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Illustration by Caitlin Kelly

For Elite Athletes, Periods Are Still A Question Mark

Vanja Lakic

For all the advances that science has made in sport, there are few studies and little consensus about how the menstrual cycle affects athletic performance.

Illustration by Caitlin Kelly

On a sultry midsummer afternoon in Saint Kitts and Nevis last year, Priscilla Frederick was fighting gravity, her worst opponent. The 27-year-old Queens native styles herself as a diva on the track—cobalt-blue lipstick, heavy eye makeup, a weaved-in bleach-blonde ponytail. Before the high jump at the Eastern Caribbean track meet, however, she felt heavy and nauseous, and her stomach bulged out of her athletic briefs. It was the second day of her period.

Hours earlier, Frederick had taken her usual two 800 mg Ibuprofens for cramps, but her body still felt irritated as she approached the mark and closed her eyes. Before every jump, Frederick takes a moment to visualize it: the rhythmic gallops that evolve into quick, short pounces just before her spine extends and her right arm and knee drive into an elegant arch over the bar. But that day she was disappointed with her execution and finished third, behind two athletes from Saint Lucia.

"I should've won the meet," she said. "It wasn't so much a mental thing, because I had to train myself to get through it and be a fierce competitor. But it definitely affected my weight, my approach, my speed."

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Frederick has had severe menstrual symptoms throughout her athletic career. At 5-foot-10, she is one of the shortest high jumpers in a discipline led by towering Europeans, but what she lacks in height she makes up for in muscle mass and speed to power her jumps. Any extra weight, though—even just a few pounds of water weight gained during her menstrual cycle—can mean the difference between clearing the bar by a hair or knocking it down.

Frederick will represent Antigua and Barbuda, her father's homeland, at the Olympics in Rio this summer. Her period won't fall on the Olympic high jump dates—August 18th and 20th—but the premenstrual phase of her cycle will. How might that affect her performance on the world's biggest stage? Well, it's hard to say for sure.

Priscilla Frederick at the 2015 Pan Am Games. Photo by John David Mercer-USA TODAY Sports

Ignorance and misconceptions surrounding menstrual and reproductive health have been a constant factor in women's sports for more than a century. Victorian era beliefs that vigorous exercise would displace the uterus and affect fertility have for decades been used to discourage women from engaging in the same level of physical activity as men. Modern research has found no relationship between heavy exercise and uterine shifts, but the myth was slow to die: in 2010 Gian-Franco Kasper, the president of the International Ski Federation, said that the uterus might burst during landing from a ski jump; women were allowed to compete in Olympic ski jump for the first time at Sochi in 2014, 90 years after men.

Even today, there is still a cloud hovering over the menstrual cycle that can hurt female athletes, albeit in a different way. For all the advances that science has made in sport, there is still a lot we don't know about periods, and the stigma around them remains in locker rooms and athletic departments. The onus falls on athletes themselves to tame an often-intricate array of symptoms without compromising their training intensity or their performance, and solutions are not always easy or obvious.

A recent study by UK and US medical researchers found that 41.7 percent of exercising women who were surveyed believe their menstrual cycle has a negative impact on training and performance. Iron deficiency from heavy bleeding and elevated body temperature just before the period are some of the factors experts believe likely affect female athletes, but due to the dearth of research on the subject, these remain speculative. Why so little research? Women are significantly underrepresented in clinical trials—a problem the researchers highlighted last month in an op-ed published in the British Journal of Sports Medicine.

Georgie Bruinvels, one of the researchers, says that little is currently being done to solve the issue, partly because it's more expensive to administer studies of female hormones, which fluctuate more significantly on a daily basis than male hormones. But she is encouraged by the attention her team's op-ed received and hopes it will stimulate new ventures into what is still mostly uncharted territory. Bruinvels now leads a study examining 35 athletes with varying degrees of iron deficiency to analyze possible links between heavy menstrual bleeding and performance. She wants to extend her research to other aspects of an athlete's wellbeing potentially impacted by the menstrual cycle such as immunity, muscle strength, and susceptibility to injury.

The lack of major strides in medicine extends to women's options for menstrual symptom relief. The birth control pill, which many women take to reduce cramps and regulate their cycles, was invented over five decades ago, but its effect on athletic performance, especially at the elite level, is still uncertain, and conflicting studies and opinions abound.

A 2002 study led by Dr. Constance Lebrun, a medical professor at the University of Alberta, found that using oral contraceptives slightly lowered the maximal aerobic capacity of high-performing athletes, but the trial was limited to a small group of women and one type of birth control pill. She acknowledged that newer pills containing lower hormone dosages may affect athletes less, and that further studies were required.

"[It is hard] to get subjects who are regularly menstruating but fit enough that they would notice small effects on performance," she said. "And who would agree to go either on the pill or placebo for three to six months? It's quite onerous, to say the least."

Photo by Monik Markus / CC BY 2.0

Other studies by the University of British Columbia's Centre for Menstrual Cycle and Ovulation Research (CeMCOR) have found that the pill does not change endurance, muscle power, and other aspects of sports performance. However, Dr. Jerilynn Prior, CeMCOR's founder and scientific director, thinks that athletes should avoid combined hormonal contraceptives (or CHC) like the pill and the ring, which contain both synthetic progesterone and synthetic estrogen. Her review of why CHC is a bad idea for adolescents is currently in the press for the Women's Reproductive Health Journal.

"I believe that athletes who use CHC for treatment or contraception are being unwise," Dr. Prior said, citing CeMCOR research that suggests it interferes with menstrual cycle functions important for fertility, bone health, and cardiovascular fitness. She recommends that athletes use oral progesterone to regulate their cycle instead.

Alternative health practitioners are skeptical of the pill, as well. Dr. Eden Fromberg, a holistic OB/GYN in Manhattan whose clients include many yoga instructors, is concerned that synthetic hormones may affect connective tissue important for quick reflexes, agility, and recovery, citing a 2008 study.

Dr. Fromberg recommends her clients try exercises that target the organ-to-muscle reflexes she believes are connected to some menstrual symptoms. When necessary, she favors bio-identical hormones, which she says pose fewer side effects, over synthetic ones. (A 2011 review by the Harvard Medical School suggested that there is no good evidence to support the claim that bio-identical hormones are any safer.)

"It's still imposing on the natural cycle," she said. "But I believe more compatible hormones to the natural ones that the body produces reduce risks and side effects in ways that haven't yet been adequately studied."

The pill remains the most popular form of contraception in the United States. According to a 2011 study by the Guttmacher Institute, more than half of the 9.7 million women on the pill use it for reasons other than preventing pregnancy, such as for cramps and other menstrual symptoms; about 14 percent take it exclusively for noncontraceptive purposes. But not all women respond to the pill the same way. Dr. Diana Ramos, an OB/GYN at Anaheim Baldwin Kaiser Permanente in California, said that some women are sensitive to varying levels of estrogen and progesterone brought on by the pill and may experience more water retention and greater mood swings. Competitive athletes who want to go on birth control, she said, must start the search for a formula that works for their body at least six months prior to important events.

"Athletes have an unspoken challenge," she said. "And we, unfortunately, have a disadvantage in that there is no one solution for everyone."

Frederick will be competing in Rio next month. Photo by John David Mercer-USA TODAY Sports

As Antigua and Barbuda's best high jumper, Frederick knew she was headed to the Olympics early in 2016, but she sought medical advice for her menstrual symptoms for the first time only in June. Before that, her period had never been a topic of discussion with her coach, who is also her boyfriend.

"Sometimes I cry and I'm super emotional, and when I gain weight I freak out, and he doesn't know how to help," she said.

Her doctor suggested that she consider Yaz or Yasmin, daily birth control pills that contain drospirenone, a diuretic that helps to reduce bloating. Concerned about the pill's effect on her performance, however, Frederick hasn't picked up her doctor's prescription. Instead, she is testing a diet rich in proteins and vegetables to help reduce excess body fluids.

"I don't want to add something to my regimen this close to the Olympics," she said. "I've been training for so long and I've never been on the pill and I just don't know what's going to happen. There are just too many variables."

Frederick and her coach also agreed to start charting out her menstrual cycle. She marks the days of the month when she expects her worst symptoms to help her coach adjust the training schedule, and keep herself attuned to her body's changes.

Although Frederick tracks her period the old-fashioned way, current smartphone apps can make it convenient for women to enter daily information about their menstrual cycle. Clue, for example, which is used by more than 2.5 million women, calculates an individual's ovulation days, fertility window, and the likely timing of premenstrual syndrome (PMS). Users can record observations in categories that include emotions, pain, energy, skin condition, sleep and appetite, and in turn can better understand patterns—though that, as Dr. Prior's institute has found, is not always an accurate predictor of the ovulatory cycle.

As an athlete in an individual sport, Frederick can take advantage of greater awareness about her cycle to adjust her training program; athletes in team sports have less flexibility. The US Rowing team, for instance, doesn't take menstrual cycles into account.

"We don't change the rowing training for their periods," said Dr. Katherine Ackermann, the team's physician. "They have to change their periods or change how they approach it according to the rowing training."

Ackermann has advised athletes with regular menstrual cycles and healthy bone density to use CHC if they complain about frequent periods or very heavy ones. For athletes with menstrual irregularities, she recommends going on the pill when peak performance is desired—for major events like the Olympics, for example—and then going back off it afterward to promote greater natural hormone production and ensure that the body has sufficient energy.

"We don't change the rowing training for their periods," says the U.S. Rowing's physician. Photo by EPA

In a culture repulsed by menstrual blood and in a business that doesn't pardon it, athletes often keep quiet about their symptoms. When British tennis star Heather Watson lost in the first round of the 2015 Australian Open citing "girl things" as the reason for her dizziness, nausea, and low energy levels that day, it caused an uproar with a public who didn't know whether to sympathize with her, praise her bravery for finally breaking the silence, or dismiss it as an excuse. Nevertheless, research initiatives to further examine the symptoms Watson felt that day and the impact it might have made on her performance have been few.

"I've never had someone ask if I was feeling OK because of my period," said Ashley Battle, a star forward for the University of Connecticut who then played in the WNBA for six years. "It's a taboo topic. It's personal. Nobody probably wants the other person next to them to know that they're on their cycle."

Battle's period was never a performance factor but she was a heavy bleeder, which often required multiple changes of tampons during a game. As a player for the Seattle Storm, New York Liberty, and San Antonio Silver Stars, Battle said that all those teams expected their athletes to "tough out" any menstrual symptoms during game days and in practice.

"It's just like anything else when you're not feeling well," she said. "You have to put it aside, focus on performing and then take the necessary rest and time you need afterwards."

The pressure to keep your head down and power through any discomfort can be amplified when members of the coaching staff don't get periods themselves.

"I had male coaches so it was never discussed," said Chloe Sutton, a two-time Olympic swimmer from California. She used the pill to help control her cycle and took Ibuprofen to quell abdominal pain but grants that her period wasn't an issue in training and competition.

"It was honestly never a thought that it would affect my performance. I try to put it out of my mind during a meet."

Periods were likewise never discussed with Anthony Nguyen, the assistant coach of the women's tennis team at Purdue University. Occasionally his athletes will use code phrases such as "it's her time of the month" to explain why a teammate might be struggling. "I think it has to do with the fact that we're guys and they're girls," he said.

Nguyen's players are all on full scholarships, and while he says there is high expectation for them to focus on nothing but the task at hand regardless of the situation, he understands they aren't robots and encourages them to bring up issues that arise. The school's vast athletic resources also afford his athletes the chance to leave him out of the menstrual cycle conversation.

"I don't know if it actually physically hinders them," he said. "I would assume that if they're having issues with their significant other, or their parents, the period would be comparable to that. If they want to allow it to bother them, they can, but if they want to toughen it out, I would assume that they would be able to."

About half the world's population will never know what it means to live with the menstrual cycle, its stigma, and its symptoms. Women have broken world records on their period, and athletes whose prowess isn't built on vulnerability aren't likely to use it as an excuse. But the near-total absence of discussion around the topic does athletes a disservice in a way, too.

Frederick will appear at her first Olympics with neon-purple weaved-in hair, an Asics-sponsored navy blue top, and no-name bottoms the color of Antigua and Barbuda's flag. She plans to use this year's off-season, which begins in September, to test her body's reaction to the birth control pill that her doctor prescribed and evaluate whether it can help her moving forward.

"It's something I definitely have to get under control," she said. "This is my job and this is a business. There can't be any excuses when it comes to performing."

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