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Vicious Cycle - how coaches can help when menstruation affects women’s athletic performance

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Article from Coaching Edge Summer 2015: Outnumbered but Undaunted

When Heather Watson blamed a poor straight-sets defeat on period problems, she unwittingly lifted a veil of silence from what’s long been a taboo subject. Mike Dale asks how coaches can help when menstruation affects women’s athletic performance

It all started with just two timidly spoken words. ‘Girl things’ was how Britain’s No.1 female tennis player rather bashfully explained her lacklustre first round defeat at the Australian Open in January.

It’s unlikely she intended to break one of sport’s few remaining taboos, but that was certainly the effect her meek, euphemistic phrase had. Within hours fellow athletes, coaches and commentators were all asking, ‘Why has no-one spoken publicly about this before?’

The effects of menstruation on athletic performance are highly subjective and underresearched. Titles have been won and personal bests achieved at every stage of the menstrual cycle (Paula Radcliffe, for example, broke the world marathon record while on her period), yet for some athletes, menstrual problems inflict physical and psychological damage.

To further complicate matters, there are no ‘one size fits all’ solutions. Even if two women’s symptoms are identical, the same treatment may not work for both.

Pain, bloating, fatigue, loss of coordination, lack of strength, cravings and mood swings are all common periodrelated symptoms that clearly have a potential knock-on effect on a woman’s athletic performance.

Whilst a coach should foster open communication with their female athletes so they’re aware of these things and can combat them together, more important is being alert to the long-term dangers to which women in aerobic and endurance sports are particularly vulnerable.

The combination of low body fat due to intense training, plus dieting and stress can mess with the menstrual cycle, or even stop periods altogether (known as amenorrhoea). Production of the hormones oestrogen and progesterone stops. The consequences can be severe.

The condition, known as RED-S (Relative Energy Deficiency – Sport, formerly known as the female athlete triad) makes athletes susceptible to stress fractures, joint injuries and osteoporosis. It can also cause infertility.

Eminent sports gynaecologist Dr Michael Dooley, who has worked with many elite sportswomen, explains: ‘It has the potential to decrease performance, affect your immune system and decrease your professional life expectancy. It’s an extremely important thing to be aware of for athletes and their trainers.

‘Trainers should ask athletes about their menstruation. If they start missing their period, you should begin to ask why. Be wary if they say, “I’ve only missed a few. It’s not a problem,” because gradually they progress to having no oestrogen or progesterone, incur a stress fracture and then it’s too late.’

Gymnastics is a hotbed for these problems. A young gymnast’s regime of intense exercise, low body fat and dieting can delay their menarche (first period), resulting in RED-S. If their period hasn’t started by 16, it may be time to consult a GP.

Many competing athletes are given the contraceptive pill to manage period ‘timing’, but with RED-S syndrome this may not be an appropriate treatment.

More common but nevertheless distressing for sportswomen are menstrual complaints which regularly hamper their performance, such as cramping, bloating, fatigue, heavy bleeding and hormonal imbalances.

When Jessica Judd was administered norethisterone to delay her period at the 2013 World Athletics Championships, she blamed its effects when she bombed out of the 800m heats. It’s since been recognised that athletes and support staff must identify and tackle problems early, rather than resort to last-minute ‘firefighting’ just days before a competition.

Warning Signs


  • Amenorrhea (periods stopping altogether)
  • Stress fractures (and overuse injuries)
  • Dehydration
  • Gastrointestinal problems
  • Hypothermia (cold intolerance)
  • Cardiac abnormalities
  • Significant weight loss
  • Muscle cramps, weakness, or fatigue
  • Dental and gum problems
  • Anxiety or depression
  • Over-exercising
  • Excessive toilet use
  • Difficulty concentrating
  • Preoccupation with weight and eating


Kay Brennan, a specialist sports doctor who has worked with Great Britain Olympic divers, swimmers and gymnasts, recommends keeping a symptom and performance diary to help identify the specific problem in advance.

She says: ‘If you can demonstrate that your performance is dropping at a certain point in the cycle, due to pain caused by ovulation or PMS (premenstrual syndrome) for example, it can really help the doctor decide on the next step. Whether that be starting specific treatment or arranging some investigations.

‘If the coach and the athlete together make themselves aware there is a problem every month then they can tackle it way in advance of any major competition, rather than a few weeks before. As a doctor, I have limited “last-minute” tools to offer an athlete heading into competition.’

Incidentally, a coach who does identify a ‘trouble spot’ in their athlete’s menstrual cycle might want to take note of the ‘nocebo effect’. If an athlete becomes all too aware of her dip in performance at that particular time of the month, it can fuel anxiety, which in turn damages her performance even more. Research on this is scarce, but it’s potentially a vicious cycle which a coach mustn’t allow to develop.

Overall, though, the message is a positive one. As Dr Dooley states: ‘Every coach needs to be encouraged that there is no reason why this should upset their athlete’s performance. You need education and understanding, sympathy and empathy, but most of all the message is that the vast majority of cases can be helped.’

Dr Brennan adds: ‘The major thing for a coach is to show an interest. You don’t have to be an expert, it’s just about signposting to someone locally with gynaecological expertise so they’re properly supported and not palmed off.’

There’s a growing sense of governing bodies of sport embracing the issue too. Great Britain’s hockey team, for example, has had individual training regimes based around each player’s menstrual cycles since 2011.

Two words from Heather Watson opened the topic up for discussion. Hopefully they’ll also lead to better help and understanding in the future.

The Coach’s Edge

  • Look out for athletes missing periods for over three consecutive months, which is an early danger sign of RED-S.
  • An honest and trusting relationship between coach and athlete will encourage open discussion of menstrual problems, which might otherwise be ‘hushed up’.
  • Show an interest, arm yourself with some basic knowledge and find a local source of specialist gynaecological help.
  • Properly investigate any problem well in advance of any major competition. ‘Quick-fix’ solutions are rarely effective.

Visit the sports coach UK website for more information on how you can receive Coaching Edge.

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Comments (1)

I wished this information was out when I was a competing athlete, I hardly had a menstrual cycle due to the heavy training, didn't start my period until I was nearly 17 had no bust, weight 6 stone probably less. In this day and age coaches shouldn't be afraid of asking athletes about there monthly cycle this should be incorporated into the training programs. This should help coaches to see how athletes perform better and not so good.

I have seen young athletes compete whilst on there period and win competition then iv also seen the opposite effect.
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