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UK Coaching Team
Females Safety and Welfare

Menstrual Health: Understanding Menstrual Dysfunctions

In the fourth resource in a series, the Welsh Institute of Performance Science’s Natalie Brown explains how hormones in the menstrual cycle act like a relay race: if one hormone doesn’t pass the ‘baton,’ things can slow down or stop altogether, and when a female participant should seek advice from a GP

The menstrual cycle is an vital signal for female participants, as a regular cycle can help identify when a female is in a usual rhythm, when something is a bit off or even if there is an underlying medical condition that requires treatment. 

Reproductive hormones associated with the menstrual cycle play a role beyond reproduction and can affect sleep, mental health, weight, bone density and heart health. If cycles consistently fall outside of ‘normal’ ranges, it can have short- and long-term health impacts, as well as affecting current performance. For more on this, read our guide, Understanding the Menstrual Cycle and The Biology of the Menstrual Cycle (coming soon).

Menstrual cycle symptoms are described as regular and irregular, referring to cycle length and how much this varies cycle-to-cycle. There are regular and irregular ranges for menstrual bleeding and pain/menstrual cramps. The heaviness and length of a period can vary due to hormone levels and temporary changes caused by external factors such as stress.

It is important to note that in the first 2-3yrs after a female starts her period, cycle lengths may vary, bleeding heaviness can change, and they can experience some heavy bleeds. In addition, other symptoms may change and differ between cycles until a regular pattern is established. 

My periods were definitely worse when I was a teenager."

Menstrual dysfunctions

There are several different menstrual dysfunctions to be aware of, including:

  • Amenorrhea: absent periods.
  • Oligomenorrhea: cycles last longer than 38-45 days (range dependent on age, when first starting a period 40-day cycles are not irregular, 21-35 days in the average regular range).
  • Polymenorrhagia: a cycle that lasts less than 21 days.
  • Menorrhagia: heavy menstrual bleeding, common in adolescent girls and women approaching menopause.
  • Dysmenorrhea: excessive pain/cramps (interfering with daily activities).
  • Premenstrual syndrome or premenstrual dysphoric disorder: severe emotional and physical symptoms caused by hormonal changes.
  • Anovulatory cycle: ovulation does not occur.
  • Polycystic ovary syndrome (PCOS): a group of symptoms related to anovulation and a high level of androgens.
  • Ovarian cysts: fluid-filled sacs that develop on the outside of the ovary.
  • Fibroids: non-cancerous benign growth of the uterine muscle/wall.
  • Endometriosis: a common condition that affects at least 1/10 women in which bits of tissue similar to the uterine lining grow in places other than inside the uterus. Its main symptom is pain which can occur in the uterus during a period or in other places such as rectum, bladder, legs or throughout the pelvis. It can also cause other symptoms such as bowel problems, fatigue, headaches, nausea and bloating.

Relative Energy Deficiency in Sport

A delay in starting the menstrual cycle (referred to as menarche) or periods becoming irregular/absent can be caused by energy deficiency specifically termed relative energy deficiency in sport (RED-S). This occurs when there is low energy availability, and the intake is not sufficient to cover the energy demands of exercise training and bodily processes. It can affect male and female athletes of all levels and ages.

A balance of dietary energy intake and energy expenditure is required for health and activities of daily living, growth and supporting activities. RED-S can affect menstrual function, metabolic rate, bone health, immunity, and cardiovascular health, among other things. It can also impact performance with female participants experiencing a decreased response to training, impaired coordination, and increased risk of injury. 

Even when body weight is steady, low energy availability may be present due to high/increased training loads and endocrine or metabolic adaptations occurring to prevent weight loss. Initially performance (results) can appear to improve in the early stages, but this is a poor indicator of health, well-being and longer-term benefits. In females, a loss of or irregular periods are a sign of RED-S.

It is important to have an awareness of the negative impact of RED-S on health and performance. Factors such as specific body types (aesthetic) or weight-making sports can increase the risk and influencing factors. Sports with a focus on leanness (e.g., gymnastics, endurance and weight categories) can be a higher risk. 

Always carefully consider recommendations in changes to weight and discuss these with a registered dietician/nutritionist before speaking to a participant.

RED-S can:

  • cause impaired growth and development (not just young in participants: development of physiology such as muscle strength and endurance from training affected as well)
  • have an impact on health and well-being
  • have an adverse effect on performance.

As such, the regular menstrual cycle is a ‘barometer’ for hormone health.

Amenorrhea can cause:

  • loss of period
  • infertility
  • mental fatigue
  • time lost training
  • urinary incontinence (caused by oestrogen deficiency) 
  • decreased performance
  • longer post training/race recovery
  • decreased bone health, increasing risk of bone injuries (fractures).

Discover more about the impact of RED-S on athletes in the UK Climbing article, Relative Energy Deficiency in Sport – A Cautionary Tale.

Could you use Mina's story to create opportunities to discuss RED-S with the people you coach?

For management of RED-S/amenorrhea, it is advised to seek medical advice and restore the optimal balance between training, nutrition, and recovery. This needs an integrated support network with medical guidance. Don’t avoid conversations or ignore menstrual dysfunctions.

What could you change to improve awareness of the importance of regular periods and support the female participants that you coach? What could you do to implement self-monitoring for cycle length and symptoms with your participants?

More from Natalie Brown

This is the fourth resource in a series on menstrual health developed with Natalie Brown


Related Resources

  • Coaching Female Participants

  • Menstrual Cycles and Participation

  • The Menstrual Cycle: Female Athletes' Experiences and Perceptions


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