Flashback to the 2022 Athletics European Championships, a visibly frustrated Dina Asher-Smith blamed “girl stuff” for her ‘poor’ performance. This comment made by one of the sport’s biggest names got people thinking – why if something that affects 50 per cent of elite athletes worldwide, is there not more research being done and why is menstruation still such a taboo topic?
We caught up with one of the speakers from our 2022 conference, Dr Laura Forrest, Senior Lecturer in Sport and Exercise Science at the University of the West of Scotland (UWS), to discuss her work in the field.
After completing her PhD at the University of Glasgow, she worked at the Scottish Institute of Sport as an Exercise Physiologist, a role which she credits really ‘sparked her interest in female athletes’.
Through the Institute’s female athlete working group they started to look at the menstrual cycle and its impact on these athletes. Laura took this interest with her as she returned to academia, focusing on building an evidence base for the perceptions and experiences of athletes around their period, something she was seeing first-hand and anecdotally in her Institute role.
Laura’s first study, published in 2020, focused solely on elite athletes, surveying a group of international rugby players.
The results found almost all (93 per cent) experienced some sort of menstrual-related symptoms, with two-thirds believing it impaired their performance.
From there, Laura and her team widened the scope of their research subjects. This further study highlighted the effect of period-related symptoms on athletes, as well as the varying level of comfort they had in discussing their menstrual health with peers and support staff.
As a result of her research, Laura emphasised the importance for athletes to understand their own bodies, their cycle and how it, or any hormonal contraceptive use, affects them. This, alongside coach education, will help women have these important conversations with their support team.
While previous studies have focused on elite athletes and how we can better support them, the implications for amateur and junior athletes are just as important to study in Laura’s opinion.
Many girls will stop participating in sports long before reaching elite level, because of period-related issues and peer pressure.
The next step is for Laura and her team to release a survey which aims to look much wider, involving a variety of sports at different levels: “I feel really strongly about it being a top-down but also a bottom-up approach so we have it from the real roots underpinning, so our next generation of athletes don’t have the same experiences as current or past athletes do. Hopefully, we are doing our bit to try and improve that long term.”
Laura discussed some of the key recommendations that have come from her research to date. As a bare minimum, she recommended women track their cycle, using anything from specially-designed apps to paper and pen. This will monitor how long, how heavy, and any associated symptoms which can be compared month to month. Alongside this, elite athletes can track performance metrics, to understand any impact their menstrual cycle could be having on their performance.
Menstrual profiling (e.g. on an annual basis) should also be completed. There is no ‘one size fits all’ for how an individual’s cycle affects them or their performance – but once tracked, strategies can be put in place to help tackle any issues and optimise training. It was also recommended that athletes have a main point of contact they can go to, which may be of particular benefit in a team environment. While generally, coaches reported they were comfortable, the perception of athletes was often that either they felt uncomfortable, or felt they may make the coach feel uncomfortable when discussing menstruation.
Sometimes simple things can make a big difference. Laura’s original research prompted quick and tangible changes in practice (e.g. period products available on-site whether a home or away game).
Another positive change we are starting to see is greater flexibility around clothing so women are not asked to wear white, a potential cause for anxiety when menstruating. It has recently been announced that from 2023, women will no longer be required to wear white undershorts at Wimbledon. Many rugby and football teams are also starting to switch up their kit to remove this concern.
While kit is often now shaped for women, the branding has often been driven by men, with women’s strips following suit. While there are obvious physical and practical benefits of removing white shorts, what is really interesting to consider is the psychological effect. Even if the likelihood of a female athlete having an issue or a leak may be low, if it is causing them stress or anxiety, how will this be affecting their performance?
Laura explains the rationale behind this thought process and why it’s not a simple issue: “If they are worrying about it and feeling distracted then their full focus may not be on the task at hand,
“If you can take that element away it can only be of benefit. Most athletes will have a fear of leaking at some point. Not just sports with white shorts but also many other sports, for example, swimming or gymnastics, where clothing is minimal. In the future, we really need to consider uniforms as a big factor that can help athletes feel more comfortable.”
Both myself, and Laura have an undergraduate sports science degree – we discussed how even 10 years ago there was no real inclusion of the menstrual cycle as part of our studies.
This is incomprehensible when you consider that 50 per cent of athletes are affected, but not unsurprising. Laura attributes this largely to the additional challenges often associated with women’s research; it is costly as more samples and hormonal analysis is required, and it also takes longer if you want to track athletes’ cycles alongside other elements of a study.
At UWS, from next year they will have a female athletes module as part of their fourth-year studies, but it will also be open to external participants as there is recognition that this is needed as well. This will cover not just menstruation but other women’s issues such as breast support, pregnancy and pelvic health.
Laura said: “If you think menstrual health is a taboo issue then pelvic health and incontinence issues in athletes are really taboo. You have athletes that will talk about their menstrual cycle, there are fewer athletes that will talk about continence issues. So, there is still a big bit of work to do for the next generation of sports scientists.”
Following on from the work they had done within sports, the team began looking at the impact on education, with education around the menstrual cycle in schools being one of the key recommendations from the original study (2020).
Laura emphasised: “there is a need to develop awareness, develop openness and normalise the conversation”.
However, in order to do this people need the knowledge to back it up. This is important not only for the sporting environment but also in a wider social context.
Laura and her team’s latest research looked at the current state of play of teachers’ perceptions and experiences of menstrual cycle education across the UK. The survey shone a light on two key issues.
Firstly, not all teachers feel comfortable delivering or discussing menstrual education (almost 1 in 4). Secondly, some teachers felt more comfortable talking about it than their knowledge allowed them. Almost 9 in 10 (88%) teachers perceived that menstruation impacted participation in P.E.
Since then, Laura has received a Royal Society of Edinburgh Individual Research Fellowship that has allowed her to continue this work alongside her collaborators, with a real focus on barriers and enablers of menstrual education in schools. The ultimate goal is to help P.E. teachers to facilitate and improve participation in P.E. We are fortunate in Scotland that teachers are provided with resources and in many ways, are leading the way compared to many other countries, but what Laura feels is still missing is the integration with P.E. From their teacher survey they know current resources are primarily biology driven with less focus on symptoms or how to manage them.
For example, P.E. itself may be able to help with those symptoms, as we know that aerobic exercise can improve some menstrual cycle symptoms (disclaimer: to be enjoyed alongside a balanced cycle of ice cream and rom-coms).
Going forward in her research, Laura has a number of points she plans to highlight in her future research, these include ensuring that period products are available in all schools and workplaces. Scotland is leading the way but this needs to be more widely available to tackle period poverty.
More consistent and focussed menstrual education in schools as the potential impact is massive.
More athletes opening up about their experiences so it is part of the normal conversation for the next generation.
From a research perspective – more investment in female athletes, female athletes research and symptom management, not just pharmaceutical but other coping strategies.
Read more about Laura and her ongoing research here.
sportscotland has recently released new resources on supporting female athletes that are free and accessible to everyone here.