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Physical activity and the menstrual cycle
1
Physical activity and the menstrual cycle: A mixed-methods study of 1
women’s experiences. 2
Petra V. Kolića*, David T. Simsa, Kirsty Hicksb, Laura Thomasc and 3
Christopher I. Morsea 4
aDepartment of Sport and Exercise Sciences, Manchester Metropolitan University, 5
Manchester, United Kingdom (UK); bDepartment of Sport, Exercise & Rehabilitation, 6
Northumbria University, Newcastle, UK; cSchool of Sport and Exercise Sciences, 7
Liverpool John Moores University, Liverpool, UK 8
*Corresponding author. Department of Sport and Exercise Sciences, Manchester 9
Metropolitan University, Oxford Road, Manchester M15 6BH, UK. Email: 10
P.Kolic@mmu.ac.uk. ORCiD ID: https://orcid.org/0000-0003-3402-1857 11
12
This article is presented as the Pre-print green open access. The published article 13
can be found here: Kolić, P.V., Sims, D.T., Hicks, K., Thomas, L. and Morse, 14
C.I., 2021. Physical Activity and the Menstrual Cycle: A Mixed-Methods Study 15
of Women’s Experiences. Women in Sport and Physical Activity Journal, 1(aop), 16
pp.1-12. DOI: https://doi.org/10.1123/wspaj.2020-0050 17
Physical activity and the menstrual cycle
2
Physical activity and the menstrual cycle: A mixed-methods study of 18
women’s experiences. 19
The menstrual cycle is an important biological process in women that is 20
associated with a range of physical symptoms, which can shape how women 21
think, feel, and participate in activities of daily life. This study employed a 22
mixed-methods design to investigate adult women’s physical activity throughout 23
the menstrual cycle. One hundred and twenty-eight participants completed online 24
questionnaires that explored events of the menstrual cycle (e.g., bleeding, pain, 25
fatigue) and physical activity. Semi-structured interviews with 21 questionnaire 26
respondents unpacked individual experiences of physical activity throughout the 27
menstrual cycle. From the questionnaire data, 44 participants were categorised as 28
avoiders and 84 as non-avoiders of physical activity due to menstrual events. 29
Avoiders of physical activity reported longer periods, heavier menstrual flow, 30
higher levels of fatigue and pain compared to non-avoiders. Interviews revealed 31
that avoidance of physical activity ranged from complete avoidance to adaptation 32
(e.g., types of exercise). Reasons for avoidance and adaptation of physical 33
activity included menstrual symptoms, personal thoughts, and concerns about 34
other people’s views of the period. The present study findings emphasise the 35
importance of recognising women’s individual perspectives and established 36
societal norms in addition to physical symptoms in order to better understand and 37
normalise physical activity throughout the menstrual cycle. 38
Keywords: menstruation; period; questionnaire; interview; symptoms; avoidance; 39
self 40
Physical activity and the menstrual cycle
3
Introduction 41
The menstrual cycle is a natural process in women’s reproductive years that represents a 42
highly individual and personal experience (Brantelid et al., 2014). The start of every 43
menstrual cycle is marked by the period, also known as menstruation, which can lead to 44
symptoms, such as bleeding (Santer et al., 2007, 2008), pain (Chen & Hu, 2019), mood 45
changes (Samy et al., 2019), lethargy and fatigue (Bruinvels et al., 2016). The 46
symptoms can extend beyond the period and throughout the entire menstrual cycle and 47
affect how women feel and think about their bodies (Chrisler et al., 2015; Spadaro et al., 48
2018). How women feel, think, and act is framed further by normative expectations, 49
stereotypes, and myths about the menstrual cycle (Kowalski & Chapple, 2000; Marván 50
et al., 2006). A combination of menstrual symptoms, women’s thoughts and feelings, 51
and social norms could contribute to changes in activities of daily life (Brantelid et al., 52
2014; Chen et al., 2016; Houston et al., 2006). 53
The most commonly reported menstrual symptoms represent painful cramps 54
(dysmenorrhea) and tiredness (Schoep et al., 2019), as well as heavy bleeding 55
(Bruinvels et al., 2016). On days of the period, the burden of these symptoms has been 56
shown to prevent women from participating in daily activities (Schoep et al., 2019). For 57
instance, 43% of adolescent women avoided aspects of daily life due to menstrual 58
events (e.g., bleeding and pain) of which 21% missed at least one in 30 school days 59
(Houston et al., 2006). Similarly, 64% of adult women missed an average of 2.6 60
workdays per month due to severe menstrual bleeding and pain (Fourquet et al., 2010). 61
Aside from the severity of menstrual symptoms, women’s behaviour changes could be 62
shaped by upbringing (Marván & Molina-Abolnik, 2012), education (Stubbs, 2008), and 63
media coverage (e.g., advertisements) (Spadaro et al., 2018). Presentations of the period 64
as a matter of secrecy led women to be vigilant, self-conscious, and selective of daily 65
Physical activity and the menstrual cycle
4
activities they undertook and avoided (Johnston-Robledo & Chrisler, 2013). Beyond 66
daily activities, however, limited studies have investigated how women experienced and 67
perceived the menstrual cycle and its impact on sporting performance (Findlay et al., 68
2020; Moreno-Black & Vallianatos, 2005). A study conducted by Moreno-Black and 69
Vallianatos (2005) with first-year students, who had a history of sport participation, 70
found that women associated menstruation with shame and therefore disguised any 71
associated signs (e.g., sanitary product). The participants were concerned and anxious 72
about the visibility of menstruation (e.g., through leakage) and subsequent, negative 73
public attention. Such negative connotations were perpetuated by comments from 74
parents, teammates, and coaches of young women (Moreno-Black & Vallianatos, 2005). 75
Similarly, Findlay et al.’s (2020) study with international rugby players demonstrated 76
that athletes were highly aware and, at times, worried about the impact of their 77
menstrual symptoms on performance. Although severe symptoms, such as 78
dysmenorrhea, limited the participants during strenuous exercise (e.g., high intensity 79
training), the athletes had established coping strategies (e.g., by accepting their 80
menstrual experience or adapting to it), they had sought advice from medical 81
professionals to manage menstrual symptoms, and spoke to trusted others to process 82
their experiences of the menstrual cycle (Findlay et al., 2020). There remains no 83
comparison, however, how physical activity in a non-athlete population might be 84
affected by not only menstrual symptoms, but also women’s individual experiences and 85
social understandings of the menstrual cycle. 86
Identifying that there is no extent data on the menstrual impact of physical 87
activity, broader comparisons could be made with examples from the effect of 88
pregnancy, adult life transitions, and body awareness on physical activity. In physically 89
active women, who adapted routines throughout pregnancy, decisions whether to 90
Physical activity and the menstrual cycle
5
participate in physical activity and, if so, to which extent, depended on the nature and 91
severity of pregnancy-related symptoms (e.g., nausea, fatigue, backache), as well as 92
women’s perceptions of their own pregnancy and social expectations regarding physical 93
activity throughout pregnancy (Cioffi et al., 2010). Women self-managed the type, 94
intensity, and amount of physical activity they undertook, thoroughly evaluating 95
societal expectations, information received from health professionals, and myths that 96
relatives and friends shared with them (Cioffi et al., 2010). Similarly, a survey with 97
14,779 women aged 18–23 years showed that marriage and motherhood, both 98
significant transitions in adult life, put pressure on the time available for physical 99
activity and led to an increase in inactivity (Brown & Trost, 2003). Comparably, body 100
consciousness and the awareness of social norms regarding a desirable body image led 101
women to avoid physical activity (Markland, 2009). The perceived pressure to look a 102
certain way and comparisons to other women in physical activity settings reduced 103
already deflated levels of body satisfaction and affected drop out from physical activity 104
(Pridgeon & Grogan, 2012). This drop out is concerning as it has been shown that 105
physical activity could have a positive effect on dysmenorrhea (Dehnavi et al., 2018) 106
and self-esteem (Zamani Sani et al., 2016). 107
Within the United Kingdom (UK), 15% fewer women than men aged 16-34 108
meet aerobic exercise guidelines and 47% of young adult women undertake no 109
structured exercise compared to 32% of men (NHS Digital, 2017). Barriers to physical 110
activity are multifactorial and the lower level of daily physical activity in women could 111
be attributed to numerous factors. It is however impossible to discount that the 112
menstrual cycle, known to influence other aspects of daily life (e.g., school [Houston et 113
al., 2006], work attendance [Fourquet et al., 2010]), may account in part for lower 114
physical activity in women compared to men. One approach to determining whether 115
Physical activity and the menstrual cycle
6
physical activity is impacted by the menstrual cycle is to combine quantitative and 116
qualitative methodology and facilitate a holistic understanding of the quantifiable (e.g., 117
pain and flow) and the personal (e.g., experiences and perceptions) (Santer et al., 2007; 118
2008). Within the context of limited qualitative studies in athletic populations (Findlay 119
et al., 2020; Moreno-Black & Vallianatos, 2005), there remains no broader analysis of 120
physical activity and the menstrual cycle in the general population. The aim of this 121
study was therefore to, (1) quantify events of the menstrual cycle and self-reported 122
physical activity avoidance in women and (2) understand women’s lived experiences of 123
physical activity throughout the menstrual cycle. The use of mixed methodology was 124
envisaged to aid an in-depth understanding of the multi-facetted factors affecting 125
physical activity throughout the menstrual cycle, which could usefully inform physical 126
activity recommendations and agendas. We hypothesise based on the avoidance of 127
school (Houston et al., 2006), work (Fourquet et al., 2010) and elite athlete training 128
commitments (Findlay et al., 2020), that women in the present study will show 129
avoidance of physical activity as a result of menstrual events. 130
131
Methodology 132
Design 133
The authors utilised a mixed-methods design for the purpose of which they adopted a 134
pragmatic research positioning in line with Morgan (2007). Within this view, emphasis 135
is on (1) drawing on the strengths of quantitative and qualitative methods, (2) following 136
an abductive research process, and (3) acknowledging intersubjectivity. In the present 137
study, quantitative research methods were utilised to quantify the extent to which 138
women experienced menstrual symptoms and participated in physical activity while the 139
Physical activity and the menstrual cycle
7
use of qualitative research methods gave insight into the different ways in which 140
individual experiences of the menstrual cycle affected women’s physical activity. By 141
working back and forth between quantitative and qualitative components of this study, 142
the authors followed an abductive research process in line with Morgan (2007). Finally, 143
equal value was placed on the worldviews of the research team members, who 144
recognised and accepted that their individual interpretations about “one world” might 145
differ (Morgan, 2007). In doing so, the authors sought to aid the development of the 146
research (Sandelowski, 2000) and the comprehensiveness of the study findings 147
(O’Cathain, 2010). 148
A questionnaire was developed to examine the frequency and extent of 149
menstrual events as well as self-reported physical activity throughout the menstrual 150
cycle. Semi-structured interviews explored in-depth women’s individual experiences 151
and meanings of physical activity and the menstrual cycle (Creswell et al., 2010). 152
Figure 1 visualises how the quantitative and qualitative components were prepared, 153
utilised, and integrated. 154
To ensure research quality, the researchers employed traditional and alternative 155
criteria (Bryman et al., 2008) and aligned their thinking with the integrative framework 156
by Tashakkori and Teddlie (2008). For design quality, focus was on the suitability and 157
adequacy of research design and methods, on whether the study components flowed in a 158
sound manner, and whether the strategies for data analysis were appropriate to meet the 159
research aims. To achieve interpretive rigor, it was of importance to engage in critical 160
debate and to seek interpretive agreement in the research team, to ensure distinctiveness 161
of interpretations, and adequate integration of quantitative and qualitative results. 162
Finally, the transferability of quantitative and qualitative results into other contexts and 163
Physical activity and the menstrual cycle
8
participant groups was prioritised over rigid emphasis on generalisability or context-164
dependence of the study results (see discussion). 165
166
Insert figure 1 here. 167
168
Participants 169
Following ethical approval from the Institution Review Board, participant recruitment 170
took place via social media (Twitter and Facebook) and leaflets, which were distributed 171
at fitness centres affiliated to the authors’ universities by the research team. The authors 172
sought to gain a broad understanding of physical activity and the menstrual cycle from 173
women in the generic population, however, equally adopted a purposeful recruitment 174
strategy, as only women of menstruating age were eligible for participation (Collins, 175
2010). This approach proved successful as patterns were later observed in the data 176
gathered from the study participants. The recruitment process led to a sample of 128 177
women of multiple races and ethnicities (27.9 (7.5) years, 1.65 (0.06) m, 63.2 (12.2) Kg, 178
Table 1), who completed the online questionnaire. Through the questionnaire, 82 of 128 179
participants provided consent to be contacted for further research participation and of 180
these, 38 shared their contact information (email address). 181
The 38 questionnaire respondents, who had provided contact details, were then 182
invited to a follow-up interview and 21 women took part in interviews. All of whom 183
completed the online questionnaire first and then participated in an interview. Interview 184
invitations and interviews themselves were led by the principal author, one of the 185
female researchers on the team, to facilitate the establishment of rapport and trust 186
Physical activity and the menstrual cycle
9
(Miller, 2017), which was considered important to intimate discussions about the 187
menstrual cycle (Dempsey et al., 2016). Interviews were conducted at times and 188
locations that were not only convenient, but also facilitated comfort between her and the 189
participants. Everyone, who stepped forward for an interview, was interviewed and as 190
the final interviews were arranged, saturation had been reached and the research team 191
were confident to halt data collection (Beitin, 2012). 192
193
Data collection 194
Questionnaire 195
For the purpose of this research, participants completed a questionnaire about their 196
menstrual cycle duration, menstrual flow, pain or discomfort, and lethargy, combined 197
with questions related to exercise avoidance and self-reported physical activity status. 198
All aspects of the questionnaire were completed online (Jisc, UK). Informed consent 199
was obtained via a compulsory drop down selection at the start of the questionnaire, 200
which was presented following a participant information page. Those who responded to 201
“I do not provide consent for my answers to be used in research” were directed to an 202
exit page of the questionnaire. All questions required a compulsory answer, however 203
two participants selected “not applicable” for their self-reported body mass, which is 204
therefore presented from N = 126. The questionnaire was developed adopting aspects of 205
previous studies that had reported menstrual symptoms, including items from the 206
Menstrual Bleeding Questionnaire (3 items, Matteson et al., 2015), assessment of 207
menstrual pain (1 item, Larroy, 2002), and menstrual flow heaviness (1 item, Fraser et 208
al., 2015). 209
Physical activity and the menstrual cycle
10
210
Participant demographics 211
Participants completed drop-down selections for age (yrs), height and body mass. 212
Options were given for the height in metres and feet and inches, and for body mass in 213
kg and lbs. 214
215
Hormonal contraceptive 216
Participants were given the option of seven choices related to their use of hormonal 217
contraceptive, from “none” to different forms of hormonal contraceptives, such as oral 218
contraceptive pill (including type and exogenous hormone dosage), patch, injection, or 219
intrauterine devices. For the purpose of data analysis, they are classified as: “None” if 220
they use no form of hormonal contraceptive, “Pill” if they use any form of oral 221
contraceptive, and “non-oral contraceptive” if they use any form of indwelling, injected 222
or cutaneous hormonal contraceptive. 223
224
Menstrual events 225
Participants were asked “Over the last three months, roughly how many days on 226
average has your period lasted?”; these data are reported in the present results as “length 227
of period”. In addition, participants completed a calendar style grid for the symptoms 228
experienced throughout the month for: “bleeding”, “spotting”, “discomfort, cramps or 229
pain” and “lethargy and fatigue”. Within the questionnaire, each of these menstrual 230
Physical activity and the menstrual cycle
11
symptoms contained a more detailed description. Participants were instructed to select 231
the days of the month when these symptoms normally occur, with specific reference to 232
the previous month. The frequency of each symptom was summed throughout the 233
month and is presented below as the number of days each symptom occurs during a 234
menstrual cycle (days/MC). Although reliability data is available on retrospective recall 235
for some elements of the menstrual cycle, for instance 80% of women are able to recall 236
their last period date with two days of accuracy (Wegienaka & Baird, 2005) and 237
menstrual cycle length is underestimated by one day compared to using prospective 238
logging (29.4 and 30.9 days, respectively [Small et al., 2007]), the reliability of 239
recalling period length as described above is not presently reported. There is however, 240
“excellent agreement” between daily compared to 1-month recall for menstrual 241
symptoms of bleeding heaviness and pain (Matteson et al., 2015), with the risk of recall 242
bias on these specific elements of the Menstrual Bleeding Questionnaire being 243
described by those authors as “not a problem”. It should also be noted that 52% of our 244
participants self-reported that they tracked their menstrual and pre-menstrual events 245
through an App or diary, and 88% reported that they were somewhat or very confident 246
that they “can accurately recall [their] menstrual cycle dates and pre-menstrual 247
symptoms”. 248
249
Heavy or normal menstrual bleeding 250
Participants were classified as “heavy” menstrual bleeders based on the selection of two 251
or more of the following symptoms, consistent with Fraser et al. (2015): 1) a need for 252
double sanitary products (e.g., tampons and towels) at the same time, 2) a need for 253
frequent changes of sanitary towels or tampons (every two hours or less, or 12 sanitary 254
Physical activity and the menstrual cycle
12
items per day), 3) bleeding through sanitary products onto clothes or bedding, and 4) the 255
presence of large clots within period blood. A final option of “none of the above” was 256
also included. Participants reporting one or none of the above symptoms were classified 257
as “normal” menstrual bleeders (Fraser et al., 2015). These terminologies are consistent 258
with the International Federation of Gynecology and Obstetrics (FIGO) systems for 259
nomenclature of symptoms of normal and abnormal uterine bleeding (Fraser et al., 260
2011). Despite the accepted terminology and classification of heavy menstrual bleeding, 261
there is presently no reliability data available for the classification of “heavy menstrual 262
bleeding” as established by Fraser et al. (2015). Concurrent validity has however been 263
previously reported based on menstrual symptom severity being higher in women who 264
are classified as experiencing heavy compared to normal menstrual bleeding (Matteson 265
et al., 2015), with daily and monthly flow scores showing excellent agreement (ρ = 266
0.82, Matteson et al., 2015). 267
268
Pain 269
Participants were provided with a numerical scale from 0-10 (Larroy, 2002), where 0 270
was labelled “no pain”, 5 was labelled “moderate pain” and 10 was labelled “worst 271
possible pain”. Within the questionnaire, a visual analogue scale was also provided 272
under “more info”. Participants were classified into “mild pain” if pain was between 1 273
and 3, “moderate pain” between 4 and 7 points, and “severe pain” between 8 and 10 274
points (Kural et al., 2015). Due to there being insufficient “avoider” participants (see 275
below) falling within the “no pain” category, the “no-pain” and “mild pain” were 276
compressed into a “no-to-mild pain” category representing all participants reporting 277
pain of ≤3. Analysis of menstrual pain was conducted based on both continuous data 278
Physical activity and the menstrual cycle
13
from the numerical scale (termed pain severity, Table 1), and pain classification. 279
280
Avoidance 281
Participants were asked “In the last 3 months, which, if any, of the following activities 282
have you avoided or postponed due to menstrual events or discomfort?” with the 283
options provided of “social activities”, “work or university”, “playing sport, going to the 284
gym, or other physical activities” and “none”. An open text option of “other” was also 285
provided. Where these included recreational activities such as “swimming”, “walking” 286
or “hiking” they were categorised in the “physical activity” avoidance response if this 287
was not already marked in the affirmative. Due to the focus of the present study, 288
participants were classified as “avoiders” and “non-avoiders” based on whether they 289
had reported to have previously avoided physical activity due to the events of the 290
menstrual cycle. The impact of menstrual symptoms on physical activity avoidance was 291
based on similar single question components of absenteeism from work and school 292
(Fourquet et al., 2010; Houston et al., 2006). 293
294
Physical activity 295
Self-reported physical activity status was assessed based on the following criteria: 296
sedentary (walking less than 20 mins a day); slightly active (walk over 20 mins per 297
day); moderately active (undertake at least 20 mins of moderate physical activity per 298
day); very active (undertake 40 mins of moderate intensity physical activity per day); 299
athlete (high intensity exercise 5+ days a week). For the purpose of subsequent analysis, 300
Physical activity and the menstrual cycle
14
as there were fewer than five participants within the sedentary and athlete categories, 301
the groups were condensed with their closest categories. The physical activity 302
classifications were therefore: sedentary-to-low activity, moderately active, high 303
activity-to-athlete. Despite retrospective recall having known limitations for accurately 304
quantifying daily physical activity (Lee et al., 2011), a single item physical activity 305
question is a valid approach for the purposes of participant classification as adopted in 306
the present study (Milton et al., 2013; Schechtman et al., 1991), with high test-retest 307
reliability (r = 0.82, Milton et al., 2011). 308
309
Interviews 310
Semi-structured interviews were conducted to (1) expand on the data obtained from 311
questionnaires (O’Cathain, 2010), (2) to facilitate the generation of new ideas that might 312
not have emerged from the sole use of quantitative methodology, and (3) to uncover the 313
subtleties underpinning participant perceptions ‘in diverse and enriched ways’ (Smith & 314
Sparkes, 2016, p. 3). They were useful to cover aspects important to the inquiry, while 315
rendering the flexibility to pose impromptu questions that encouraged participants to 316
express thoughts freely (Brinkmann & Kvale, 2018). 317
In this study, 21 interviews were conducted, of which seven took place face-to-318
face and 14 via video call (FaceTime or WhatsApp). Prior to interview participation, the 319
women gave written consent to voluntary interview participation, to audio recording of 320
interviews, to transcription of these audio recordings, and to the use of anonymised, 321
direct quotes in published work (e.g., conference presentations, journal articles). 322
Interviews were informed by an interview guide, which outlined topics of interest and 323
example questions. Following a summary by the principal author of the purpose of 324
Physical activity and the menstrual cycle
15
interviews, conversations then focused on understanding women’s physical activity 325
throughout the menstrual cycle (Warren, 2012). Interview questions explored how the 326
participants felt on days before, during, and after the period, what the participants’ 327
physical activity looked like throughout the menstrual cycle, how participants felt about 328
themselves throughout the menstrual cycle, how menstrual symptoms, self-perceptions, 329
and social situations shaped physical activity on days of the period, and why the 330
participants thought, felt, and acted in certain ways. Participants were prompted to 331
expand on initial thoughts with questions, such as “How did this make you feel?”, 332
“Why do you think this way?” or “Can you give me an example?” Interviews were 333
audio-recorded and transcribed by the principal author for further interpretation 334
(Davidson, 2009). 335
336
Data analysis 337
Questionnaire 338
All quantitative analyses were performed using IBM SPSS Statistics 24 software. 339
Where appropriate (i.e. ratio data), parametric assumptions of normal distribution were 340
confirmed using Shapiro-Wilk’s test (p>0.05) in all dependent variables, except for 341
height in both avoiders and non-avoiders (p<0.05). Group comparisons were made 342
using independent t-tests with equal variance (Levene’s, p>0.05) in all dependent 343
variables, other than pain (days/MC), fatigue (days/MC), and spotting (days/MC) 344
(Levene’s p<0.05). For comparison of group differences in height, the Mann-Whitney U 345
test was performed. All data are presented as mean (SD), with group differences 346
reported as: p, 95% confidence interval (CI) and effect size (d). 347
Physical activity and the menstrual cycle
16
Nominal data was assessed using Chi-square associations for classifications of 348
pain, flow, contraception, and physical activity. Participants were grouped as avoiders 349
or non-avoiders, with subsequent post-hoc analysis performed if the Chi-square reached 350
significance (p<0.05, for pain and flow). As only two classification were made for flow, 351
no post hoc was necessary. Whereas for pain, there were three classifications (no-mild, 352
moderate, and severe), in this instance cell-wise residual analysis was performed 353
(Garcia-Perez & Nunez-Anton, 2003), with the level of significance adjusted for the 354
three sub-classifications. For the nominal variables, a significant outcome of Chi square 355
is described as a significant association rather than a group difference based on previous 356
recommendations (Field, 2013; McHugh, 2013; Scott et al., 2013). 357
358
Interviews 359
Thematic analysis was utilised to identify patterns in the interview data and make sense 360
of their meaning (Braun et al., 2016). The principal author read anonymised interview 361
transcripts recurrently to define codes, which constituted of links between data and 362
ideas, and themes that helped identify commonalities and distinctions (Nowell et al., 363
2017). She recognised this phase as an active process of meaning making and adopted 364
an iterative approach by working “back and forth” between interview data, preliminary 365
themes, and interpretations (Braun et al., 2016). Analytical questions included “What do 366
the participants’ physical activity routines look like?”, “How do menstrual events affect 367
the participants’ physical activity? Why is this so?”, “How do the participants think and 368
feel about factors affecting physical activity? Why do they think and feel in certain 369
ways?” To strengthen the credibility of interpretations, the principal author liaised with 370
members of the research team, who acted as critical friends and discussed 371
Physical activity and the menstrual cycle
17
interpretations, prompted reflection, and explored interpretive avenues (Smith & 372
McGannon, 2018). In the latter stages of analysis and write-up, the dialogues also 373
explored opportunities to integrate the insights gained from questionnaires and 374
interviews to develop rich discussions of physical activity and the menstrual cycle. 375
376
Results 377
Questionnaire results 378
Of the 128 responders, 44 participants (34%) were classified as “avoider” and 84 379
participants (66%) were classified as “non-avoider” based on whether they had avoided 380
playing sport, going to the gym, or other physical activities due to their menstrual 381
events or discomfort. 382
383
Participant demographics 384
There was no significant difference in age, height or body mass between avoiders and 385
non-avoiders (Table 1). 386
387
Menstrual characteristics 388
Compared to non-avoiders, avoiders had periods that lasted 0.65 days longer (t(126) = -389
2.34, p<0.05, CI [0.10, 1.20], d = 0.40, Table 1). In terms of specific menstrual 390
symptoms, compared to non-avoiders over the course of a menstrual cycle, avoiders had 391
0.94 more days of bleeding (t(126) = -2.464, p<0.05, CI [0.18, 1.71], d = 0.46), 0.98 392
Physical activity and the menstrual cycle
18
more days of fatigue (t(126) = -4.769, p<0.01, CI [1.30, 3.61], d = 0.33) and 2.44 more 393
days of pain (t(126) = -4.191, p<0.01, CI [1.28, 3.61], d = 0.84, Table 1). There was no 394
difference in days of spotting between avoiders and non-avoiders (Table 1). 395
Pain severity (numerical scale) was 62% higher in avoiders than non-avoiders 396
(t(126) = -4.116, p<0.01, CI [1.09, 2.96], d = 0.78, Table 1). There was no significant 397
association between contraception use and physical activity avoidance (X2 (2, N =128) 398
= 2.06, p=0.35); with 61% and 57% using no form of hormonal contraceptive, 18.2% 399
and 11.9% using non-oral contraceptive, and 20.5% and 31% using some form of oral 400
contraceptive pill, in avoiders and non-avoiders, respectively. 401
There was no significant association between physical activity classification and 402
avoidance (X2 (2, N = 128) = 2.73, p=0.26), with 20.5% avoiders and 11.9% non-403
avoiders being sedentary or low physical activity, 54.5% avoiders and 51.2% non-404
avoiders being active, and 25% avoiders and 36.9% non-avoiders being very active or 405
athlete. 406
There was a significant association between pain classification and avoidance 407
(X2 (2, N = 128) = 14.5, p<0.01). Post hoc revealed that significantly less avoiders were 408
in the “no-to-mild” pain classification (20.5%) than non-avoiders (52.4%, p<0.01). 409
Similar participant numbers were found for avoiders and non-avoiders in the moderate 410
pain classification (59.1% avoiders, and 41.7% of non-avoiders), and in the severe pain 411
classification (20.5% of avoiders and 6% of non-avoiders, p<0.04, no significant 412
difference at the adjusted α = p<0.017). 413
There was a significant association between menstrual flow and avoidance 414
(X2 (1, N = 128) =22.3, p< 0.01), 63.6% of avoiders were classified as heavy flow, 415
compared to 21.4% of non-avoiders. Similarly, 36.4% of avoiders were classified as 416
normal flow compared to 78.6% of non-avoiders. 417
Physical activity and the menstrual cycle
19
418
Insert table 1 here. 419
420
Interview results 421
Following on from the questions posed throughout the data analysis, the results explore 422
women’s experiences and management of physical activity as well as factors affecting 423
physical activity throughout the menstrual cycle, including menstrual symptoms, 424
personal perspectives, and social expectations. Throughout this section, pseudonyms 425
were used to protect the identity of participants. 426
427
Periods and physical activity: Realities and experiences 428
The women, who took part in interviews, spoke openly about the menstrual cycle and 429
shared personal experiences. Although participants referred to the period as the 430
menstrual cycle phase that had the greatest impact on physical activity, they equally 431
recognised the value of physical activity when coping with menstrual symptoms. It 432
became apparent that their perspectives were informed by an understanding of the 433
effects that physical activity had on physical and mental health. For instance, Val, Lisa, 434
and Elaine explained: 435
I think exercise has been a big help with my mental health. Even going for a walk. 436
I’ll consciously do it because it makes me feel better. I feel lazy and more bloated 437
if I don’t move much. (Val, Non-avoider) 438
Physical activity and the menstrual cycle
20
I think it’s good for your longer term health. I know that people say exercise helps 439
with your periods. (Lisa, Avoider) 440
I think to begin with I was quite emotional because I wasn't active. With being 441
more consistently physically active, my mood swings are not bad at all. (Elaine, 442
Non-avoider) 443
Not only did the participants recognise the benefits of physical activity, but they also 444
sought to undertake it in everyday life. These women reported continuous physical 445
activity throughout the menstrual cycle and, in their recollections, demonstrated an 446
instilled sense of commitment. As an example, Olivia (Non-avoider) described why she 447
pushed herself to exercise: 448
I force myself to do things. I’m very active, so I tend to stay physically active. I 449
thank myself afterwards. It makes things better, especially the cramping and 450
sluggishness. All I want to do is tuck up in a ball on my bed. So forcing myself to 451
go to the gym is worth it because I do feel so much better after. 452
Sharing a perception of the period as something that should not limit activities of 453
everyday life, some of the participants felt as though they had no reason to skip the 454
gym. As a former professional dancer, Ava expected herself to commit to physical 455
activity even on days of the period. Throughout her career as a professional dancer, she 456
had developed a strong sense of commitment to routine training, which she had 457
transferred into her approaches to physical activity (Stephan, 2003). Holding high 458
expectations of herself, Ava (Non-avoider) differentiated the period from health 459
problems or injuries and explained: 460
There’s no injury or pain that’s preventing me from going. I just feel unwell. I’d 461
rather not go when I’m too tired or something is wrong with me. I think, “Okay 462
well at least you went and maybe don’t go another time.” There’s no actual 463
physical reason for me not to go. It’s a subjective feeling. 464
Physical activity and the menstrual cycle
21
Likewise, Nina (Non-avoider) described that she sought continuity in her routines: 465
I usually have a day at the start of my period, when I’m a bit off. If I planned a 466
session, I would do it and leave it behind me. I’m keen to follow my routines 467
because I don’t think that my periods are strong enough. There is no need for me to 468
change things. I’m always challenging my brain whether I need to change 469
something or whether I can try it. 470
It is noteworthy that the above-presented data extracts stem from interviews with 471
women, who described their menstrual symptoms as manageable and therefore did not 472
feel the need to avoid physical activity. Many participants, however, did describe 473
avoidance of behaviours; either of physical activity environments (e.g., the gym) or of 474
exercises (e.g., abdominal work) and types of exercise (e.g., cardiovascular training). 475
The majority of conversations in this context therefore focused on the adaptations made 476
to maintain some level of physical activity. None of the participants scheduled 477
avoidance of physical activity due to menstrual events. Rather, symptoms had to be 478
managed in situ and often left the participants feel unable to follow their “normal” 479
physical activity routines. As an example, Willow (Non-avoider) changed her workouts 480
to avoid the frustration she associated with not being able to perform the way she would 481
on days when she did not have the period. She explained: 482
On my period, I don't feel like my workouts are as productive. I will swap what I 483
do. I tend to focus more on upper body to avoid the annoyance I have if I have a 484
bad session and I’d probably stay away from cardio. 485
For Hannah (Avoider), the first day of the period usually meant avoiding physical 486
activity completely: 487
Sometimes I get home from work on the first day and think, “Forget it, not this 488
week”, and just stay at home. Then on later days, when I do decide to go for a run 489
Physical activity and the menstrual cycle
22
or do exercise, I wouldn’t put as much effort in. I’d choose an easier class rather 490
than a more intense one. 491
For Scarlett and Harper, the discomfort of using sanitary products led them to alter 492
routines: 493
I do a lot of running and I don’t really do that when I’m on my period. The 494
sensation feels weird, so I stick to weight bearing exercises. The feeling’s not there 495
as much when I do that. I don’t wear tampons because I find them uncomfortable, 496
so I wear sanitary towels and I always wonder, “Oh have they moved?” … it’s 497
about where the pad is and it can get sore. It doesn’t stop me but instead of doing 498
half an hour, I might only do ten minutes of cardio. Or I’d sit on a bike instead of 499
running because it’s not moving as much. (Scarlett, Non-avoider) 500
I’d go to the gym, but perhaps not do cardio. Because of my injured knee, I can’t 501
run and sitting on a bike with a pad or tampon is really uncomfortable. That would 502
ruin my gym session. So, sessions don’t last as long. I probably do more upper 503
body than lower body. I don’t think I do abs when I’m on my period. Especially 504
crunches or sit-ups when you’ve got a pad on. It’s not nice at all. (Harper, Avoider) 505
506
Symptoms, self, and social – Factors shaping physical activity 507
Interview participants recalled a variety of factors affecting the ways in which they 508
managed physical activity throughout the menstrual cycle. Their suggestions broadly 509
related to the symptoms associated with the period, to perceptions of self, and to social 510
expectations. 511
The most prominent influence on women’s physical activity routines was the 512
perceived severity of menstrual symptoms. Although the types of symptoms, their 513
duration, and occurrence varied, they commonly included abdominal cramps, headaches 514
Physical activity and the menstrual cycle
23
and backaches, leg pains, lethargy and fatigue. The following data extracts are examples 515
of the symptoms described by interview participants: 516
I suffer most with sciatica-type leg pain. I’m extremely lethargic to the point where 517
it's almost debilitating. Migraines as well, feeling dizzy and muggy. (Piper, 518
Avoider) 519
Normally I’m an energetic person, but when it’s that time I’m tired. I can be 520
moody, but it’s mainly tiredness. I don’t feel I have my normal amount of energy. 521
(Hannah, Avoider) 522
My body changes completely. When I put on a pair of trousers that are normally 523
loose, they’re tighter. My stomach feels heavy. And the fatigue! (Mary, Avoider) 524
There were a couple of times, where I woke up in the morning and planned to go 525
for a run, but then the cramps were so bad that I couldn’t get out of bed. (Olivia, 526
Non-avoider) 527
In addition to feeling physically unwell, many participants also spoke of a heightened 528
sense of self-consciousness. The period affected how women thought about themselves 529
and how they felt in their own skin. Interestingly, these perceptions were not only 530
limited to those who avoided (certain aspects of) physical activity, but were also shared 531
by those who made efforts to maintain activity levels throughout the menstrual cycle. 532
As an example, Harper (Avoider), described: 533
You’re not your usual self. You just feel you’re on the period. For me it’s at the 534
start, but at that point, it’s always there that thought. Just like hyper aware of it. 535
For Val and Caroline, feelings of consciousness led them to carefully select clothes 536
worn in physical activity environments. The participants recalled, respectively: 537
Physical activity and the menstrual cycle
24
I’m really conscious if I wear shorts or if my leggings are see through or thinking 538
whether I’ve leaked. I’m more aware of what I do and how that might look. (Val, 539
Non-avoider) 540
I suppose with netball, I am conscious of what to wear because of the small shorts 541
and dresses that we have to wear. I always wear a tampon over a towel and 542
underwear that keeps everything in check. I actually saw a girl at netball a couple 543
of years ago. You could see her pad through the shorts and I felt bad for her but 544
nobody said anything. (Caroline, Non-avoider) 545
Beyond the sense of self-awareness, the perceived expectations others might have about 546
menstrual events, shaped women’s physical activity routines. Interview participants 547
commonly referred to worries of being “found out” by others, recalled an awkwardness 548
surrounding periods, and described subsequent discomfort in certain physical activity 549
environments. For example, Lisa and Scarlett preferred to avoid the gym on days of 550
heavier flow due to concerns over how others might react if they discovered the reasons 551
for which they did not adhere to usual routines: 552
The gym is a social place for me. I know a lot of people. They would know I 553
wasn’t on top form. My PT would say, “Why are you lifting this today?” I 554
wouldn’t wanna turn around, “I feel shit because of my period.” I don’t know how 555
he would handle that, what his feelings would be. That’s where I suppose that 556
taboo comes in because I wouldn’t go, “I’m taking it easy today because I’m on 557
my period.” Even though I say I talk about periods, I guess I don’t because I’d 558
rather avoid telling them that I was going easy because of my period. (Lisa, 559
Avoider) 560
In the first days when I’m heaviest, I feel embarrassed. I don’t want other people to 561
know. I’m scared that if I get out of the pool, blood is gonna run down my leg. I’m 562
worried what other people would say. Especially with men in the gym. Someone 563
might put me down and I wouldn’t wanna go to the gym anymore. (Scarlett, Non-564
avoider) 565
Other participants perceived pressure to maintain their attendance at training sessions 566
Physical activity and the menstrual cycle
25
and believed there were expectations for women to carry on “as normal” regardless of 567
discomfort due to menstrual events. For Hannah and Harper, playing netball was not 568
only important at a personal level, but also in a social context (Weiss, 2015). It was 569
therefore to be continued throughout the menstrual cycle. The participants’ perceptions 570
of expectations and understandings that teammates and coaches might hold shaped their 571
dedication to the sport (Weiss et al., 2010). They explained: 572
With netball, you’ve got to go. There’s no choice. In my netball team, if you don’t 573
train, you don’t get played at the match. You’ve got that pressure. Also we pay for 574
training and matches, so you don’t want to waste money by not going. (Hannah, 575
Avoider) 576
When I played netball, I couldn’t turn around to the team and say, “I can’t play. 577
I’m on my period.” Someone might say, “I’m on my period too and I’m playing.” 578
Especially in a team of girls. You can’t let them down when they all know how it 579
feels. (Harper, Avoider) 580
Similarly, Mila and Nina believed that it was expected of women to disguise any signs 581
of menstrual events. In Mila’s (Non-avoider) words: 582
When I’m on the period I don’t want anyone to find out I’m not feeling hundred 583
percent. Maybe I complain to a female co-worker or friend but I would never, 584
even, if I called in sick, I wouldn’t admit it’s period-related. I would say I am not 585
well. I think the expectation to carry on as usual is always there. 586
Nina (Non-avoider) explained: 587
Nobody ever told me that I need to hide my tampon when I go to the loo at the 588
gym, but I do it. Because I think, other people aren’t as relaxed as me about 589
periods. We don’t talk about them. If we do, it’s awkward. 590
591
Physical activity and the menstrual cycle
26
Discussion 592
This mixed-methods study utilised an online questionnaire to quantify events relating to 593
the menstrual cycle and physical activity as well as semi-structured interviews to 594
explore women’s lived experiences of physical activity throughout the menstrual cycle. 595
The discussion draws together quantitative and qualitative results to provide rich 596
interpretations of the questionnaire and interview data (O’Cathain, 2010). 597
In the present study, the majority of women who completed the questionnaire 598
(84 of 128 women – Table 1) were categorised as non-avoiders of physical activity due 599
to events of the menstrual cycle. Interview data revealed that the participants recognised 600
the importance of physical activity and the benefits it brought to their lives. Through 601
experiences in their upbringing, education, and employment, they had learned about the 602
advantages of physical activity, which in turn affected their experiences of and 603
commitment to physical activity throughout the menstrual cycle. Consistent with the 604
knowledge that the present participants possessed, previous research has shown that 605
connections existed between people’s awareness of physical activity recommendations 606
and their actual levels of physical activity (Plotnikoff et al., 2011). Those who knew 607
about health recommendations tended to be more physically active in everyday life 608
compared to those, who did not possess this level of understanding (Fredriksson et al., 609
2018). This was so especially when individuals knew not only about guidelines, but also 610
about the health benefits associated with moderate physical activity (Heinrich et al., 611
2011). Interview data in the present study revealed that the participants had actually 612
experienced positive post-workout effects on days of the period, for instance, uplifted 613
emotional state, reduced pain, and increased feelings of accomplishment. This finding is 614
in line with studies illustrating that exercise could alleviate menstrual symptoms (e.g., 615
backaches – Chen & Hu, 2019) and enhance mental wellbeing throughout the menstrual 616
Physical activity and the menstrual cycle
27
cycle (Kanojia et al., 2013). Physical activity has also been considered as a 617
complementary treatment for dysmenorrhea (Samy et al., 2019) as it reduced the 618
duration and severity of menstrual cramps (Dehnavi et al., 2018; Kannan et al., 2015). 619
In partial agreement with our hypothesis, one third of questionnaire respondents 620
(44 of 128 participants) were categorised as avoiders of physical activity due to 621
menstrual events (Table 1). This could be attributed to these avoiders having more 622
severe menstrual symptoms, including longer periods, higher levels of pain and fatigue, 623
and heavier flow as reflected in the questionnaire data. Despite the potential bias of 624
menstrual recall (as discussed in detail in the methods) the qualitative data confirmed 625
that women could not overlook menstrual events (e.g., bleeding and pain) and when 626
considering whether to avoid physical activity, interviews revealed that the participants 627
evaluated the severity of menstrual symptoms. For instance, symptoms that the women 628
perceived as severe (e.g., migraines and abdominal pain) led the participants to avoid 629
physical activity completely. This complete avoidance is comparable to recurrent school 630
absence in adolescent women who suffered from dysmenorrhea (Houston et al., 2006). 631
In adult women, missing university or workdays represented a common self-632
management strategy for painful periods (Chen et al., 2016). The present study 633
participants confirmed that the period had to be managed (e.g., sanitary products) and 634
taken into account in physical activity routines (e.g., types of exercises). The women in 635
this research described the days of the period as limiting their ability to function as what 636
they perceived “normal” for themselves. In particular, a combination of physical 637
symptoms, lacking “energy” and motivation made it more challenging for the 638
participants to perform physical activity as normal. These findings resonate with studies 639
on the impact of the menstrual cycle on physical performance, such as through anaemia 640
from heavy menstrual bleeding (Bruinvels et al., 2016), higher body temperature during 641
Physical activity and the menstrual cycle
28
exercise in the luteal phase (De Jonge & Janse, 2003), and lower fatigue resistance in 642
the pre-menstrual phase (Ansdell et al., 2019). 643
The present study participants, however, did not necessarily avoid all forms of 644
physical activity on days of the period (a nuance not captured within the questionnaire). 645
Although the questionnaire data showed no significant relationship between physical 646
activity classification and avoidance, interviews were particularly useful to make sense 647
of this observation and to unpack the subtleties underpinning women’s reports of 648
physical activity avoidance due to menstrual events without necessarily being less 649
physically active overall. Indeed, interviews uncovered aspects of physical activity 650
adaptation that have been previously unreported. Some of the participants, who reported 651
to avoid physical activity, did not avoid all forms of activity and instead, changed 652
exercise routines, used alternative physical activity or made up for missed physical 653
activity on days when they felt less affected by menstrual symptoms. Often, it was 654
about adapting routines depending on the perceived severity of menstrual symptoms and 655
levels of discomfort, consistent with previous work showing adaptations to activities of 656
daily life due to menstrual symptoms (Kennett et al., 2016). The selective avoidance 657
and modification of physical activity was routine to some participants and could reflect 658
women’s knowledge about the benefits of physical activity to their health, physical 659
wellbeing, and mood (Fredriksson et al., 2018). Similar to women who selectively 660
avoided tasks in the workplace (e.g., meetings) due to reduced concentration, patience, 661
and efficiency (Brantelid et al., 2014), some of the present interview participants only 662
avoided physical activity that caused discomfort (e.g., lower body workouts), while 663
continuing more manageable activities (e.g., walking and upper body workouts), when 664
they believed that they could maintain some level of activity. This selective avoidance 665
of physical activity is comparable to reports of adaptation as a way to maintain physical 666
Physical activity and the menstrual cycle
29
activity levels in other populations, such as pregnant women suffering from backaches 667
(Cioffi et al., 2010) as well as individuals suffering from chronic fatigue syndrome 668
(Larun & Malterud, 2011) and migraines (Buse et al., 2012). 669
Aside from the menstrual symptoms, our qualitative findings demonstrated how 670
self-perceptions and perceptions of social expectations influenced physical activity. 671
Interviews revealed that the participants had concerns about leakage of blood, product 672
use, and pain management in the presence of other people in physical activity 673
environments. Similar to women, whose commitment to exercise suffered from 674
heightened body consciousness in physical activity environments (Pridgeon & Grogan, 675
2012), several women in the present study described a heightened sense of self-676
awareness on days of the period that led to careful selection of clothes and exercises. 677
Comparably, heightened consciousness in public spaces was previously described in 678
women, who felt their bodies did not conform to predefined norms of femininity, such 679
as female bodybuilders in the presence of casual gym visitors, in public (Shilling & 680
Bunsell, 2009), and when sharing photos of their physique on social media (Marshall et 681
al., 2019). In the present study, the perceptions of self in physical activity environments 682
were closely connected to concerns over what others might say if they found out about 683
women’s menstrual events. Sensations, such as bleeding, pain, and fatigue, associated 684
with the period in particular, were to be “dealt with” in private. This persisted even 685
though the interview participants had reframed their own views of menstrual events and 686
felt comfortable to talk about them (Lee, 2002). The participants believed, however, that 687
upbringing and societal norms of the period in particular as something shameful and 688
embarrassing led women to silence and conceal (signs of) the period (e.g., blood and 689
sanitary product) (Chrisler et al., 2015; Spadaro et al., 2018). The concerns of women in 690
the present study about how others might react to signs of the period point towards 691
Physical activity and the menstrual cycle
30
social stigma surrounding menstrual events that led women to avoid and adapt physical 692
activity (Johnston-Robledo & Chrisler, 2013; Kowalski & Chapple, 2000). Such stigma 693
surrounding exercise during the period has been similarly reported in overweight 694
individuals (Vartanian & Novak, 2011), people with mobility impairments (Mulligan et 695
al., 2017), and the LGBTQ+ community (Herrick & Duncan, 2018) undertaking 696
physical activity. 697
Due to the paucity of data on the impact of the menstrual cycle on physical 698
activity, in order to test our proposed hypothesis, it was necessary to construct the 699
components of the questionnaire from a number of different sources. These sources 700
have been acknowledged throughout the methods section including recall of menstrual 701
symptoms (Matteson et al., 2015), menstrual pain (Larroy, 2002), menstrual flow 702
heaviness (Fraser et al., 2015), avoidance (Fourquet et al., 2010), and physical activity 703
(Milton et al., 2011). Through adopting these previously validated components of the 704
questionnaire, we can state our main finding that physical activity avoiders have 705
heavier, longer, and more painful periods, despite the limitation that no assessment of 706
reliability or validity has been performed on the entirety of the questionnaire. It is 707
important to note however, that based on the nuanced responses from the interviews, 708
emphasising adaptation, over avoidance, future questionnaires on physical activity 709
within the menstrual cycle should be validated for both avoidance and adaptation. 710
In developing our questionnaire, our aim was to identify whether physical 711
activity avoidance could be attributed to menstrual symptoms. There are a wide range of 712
demographic co-variables that are unreported in the present study including education, 713
employment status, religious background, socio-economic level and ethnicity (e.g., 714
Mondragon & Txertudi, 2019). As the area of physical activity avoidance due to 715
menstrual symptoms is underreported in general, our aim was to provide the first 716
Physical activity and the menstrual cycle
31
overview of the impact of the menstrual cycle on physical activity. In future studies, the 717
prevalence of physical activity avoidance may therefore be different to the present 718
study, if presented based on some of these demographic groupings. 719
Our study demonstrated that binary measures of physical activity, such as those 720
utilised in the present questionnaire, miss the nuances that underpin avoidance 721
behaviours. The use of quantitative and qualitative methodology was therefore 722
particularly useful to developing nuanced views of factors affecting physical activity, 723
which included, but were not exclusive to, menstrual symptoms. Other important 724
considerations that shaped women’s physical activity related to perceptions of “self” 725
and social expectations about menstrual events; two areas that need to be confronted in 726
greater depth. Future research might therefore seek to employ qualitative methodology 727
to understand women’s self-presentations (e.g., Goffman, 1956) and the role of social 728
stigma (e.g., Goffman, 1963) in physical activity environments. The participants in the 729
present study understood the importance of physical activity to maintain a healthy 730
lifestyle and they enjoyed being physically active. We acknowledge, however, that the 731
limited sample size and volunteer nature of interview participation could be considered 732
limitations of this study. Although comparable sample sizes were suggested in 733
methodological texts (Onwuegbuzie & Collins, 2007) and mixed-methods research 734
investigating the menstrual cycle (Moreno-Black & Vallianatos, 2005) and voluntary 735
interviews were conducted to ensure ethical research practice (e.g., Hammersley & 736
Traianou, 2012), we recognise that our decisions might have resulted in unreported 737
differences between the present participants and those, who did not volunteer for 738
interview participation. As with the limitations of the questionnaire outlined above, a 739
worthwhile line of inquiry would therefore be to investigate how other demographic 740
groups approach physical activity throughout the menstrual cycle. In particular, the 741
Physical activity and the menstrual cycle
32
impact that the combination of menstrual symptoms, self-perceptions, and social norms 742
might have on physical activity warrants further research attention. In this context, it 743
would be of interest to explore women’s familiarity with their own menstrual cycle and 744
to unpack their typical involvement in physical activity in order to understand how 745
differences among women in these areas might affect their management of physical 746
activity throughout the menstrual cycle. 747
In conclusion, the present study suggests that menstrual events are complex, 748
individual, and personal to the women experiencing them (e.g., Brantelid et al., 2014). 749
The results demonstrated that women did not simply avoid all physical activity. Rather, 750
they adapted physical activity depending on their distinct experiences of the menstrual 751
cycle. This insight into the multi-facetted effects that the menstrual cycle could have on 752
women’s physical activity is pertinent to practitioners in the field. Creating safe spaces 753
for women who wish to speak about how their physical comfort, personal thoughts, and 754
perceptions of social norms might affect physical activity is important. Efforts in 755
academic and practitioner fields could contribute to normalising conversations about the 756
menstrual cycle (Johnston-Robledo & Chrisler, 2013; Kowalski & Chapple, 2000) and 757
support physical activity throughout the menstrual cycle in women of all ages and 758
abilities. 759
760
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1049
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42
Tables 1050
Table 1. Mean (SD) participant characteristics and menstrual cycle symptoms taken 1051
from the questionnaire. 1052
All
Avoider
Non-avoider
N
128
44
84
Age (yrs)
27.9 (7.5)
28.2 (8.0)
27.2 (7.3)
Height (m)
1.65 (0.06)
1.65 (0.06)
1.65 (0.06)
Body mass (kg)
63.2 (12.2)
61.9 (12.8)
63.8 (11.8)
Length of period
(days)
4.64 (1.80)
5.07 (1.11)*
4.42 (2.04)
Bleeding
(days/MC)
3.81 (2.10)
4.43 (2.07)*
3.49 (2.05)
Spotting (days/MC)
1.51 (1.80)
2.02 (2.37)
1.24 (1.35)
Fatigue (days/MC)
2.82 (2.99)
4.43 (3.45)†
3.45 (2.34)
Pain (days/MC)
2.60 (2.87)
4.20 (3.60)†
1.76 (1.95)
Pain severity
(numerical scale)
3.95 (2.80)
5.27 (2.41)†
3.25 (2.75)
MC, menstrual cycle. *denotes significant difference from non-avoider (p<0.05), 1053
†denotes significant difference from non-avoider (p<0.01). 1054
1055
Physical activity and the menstrual cycle
43
Figures 1056
Figure 1. Overview of study design (adapted from Ivankova, 2014) 1057
1058
