• Micaela Zettel, PT, MScPT, BScHK(hons), CMAG

Track It, Train Smarter: Optimize training, recovery and injury rehab for the female athlete

Tracking your menstrual cycle has become increasingly popular for fertility and health reasons and is now gaining some traction as a priority for female athletes and athletic performance. The knowledge gained from cycle tracking can be used to adjust training, fuelling and even treatment of sport related injuries. Depending on the phase of the cycle an athlete is in, different symptoms may be present and different recommendations can be made for training and rehab.


This information is starting to transform the way we train, assess and rehabilitate female athletes.

In this article I outline the physiological phases of your menstrual cycle with important considerations for the female athlete. I also review a different way to break the menstrual cycle into four phases that can help adapt an athlete’s training and recovery based on which phase they are in.



In healthy females, the overall cycle ranges from 21-35 days with an average of 28 days (Briden, 2018). The information here will be presented based on the average 28 day cycle. It is important for anyone reading this to understand that every athlete is different and they will each have their own unique presentation and cycle range.


There are phases of fertility/menstruation that are broken down based on hormone changes. These phases are also named to label the physiological processes occurring with these changing hormones.


When referring to the cycle for menstrual health and fertility, we typically hear about these four phases and they are: menstruation, follicular phase, ovulation and the luteal phase.


Let’s take a closer look at the phases of the menstrual cycle and some implications that are important for the female athlete. These phases are based on the physiology of the menstrual cycle for fertility and health.


Menstruation:

  • When you bleed, lasts 2-7 days typically

  • Should be relatively pain free

  • If the athlete experiences severe PMS symptoms or abnormal bleeding, either very heavy or really light, these could indicate a deeper dysfunction and the athlete should likely seek medical advice from a trained professional

Follicular Phase:

  • Can last 7-21 days

  • Estrogen is on the rise

  • When follicles are growing - stimulated by FSH (follicle stimulating hormone released from your pituitary gland located at the base of your brain)

  • These follicles then produce estradiol - one of 3 forms of estrogen in the female body

  • Estradiol boosts serotonin and dopamine → both serotonin and dopamine are important for mood and brain health

  • Estradiol enhances insulin sensitivity (Mauvais-Jarvis, 2013). This information can be crucial for the athlete. Insulin sensitivity is an early indicator of inflammation and metabolic dysfunction. When insulin sensitivity is present, it affects the function of the nervous and muscular system and its ability to produce energy within the cells themselves. This is not a good situation for an athlete who is requiring increased energy expenditure for their sport, for training and recovery from training.

  • Estradiol is necessary for bone, muscle, skin, heart, sleep, metabolism (Briden, 2018). Definitely important for an athlete.

If an athlete is having hormonal dysfunction it can impact their energy production. Another factor stressing the importance of a healthy menstrual cycle for a female athlete.


Ovulation:

  • 1 day, happens around day 14 of your cycle on average

  • Release of an egg from a follicle, stimulated by luteinizing hormone (LH)

  • Either you ovulate or you don’t

If an athlete is on hormonal contraceptives, they DO NOT ovulate (Briden, 2018).

This means the athlete misses out on the benefits of progesterone, read on to learn more.


Luteal Phase:

  • 10- 16 days

  • The ruptured follicle that releases the egg for ovulation now becomes something called the corpus luteum, which produces progesterone.

  • This is the ONLY way females produce progesterone. In hormonal contraceptives (HC) it is a synthetic version and does not have the same effects on the body.

  • If you have inflammation, thyroid disease, insulin issues, and nutrient deficiencies such as a deficiency in magnesium, vitamin D, B vitamins, zinc, iodine, and selenium (Briden, 2018), this can affect your ability to produce progesterone. Many athletes can have deficiencies with these due to the load and inflammation produced with training.

  • If an athlete isn’t producing progesterone they are missing out on all the health and training benefits including:

  • Reducing inflammation (Melcangi, 2014)

  • Building muscle (Smith, 2014)

  • Promoting sleep (Schussler, 2008; Mong, 2011)

  • Calming the nervous system, helping to cope with stress (Gordon, 2015).

The takeaway here is that progesterone is the balance to estrogen for the female athlete and both are beneficial and important for health and performance. If you know what should be happening in your body at certain times of your cycle, you have markers to look for and you can adjust your training accordingly.


Menstrual cycle tracking for an athlete can be different than tracking for fertility. The cycle can also be divided into four phases that are slightly different than the physiological phases/processes just listed. These phases focus around the hormones and their influence on training and athletic performance - training phases. In the following diagram you will see a comparison of the stages of the menstrual cycle with hormonal training phases over a cycle.




Training Cycles are broken into 4 phases for training. This information comes directly from the FitR Woman App (details discussed and link to app provided later in the article as well).


Phase 1: The first to last day of your period.

  • Estrogen and progesterone are at the lowest

  • Inflammatory response to the drop in homeons from phase 4 is sustained in phase 1

Phase 2: From the end of your period to just before ovulation

  • Estrogen is rising (as the follicles are developing) and progesterone remains low

Phase 3: From ovulation until your hormones start to drop - usually lasts 9 days

  • Initially a drop in estrogen and progesterone at the time of ovulation, then progesterone increases (the ruptured follicle that releases the egg becomes the corpus luteum which produces progesterone. If an athlete is on hormonal contraceptives, they do not ovulate and do not produce natural progesterone - this is really important to understand).

  • Estrogen also rises during this phase but is less than progesterone.

Phase 4: The days just before your period (ex days 24-28)

  • Estrogen and progesterone drop and are at their lowest during this phase, and this triggers an inflammatory response in the body.

  • This inflammatory response may also be responsible for PMS symptoms.


Following the phases of your cycle for training provides an easy way for an athlete to understand the changes they are going through and how this can affect their mood and their ability to perform.

As an example, I work with a high level female athlete who is currently training for a big competition. She is tracking her resting morning heart rate and her cycle. These are both great things to measure and track to indicate how an athlete is adapting to their training.


When she comes for treatment, one of my priorities is to monitor her training load and ensure that she is not overtraining/under-recovering in order to prevent unnecessary injuries and ensure she is peaking for her competition.


By knowing where she is in her cycle, we can see which symptoms are normal for her during that time.


Recently, she came in saying she felt tired and was not sure why. She described her body as sluggish after hard training and the next day not feeling physically energized for a full training session. Everything was fatigued out of what was normal for her.


In this case, we looked at where she was in her cycle to understand the hormonal influence on her symptoms. She was in phase 4 where there is an increase in inflammation and sleep can be disrupted and recovery is decreased as a result.


With this information, I was able to treat her system accordingly (focusing on recovery and regulation of the autonomic nervous system to support recovery and sleep), and make recommendations to optimize recovery and settle her mind. There was no need to panic or make significant changes to her training or treatment.


The following week, she had no concerns and her energy was back. There is also other physical evidence I can look for in the motor and nervous system to check for fatigue and overtraining. Combining all of this together, the plan was clear, easy to execute and the athlete did not have any deleterious effects; she is continuing to progress towards competition.


Athletes, coaches and strength and conditioning specialists can all incorporate cycle tracking with their athletes, looking at these four phases to gain an understanding of how that athlete could adjust training if needed and to learn their own patterns and tendencies.

Female athletes' hormones are cyclical, often in a predictable pattern each month. This variation can be critical to the athlete’s performance. In tracking, an athlete can also identify symptoms that are outside of the norm and potentially pathological.



With strength and conditioning, different periodization and training progressions may need to occur to capitalize on the fluctuating hormones of females throughout their cycle. More research is needed in this area, but based on physiology and the effects of fluctuating hormones I would argue that these changes could already inform adapted training for the female athlete.


As a health care provider or sports performance practitioner, if you understand these fluctuations and what they mean for the athlete, you can properly educate them on how to work with the changes, and you can identify issues much sooner for the athlete. Maybe you notice that they always have an increase in their pain during a certain part of their cycle. If this is the case, maybe they need to work with someone to check their inflammation, their cycle and their sex hormones as there is possibly an early-detectable dysfunction that needs attention.


You can understand that in certain parts of their cycle, they will have poorer recovery due to increased inflammation and sleep disruption. If so, you can recommend adjustments to their training to help manage these effects and apply injury prevention principles at the right time for these athletes.


Researchers are now hypothesizing and investigating hormonal influences on the incidence of non-contact ACL injuries. We also know the visceral connection between the pelvic organs and the low back, knee and hip in the female athlete. There is much to learn and understand, but we also have significantly more information to go on than we did previously.


The first step is understanding the female physiology and hormonal cycle for the female athlete.

Fortunately, some very dedicated researchers, Dr. Georgie Bruinvels and Dr. Charlie Pedlar, have developed an incredible app that makes tracking and understanding the cycle much more accessible for the female athlete and their team. FitR Woman provides all this information in one easy to follow app. This app is a wonderful resource for female athletes and I believe that it, along with this information, will contribute to changing the way we treat and train female athletes.


As always, I’m here to help. If you have questions, reach out to me via email or social media and check out my YouTube channel for more information.


Micaela.


Resources:


FitR Woman app - Dr Georgie Bruinvels & Dr Charlie Pedlar. https://www.fitrwoman.com/



References:


Briden, L. (2018). Period repair manual: Natural treatment for better hormones and better periods. Greenpeak Publishing.


Gordon JL, Girdler SS, Meltzer-Brody SE, Stika CS, Thurston RC, Clark CT, et al. Ovarian hormone fluctuation, neurosteroids, and HPA axis dysregulation in perimenopausal depression: a novel heuristic model. Am J Psychiatry. 2015 Mar 1;172(3):227-36. PubMed PMID: 25585035

Mauvais-Jarvis F, Clegg DJ, Hevener AL. The role of estrogen in control of energy balance and glucose homeostasis. Endocr Rev. 2013 Jun;34(3):309-38.PubMed PMID:23460719


Melcangi RC, Giatti S, Calabrese D, Pesaresi M, Cermenati G, Mitro N, et al. Levels and actions of progesterone and its metabolites in the nervous system during physiological and pathological conditions. Prog Neurobiol. 2014 Feb;113:56-69. PubMed PMID:23958466


Mong JA, Baker FC, Mahoney MM, Paul KN, Schwartz MD, Semba K, et al. Sleep rhythms and the endocrine brain: influence of sex and gonadal hormones. J Neurosci. 2011 Nov 9;31(45):16107-16. PubMed PMID: 22072663


Schussler P, Kluge M, Yassouridis A, Dresler M, Held K, ihl J, et al. Progesterone reduces wakefulness in sleep EEG and has no effect on cognition in healthy postemnaopausal women. Psychoneuroendocrinology. 2008 Sep;33(8):1124-31. PubMed PMID:18676087


Smith GI, Yoshino J, Reeds DN, Bradley D, Burrows RE, Heisey HD, et al. Testosterone and progesterone, but not estradiol, stimulate muscle protien synthesis in postmenopausal women. J Clin Endocrinol Metab. 2014 Jan;99(1):256-65. PubMed PMID:24203065


Disclaimer: All information provided by instilphysio.ca can at no time substitute medical advice and individual assessment by a qualified medical professional. instilphysio.ca recommends seeking professional advice before commencing any type of self-treatment, as the information provided is not intended to be relied on for medical diagnosis and treatment.

Visitors of the website instilphysio.ca use the information provided at their own risk. instilphysio.ca will not accept responsibility for any consequences or injuries.

By accessing the website instilphysio.ca, visitors agree not to redistribute the information and material presented. instilphysio.ca provide links to companies for the visitor’s convenience only, and does not endorse or recommend the services of any company. The company selected by the visitor of instilphysio.ca is solely responsible for the services provided to you. instilphysio.ca will not be liable for any damages, costs, or injuries following or in any way connected to the visitor’s choice of company/service.



 400 Woolwich St,

Guelph, Ontario 

Email: info@instilphysio.ca

Phone: 519-400-2818

Our Hours:

Tuesdays: 10am-7pm

Thursdays: 9am -5pm

Fridays: 1pm-6pm

Virtual appointments available upon request. 

Please be aware we do not have reception in the clinic. Please email for enquiries regarding service or book online. 

Connect with us!

  • YouTube
  • LinkedIn Social Icon
  • Facebook Social Icon
  • Instagram Social Icon

© 2021 Instil Physio. Design by Creative Type