The menstrual cycle, a key physiological process in women, significantly impacts performance, neuromuscular control, metabolism, and immune response. For professional female athletes, hormonal fluctuations throughout the menstrual cycle could influence the risk of injury. A recent study conducted by researchers in Spain and the UK has examined whether menstruation affects injury incidence or severity in professional female football players. The findings, published in Frontiers in Sports and Active Living, reveal that while menstruation does not increase the frequency of injuries, it does exacerbate their severity.
“We show that menstruation itself does not increase how often injuries happen,” said Dr. Eva Ferrer, the study’s first author and a sports medicine specialist at Sant Joan de Déu Hospital, as well as a female health expert at the Barça Innovation Hub in Barcelona. “Although athletes were not injured more often during their period, the injuries that happened during menstruation caused three times more days lost than injuries occurring at other times of the cycle.”
On the Bench: Data and Findings
Over four seasons, from 2019/20 to 2022/23, the research team monitored the self-reported menstrual cycle data of 33 elite football players competing in Spain’s top league for women’s football, Liga F. Eleven players participated throughout all four seasons. Players documented bleeding and non-bleeding days, the only phases of the menstrual cycle that can be reliably identified without blood hormone testing. The study recorded 852 menstrual cycles and 80 lower limb injuries, 11 of which occurred during menstrual bleeding phases.
The findings indicated a significantly higher injury burden during bleeding phases, suggesting a greater impact of injuries occurring during menstruation. These injuries were more severe and took longer to heal. For instance, the burden of soft tissue injuries—affecting muscles, tendons, and ligaments—was more than three times higher during bleeding days compared to non-bleeding days, with 684 vs 206 days lost per 1,000 training hours, respectively.
Understanding the Causes
Injuries are caused by multiple factors, and hormonal influences alone cannot be understood as the sole cause. “Hormonal levels may not cause the injury, but they may influence how severe the injury becomes and how long recovery takes,” Ferrer explained. Low estrogen levels may reduce muscle repair, while increased fatigue, pain, and sleep disturbances can alter neuromuscular control. Similarly, iron loss can lower endurance and slow recovery, and inflammation heightened during menstruation can cause worse tissue damage when it occurs.
To prevent injuries during menstruation and reduce their impact on players’ health, small adjustments may be beneficial. “Small modifications such as longer warm-ups, adjusted high-speed workload, or added recovery support may help reduce the severity of injuries if they occur,” Ferrer pointed out.
Implications Beyond Professional Football
The team suggests that their findings have implications beyond professional football. Women who exercise can adapt their training schedules according to the phases of their menstrual cycle. Dr. Ferrer emphasized the importance of menstrual tracking, stating, “You do not necessarily need to avoid training during your period, but you may need to adapt it. Tracking your cycle and symptoms can help guide training intensity and recovery strategies.”
While the athletes in the study followed consistent injury prevention protocols, had access to professional medical support, and trained under standardized methods, the results may not be readily transferable to all female football players, as participants all belonged to the same club. The unequal amount of bleeding and non-bleeding days, four against 27 in a month, could limit the statistical power to detect differences in incidence. Additionally, no hormone measurements were conducted, and external factors such as stress, sleep, nutrition, and symptom severity were not measured.
Looking Forward: The Need for Further Research
Despite these limitations, the observed trends, combined with the significant difference in injury burden, underscore the importance of further research. The study also highlights the importance of individual menstrual tracking, at least with a calendar-based method, for injury prevention. It represents an important step toward integrating menstrual cycle awareness into athlete health monitoring. “It supports a growing movement toward female-specific sports science instead of applying male-based research models to women,” concluded Ferrer.
This development follows a broader recognition within sports science of the need to tailor research and training protocols to the unique physiological characteristics of female athletes. As awareness grows, the integration of menstrual cycle tracking into training regimens could become a standard practice, potentially reducing injury severity and improving overall athlete health.
