Menstrual health and rugby
What is menstrual health and how can teams create a period-friendly environment? Dr Seren Evans and Lydia Shale explain and give tips to players, coaches and clubs.
What is menstrual health?
What is the menstrual cycle and menstrual health, how do the terms differ? Dr Seren Evans explains:
“When we talk about menstrual health we always (including me) jump to discuss the menstrual cycle, which in very broad terms can be divided into four key phases: follicular, ovulation, luteal and menstruation phases.
These are where there are fluctuations of the predominant hormones of oestrogen, progesterone and testosterone over a period of between 28-31 days (which notably fluctuates greatly between each person).
However menstrual “health” is about the biopsychosocial impacts of the menstrual cycle. It is more to do with policies and frameworks that are put in place to ensure people who menstruate have adequate resources, education and access to healthcare surrounding the menstrual cycle.
When it comes to sport it’s about ensuring that participation is not affected by their menstrual cycle and that they are adequately supported.
Menstrual health has huge variability between players and the general population, not one cycle is the same and varies in length, symptoms and symptom severity between each person.”
How does it affect players’ participation and performance?
Players may experience a range of symptoms. Dr Seren Evans explains this and the lack of resources that potentially leads to players not participating in sports during their periods:
“From experience, players often report abdominal cramps, headaches, fatigue and low mood around that late luteal/menstruation phase. Research has shown that athlete perceive their menstrual cycle to have significant negative detriments to their performance in sport.
The current evidence is low quality, and further work is needed in this area to solidify physiologically how the menstrual cycle might impact on sport performance. This is difficult to do due to the variability between people on what they experience.
From a sociodemographic perspective, adolescent girls have high dropout rates or reduced participation during their menstrual cycle, and this can have a lot to do with education and resources available to support them through this.”
Lydia Shale conducted recently conducted research into participation during periods.
She explains her findings from ‘The menstrual cycle: barriers to football and rugby participation, with interventions to maximise perceived sporting performance and participation’(Shale 2024).
“The data collected in this research study was collated from rugby players and football players, and combined due to them both being field and contact sports. The only time the two sports were separated was during the focus group, where one of the groups had international rugby players.
81% of survey respondents are negatively impacted by their menstrual cycle, with 39% of participants missing training and/or matchdays due to symptoms.
Inaccessibility to facilities is “another barrier for females in sport”, leaving players feeling “uncomfortable” and “embarrassed” while menstruating, as well as having to “sneak out period products from the bathroom into a bag outside”.
Despite the fact that changes in sleeping trends are mixed (36% sleep less, 34% sleep more, and 30% notice no change), 83% of people feel more tired when on and approaching their period.
This is reflected when fatigue was ranked as the most impacted element of physical performance, followed by endurance, power, agility and speed.
Interestingly, 17% of respondents experienced amenorrhea (no periods for 3 months or more), and 61% of those were exercising excessively or following a poor diet during that time.
Amenorrhea is an indicator of Relative Energy Deficiency in Sport (RED-S), yet 75% of survey respondents hadn’t heard of it. RED-S can cause symptoms such as fatigue, osteoporosis, reduced immune system and cardiovascular issues which will inevitably impact performance for rugby players.
Are there links with menstruation and injury?
Does a period impact a player and make them more at risk of injury? Dr Seren Evans explores whether there are links between menstruation and injury:
“There has been attempts at correlating injuries and menstruation. For example, anterior cruciate ligament injuries (ACL) have been linked to certain phases in a female athlete’s menstrual cycle due to the supposed increased joint laxity due to an increase in body temperature.
However it’s important to consider the multifactorial nature of sports injuries, it would rarely be the case that menstruation was the only contributing factor to that ACL injury. For example, a player may have poor movement biomechanics with knee valgus, previous injury history, and increased fatigue.
It’s important to consider the athlete as a whole. However, interestingly, when it comes to contact sport athletes, concussion symptoms tend to be more severe in the female population, and when a concussion is sustained during certain phases of the cycle.
Players report worsening and prolonged symptoms when compared with other phases. I think overall as examples, the menstrual cycle influences a player’s ability to recover effectively, energy levels, co-ordination and perception of fatigue, and there is most likely an interplay there with injury risk.”
How can physios help players?
Dr Seren Evans is the WRU PDC North Physiotherapist. She explains how she helps players and how other physios can create a period-friendly environment:
“It’s about normalising the conversation, and fostering a gendered environment where players feel like they can talk to you about their menstrual health, particularly in youth populations.
Facilities are important, ensuring that access to period products and sanitary bins is another way of ensuring continued participation during their menstrual cycle; and for period products to be a part of your physio bag.
Education is another one, physios are relatively well placed to provide the basic information on symptom management, and can lean on experts in the field.
I know of people who are far more qualified than me to give detailed education to my players and I will always lean into that.
It’s important as physiotherapists that we don’t go outside our scope of practice That highlights the need for more education for healthcare practitioners on management of menstrual health (and women’s health in general!) and for us to keep up with evidence-based practice.
Wellbeing forms that athletes fill in before a training session has been useful to identifying trends in symptoms which prompts us to act on it when they come in for training.
Individualised approach
An individualised approach is important for all aspects of coaching especially if you’re seeking to create period-friendly environment.
Dr Seren Evans discusses how to support each player if they’re training or playing during their period:
“As it’s important to remember that match days may land on a day that players typically experience the worst of their symptoms, so we as practitioners and coaches need to make sure that this person can still perform on these days.
We understand that athletes often experience symptoms that may affect their performance, it’s how we support that as practitioners that matters.
When we are collecting this wellbeing data on their symptoms of menstrual cycle, it’s important that the athlete sees us reacting to it and actively acting on the data that comes in to us.
For example, if a player consistently reports poor sleep and fatigue around certain phases of their cycle, can we educate around sleep hygiene and ensure adequate fuelling, hydration and maybe as far as giving electrolytes to give them some energy during training?
I can see in some cases the need to modify a session intensity i.e lowering the weights in the gym, as sometimes for some people they really struggle to push through those symptoms. However, as soon as we identify those patterns, we need to be proactive and support them through their session.
How can coaches support players?
Coaches play a vital role in creating a period-friendly environment.
Dr Seren Evans has some tips on how coaches can support players if they’re training or playing during their period:
“If a coach fostered that safe environment to share experiences, a player’s period pain is negatively affecting their performance during that training session, the player can communicate that with you.
It’s about those subtle check in points with them, and an individualised approach to how you manage it. Contact sport also adds another layer to that with the impact that might have on their abdominal pain as well as breast pain which is typically experienced during menstruation.
It’s about giving players as much of the tools as you can with the resources that you have and being adaptive.
For example, if their desire is to sit out of a high intensity contact session due to their pain, can you be adaptive and suggest that they have someone run some 1-1 contact prep activities.
This can still expose them to enough contact exposure that they are game-day ready, but doesn’t mean that they have to sit out entirely and further exacerbate their pain.”
With thanks to:
Lydia Shale, BSc Sports Science and Physiology
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