared to all other phases. Due to the trivial effect size, the large between-study variation and the number of poor-quality studies included in this review, general guidelines on exercise performance across the MC cannot be formed; rather, it is recommended that a personalised approach should be taken based on each individual's response to exercise performance across the MC.
... The persistent underrepresentation of women in sports science 1 is reflected in the fact that, notwithstanding substantial anatomical, physiological and endocrine differences between male and female athletes, most training methods are derived from research on men. 2 One of the most fundamental differences between males and females is the menstrual cycle, which influences cardiovascular, respiratory, metabolic and neuromuscular parameters 3 and can affect athletic performance. 4 Moreover, excessive athletic activity can cause menstrual irregularities with detrimental health effects. ...
Article
Full-text available
The menstrual cycle is one of the most fundamental differences between men and women and is capable of influencing the performance, well-being and health of female athletes. Despite increasing research, the influence of the menstrual cycle on athletic performance is still largely a mystery and highly individual. This in turn increases the importance of effective communication between coaches and female athletes. The purpose of this study is to analyse the existing communication behaviour of coaches as perceived by female athletes, as well as their willingness to communicate about the menstrual cycle. Therefore, we developed an online questionnaire addressed to female sports club athletes (n = 1195). Questions about the coach's thematisation of the menstrual cycle and the female athlete's willingness to communicate served as dependent variables. Ordinary least squares regressions were conducted for both dependent constructs. We found that communication behaviour depends on coaches' age, type of sport and training frequency. Communication willingness depends on the gender of the coach, athletes' age, type of sport, training frequency and perception of cycle-related performance fluctuations. Overall, the results of our study also show a large gap between desire and reality-even in 2022 coaches rarely talk about the menstrual cycle, although a large proportion of female athletes would be willing to do so. Both coaches and athletes should be empowered to communicate more openly about men-strual cycle. Improving communication skills on both sides may also improve the coach-athlete relationship.
... these two phases. Therefore, the MC is typically expressed in research using sub-phases, such as early follicular, late follicular, ovulatory, early luteal, mid luteal and late luteal [4]. ...
Article
Full-text available
The effect of the menstrual cycle on physical performance is being increasingly recognised as a key consideration for women’s sport and a critical field for further research. This narrative review explores the findings of studies investigating the effects of menstrual cycle phase on perceived and objectively measured performance in an athletic population. Studies examining perceived performance consistently report that female athletes identify their performance to be relatively worse during the early follicular and late luteal phases. Studies examining objective performance (using anaerobic, aerobic or strength-related tests) do not report clear, consistent effects of the impact of menstrual cycle phase on physical performance. Overall sport performance can be influenced by both perceived and physical factors. Hence, to optimise performance and management of eumenorrheic female athletes, there is a need for further research to quantify the impact of menstrual cycle phase on perceived and physical performance outcomes and to identify factors affecting variability in objective performance outcomes between studies.
... There is also a lack of distinction between sexes, with only two papers discussing females exclusively (Miarka, Coswig et al., 2016;Schick et al., 2012). Given the inherently different responses to training and performance between sexes (Pitchers & Elliot-Sale, 2019), this would be an important area for research focus. These conclusions place the current review in stage 1 of ARMSS, defining as it does the current gaps in MMA research. ...
Article
Full-text available
The physical and physiological demands of mixed martial arts (MMA) training and competition is not yet well quantified. The Applied Research Model for the Sport Sciences (ARMSS) provides a framework through which to conduct sport science, determining pertinent questions to apply and test research findings in real world settings. The aim of this review was to evaluate MMA research within the context of ARMSS to critically analyse our understanding of the physical and physiological requirements of MMA training and competition. Research databases were searched, with 70 peer-reviewed articles being discussed in relation to the specific stage of the ARMSS in which their results best fit. MMA research was found to be mostly foundational and descriptive in nature and has generally not developed along systematic lines. The internal and external physiological loads and responses to training and competition have not been adequately identified. Therefore, it is not currently possible to state which variables are key predictors of success, or how coaches can optimally manipulate these variables. We propose that MMA research could be refocused to be conducted within ARMSS. Specifically, stage 2 studies describing the physical, physiological and technical demands of MMA training and competition, and stage 3 studies determining the physiological predictors of competition performance should be initially prioritised.
Chapter
Resistance training (RT) configures a specialized method of training that involves the progressive use of a wide range of resistive loads, different rate of muscle activation or movement velocities, and a variety of training modalities. RT is currently considered essential in athletic preparation. It is a key component for optimizing growth and maturation in children, promoting health and quality of life in the elderly, or to attenuate the incidence of injuries in physically active populations. Qualified professionals are necessary to design individualized RT programs for athletes from varying disciplines with very specific performance outcomes. The professional must consider specific needs for all ages, not only the athletic population, making the necessary adaptation to meet their level of ability and desired outcomes. Effective training stimuli should help increase performance and avoid overtraining. This is accomplished by manipulating physiological, neurological, and biomechanical-related variables. There is hard science behind the importance of menstrual cycle-based periodization, and—although research in this area is scarce—results suggest that designing training programs integrating the menstrual cycle hormonal fluctuation or the ingestion of triphasic contraceptives might be of relevance to optimize performance in premenopausal women.
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Background Women are at substantially greater risk for anterior cruciate ligament (ACL) injuries than are men. Purpose To conduct a systematic review and meta-analysis of the literature to clarify the effect of the menstrual cycle and contraceptives on the laxity of and noncontact injuries to the ACL. Study Design Systematic review; Level of evidence, 4. Methods Searches were conducted using MEDLINE (1946–August 2016), the Cochrane Library Database, clinical trial registries, and related reference lists. Search terms included athletic injuries, knee injuries, ligaments, joint instability, menstrual cycle, ovulation, hormones, and contraceptives. Investigators independently dually abstracted and reviewed study details and quality using predefined criteria and evaluated overall strength of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. Results Twenty-one studies totaling 68,758 participants were included: 5 on the menstrual cycle and ACL injury, 7 on hormonal contraceptives and ACL injury, as well as 13 on menstrual cycle and ligament laxity. Four of 5 studies of women not using hormonal contraception indicated that the luteal phase was the least associated with ACL injuries. The 2 largest and highest quality studies on hormonal contraceptives suggested that hormonal contraceptives may be protective against ACL injury. Six of 12 studies on ACL laxity provided quantitative data for meta-analysis, finding significantly increased laxity during the ovulatory phase compared with the follicular phase. Conclusion The literature suggests an association between hormonal fluctuations and ACL injury. Recent studies have suggested that oral contraceptives may offer up to a 20% reduction in risk of injury. The literature on ACL injuries and the menstrual cycle has more than doubled over the past decade, permitting quantitative analysis for the first time. However, the overall strength of this evidence is low. Promising potential directions for future research include long-term observational studies with ongoing hormonal assays and large interventional trials of follicular suppression, including newer hormonal methods.
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Introduction: Some of the physiological factors and athletic performance might show variation along the phases of menstrual cycle. The alterations seen in these physiological parameters of various systems relating to oscillations in hormonal levels do affect the autonomic nervous system and metabolic functions. Former studies heave inconclusively about the influence of hormones on exercise performance, predominantly muscle strength and rate of fatigue during different phases of the menstrual cycle. Studies regarding influence of these variations during bleeding phase were not done. Aim: To evaluate the muscle strength variations and also the rate of fatigue during various phases of the menstrual cycle in young adults. Materials and methods: This was a prospective study conducted among 100 healthy adult female volunteers aged 18-24 years, with normal regular menstrual cycles persistent between 26- 32 days (average of 28 days), for a minimum of last 6 months. Muscle strength was assessed by calculating the work done and fatigue rate using Mosso's ergograph and by handgrip dynamometer strength. Each subject was evaluated consecutively for two menstrual cycles in all three phases which were classified as Phase 1- Menstrual phase, Phase 2- Follicular phase and Phase 3- Luteal phase. The data obtained was analysed by statistical tool One-way ANOVA followed by a post-hoc Tukeys test. A p-value of ≤ 0.05 was considered significant. Results: The amount of work done and handgrip strength was significantly higher in phase 2 (p<0.001) and relatively reduced in phase 1 and 3 (p<0.001) of menstrual cycle. In terms of fatigue rate percentage, phase 2 showed significantly lesser values (p<0.001) as compared to phase 1 and 3 of menstrual cycle. Conclusion: We conclude that the cyclical variation in endogenous reproductive hormones increases the muscle strength in follicular phase of the menstrual cycle. Thus provide support for the influence of these hormones in regulation of these parameters in the premenopausal age group.
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The breast does not contain muscle; the only two supporting structures are the skin and the Cooper’s ligaments, both of which are quite weak mechanically, and, therefore, when exercising, the breast moves independently. The negative consequences of an unsupported breast include breast pain, breast ptosis (sag), embarrassment, and potential negative performance effects. Excessive breast motion during exercise, caused by a lack of appropriate breast support, can also be a barrier to women participating in sport and exercise. It is, therefore, imperative to ensure the breast is held firmly in place. In this chapter, the mechanics of the breast and breast movement are explained, as well as the negative consequences of breast movement. Advice is provided on the styles of sports bras (e.g., encapsulated or compression) recommended for the individual, based on their breast size and type of exercise. An overview of how wearing bras with low breast support may negatively impact on performance in sport and exercise is also provided.
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Purpose: To identify the period prevalence of hormonal contraceptive (HC) use and characterise the perceived side effects associated with the menstrual cycle and HC use. Methods: 430 elite female athletes completed a questionnaire to assess; the period prevalence of HC use, the reasons for initiation and discontinuation of HCs and the side effects experienced by HC and non-HC users. Descriptive statistics, between-group comparisons and associations between categorical variables were calculated. Results: 49.5% of athletes were currently using HCs and 69.8% had used HCs at some point. Combined oral contraceptives were most commonly used (68.1%), with 30.0% using progestin-only contraceptives (implant = 13.1%; injection = 3.7%; intrauterine system = 2.8%). Perceived negative side effects were more common with progestin-only HC use (39.1%) compared to combined HC use (17.8%; P = 0.001) and were most prevalent in implant users (53.6%; P = 0.004). HC users reported perceived positive side effects relating to the ability to predict and/or manipulate the timing, frequency and amount of menstrual bleeding. Non-HC users had a menstrual cycle length of 29 ± 5 d and 77.4% reported negative side effects during their menstrual cycle, primarily during days 1-2 of menstruation (81.6%). Conclusions: Approximately half of elite athletes used HCs and progestin-only contraceptive users reported greater incidences of negative side effects, especially with the implant. Due to the high inter-individual variability in reported side effects, athletes and practitioners should maintain an open dialogue to pursue the best interests of the athlete.
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Purpose: Menstruation and menstrual symptoms are commonly-cited barriers to physical activity in women. The delay or avoidance of menstruation through extended oral contraceptive regimens may mitigate these barriers, yet information on menstrual manipulation practices in young physically-active women is sparse. The objective of this study was to investigate prevalence of, and reasons for, menstrual manipulation with oral contraceptives in recreationally- and competitively- active women. Methods: 191 recreationally-active (self-reported moderate-to-vigorous physical activity 150-300 min.week(-1)) women (aged 23±5 years), 160 sub-elite recreationally-active (self-reported moderate-to-vigorous physical activity >300 min.week(-1)) and 108 competitive (state-, national- or international-level) athletes (aged 23±4 years) completed a self-administered questionnaire assessing oral contraceptive regimen habits and reasons for manipulation of menstruation. Results: The majority (74%) of oral contraceptive users reported deliberately manipulating menstruation at least once during the previous year, with 29% reporting manipulating menstruation at least four times. Prevalence of menstrual manipulation (at least once in the previous year) was not different between competitive athletes, sub-elite recreationally-active and recreationally-active women (77% vs. 74% vs. 72%; p>0.05).The most cited reasons for manipulating menstruation were special events or holidays (rated by 75% as important/very important), convenience (54%), and sport competition (54%). Conclusions: Menstrual manipulation through extended oral contraceptive regimens is common practice in recreationally- and competitively-active young women, for a range of reasons relating to convenience that are not limited to physical activity. This strategy may assist in reducing hormone related barriers to exercise participation, thereby positively impacting on participation and performance.