Exercise performance at different phases of the menstrual cycle: measurements, differences, and mechanisms - a narrative review

With the increasing participation of women in sports, research on women’s sports has gradually increased but remains less than that on men’s sports as a whole. The menstrual cycle is a unique physiological feature of women. Hormone fluctuations during this period can have a potential effect on exercise performance through various mechanisms, including substrate metabolism, cardiopulmonary function, body temperature regulation, and psychological factors. This narrative review analyzed the changes in aerobic performance, anaerobic performance, and strength during the menstrual cycle by analyzing domestic and international research on exercise performance at different phases of menstrual cycle and preliminarily discussed the influence of menstrual cycle-related factors on exercise performances. Results show that although a considerable proportion of female athletes believe that their exercise performance is affected by their menstrual cycle (poor exercise performance during the early follicular and midluteal phases), various exercise performance during different phases of the menstrual cycle are inconsistent. Such variability may be related to the inconsistency of current research methods, such as the method for identifying menstrual cycle phases. Current research focuses on aerobic, anaerobic, and strength indices, and only a few studies on speed, sensitivity, and flexibility exist. Studies that support the differences in transport performance during different menstrual cycle phases have the overall consensus that aerobic performance in the follicular phase is higher than that in the luteal phase and the effect of hormonal fluctuations on aerobic performance during the menstrual cycle can be reduced by ingesting glucose. Maximum strength is poorest during the luteal phase. However, strength training can be planned on the basis of the hormone fluctuation characteristics of the menstrual cycle. Most studies have shown that anaerobic performance is unaffected by the menstrual cycle. Further research is needed to quantify exercise performance during different phases of the menstrual cycle and determine the relevant factors affecting exercise performance to understand women’s exercise performance fully. It provides help to athletes in regulating their physiological cycle before games and ensuring their maximum performance during competition.

1 Introduction

The influence of female athletes on international competitive sports is increasing daily. The proportions of participants in previous Olympic Games (2.2% in the first session to 48.7% in the 32nd session) and participating projects (2.1% in the first session to 46% in the 32nd session) are constantly rising (1). The contribution of female athletes to China’s competitive sports is also growing. The proportion of female athletes in China who won gold exceeded that of men from the 24th to the 32nd Olympic Games and that in the 32nd Olympic Games reached 64%. China’s mass women’s sports participation has gradually increased, and women’s fitness enthusiasm has been significantly higher than that of male (2).

From puberty to perimenopause, women experience fluctuations in ovarian hormones due to menstruation. Estrogen and progesterone can fluctuate by 5 and 50 times, respectively (3). Studies have shown that hormones are an important factor affecting the development of exercise performance: estrogen and progesterone can not only affect nerves and muscles (4), they also affect substrate metabolism, ventilation, immunity, cognition, body temperature, the cardiovascular system, and other aspects (5–7). A close relationship exists between women’s exercise performance and the menstrual cycle (MC). Although women’s sports participation rate and performance are increasing, the research on men’s sports continues to predominate and that on women’s sports is scarce (8). Differences exist between men and women in terms of bone morphology, biomechanics, reproductive and endocrine systems, and other aspects. The results of male exercise research are not fully applicable to women (3). In addition, the specific problems associated with women’s menstruation remain to be solved. Such problems include the potential effects of exercise-induced MC disorders, changes in the MC through drugs, and coincidence of major competitions with the LF phase. Given that the MC is an unavoidable physiological law of the life processes of women, especially those who are athletes, and affects sports participation and performance, balancing the relationship between the MC and exercise performance remains a problem that has not been overcome in the field of competitive sports. In light of this context, the present study synthesizes and categorizes relevant domestic and international research on exercise performance across different phases of the MC. Building on these reviewed literatures, it further analyzes the relationship between the MC and exercise performance, aiming to provide a foundational reference for the manual regulation of the MC and to support the optimal utilization of exercise performance in major competitions.

1.1 Characteristics and rules of different phases of the MC

The MC is a process wherein the endometrium periodically and orderly sheds under the interaction of hormones produced by the hypothalamus, pituitary gland, and ovaries. The shed endometrial tissue and blood are then discharged from the vagina. The beginning of the MC is the first day of menstruation; the MC is generally 28 days long but varies between 25–35 days due to individual differences (9). The day of ovulation is approximately the 14th day. The MC is divided into the follicular phase (FP) and luteal phase (LP) on the basis of ovulation and further divided into subphases (taking a 28-day MC as an example): early follicular (EF) (days 1–5), LF (days 6–12), ovulatory (OVU) (days 13–15), early luteal (EL) (days 16–19), midluteal (ML) (days 20–23), and late luteal (LL) (days 24–28) (10). The MC is regulated by the hypothalamus–pituitary–ovarian axis. The sex hormones related to the MC are mainly estrogen, progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and gonadotropin-releasing hormone (GnRH) (9). GnRH is secreted by the hypothalamus. It stimulates or inhibits the secretion of pituitary gonadotropin. LH and FSH are pituitary gonadal axis hormones. LH and FSH act synergistically on theca and granulosa cells in the ovary to stimulate the synthesis of gonadal steroids and peptides and formation of ovarian follicles (9). Estrogen and progesterone are the main sex hormones. Hormone fluctuations during different phases are shown in Figure 1 (10).

Figure 1

Figure 1. Hormone changes during different phases with a 28-day MC as an example (10).

During a MC, follicles (one follicle contains an egg) develop continuously in the FP, and a small amount of estrogen and progesterone are secreted in the ovary during EF. As the follicles gradually develop, the levels of estrogen and progesterone continue to increase. When the secretion of estrogen peaks, the hypothalamus secretes GnRH, and GnRH stimulates the pituitary gland to secrete FSH and LH. After the LH peaks during LF, the mature follicle ruptures, and eggs are released into the uterus to complete ovulation. EL occurs after ovulation, and ruptured follicles turn into the corpus luteum, secreting progesterone and a small amount of estrogen. During ML, estrogen reaches a second low peak, and progesterone also peaks to prepare for the implantation of fertilized eggs. If eggs are not fertilized, the corpus luteum degenerates during the LL, the secretion of estrogen and progesterone gradually decreases, the endometrium sheds, and the next cycle occurs (9). Given that different individuals have different ovulation times, large individual differences in OVU exist, as illustrated in Figure 2.

Figure 2

Figure 2. Differences in the effects of estrogen and progesterone on the body system. ↑ = increases; ↓ = inhibition or reduce; ↔ = maintain.

Estrogen is a steroid hormone. It mainly includes estradiol, estrone, and estriol, which are secreted by the ovary. Its receptors are widely distributed in the uterus, vagina, breast, pelvic cavity, skin, bladder, urethra, bone, and brain. Therefore, estrogen can not only promote and maintain female reproductive organs and secondary sexual characteristics, it can also affect the cardiovascular system (including blood pressure, heart rate and rhythm, vascular blood flow, body fluid balance, vascular tension, and cardiovascular response to stress), respiratory system, substrate metabolism, cognition and emotion, and even the brain itself (5–7). It can promote skeletal muscle formation. Hormone replacement therapy with exogenous estrogen can reduce the decrease in muscle strength in perimenopausal and postmenopausal women (4) Progesterone can affect the regulation of body temperature; respiratory system; and even the choice and use of energy, such as the promotion of protein catabolism (5).

The two sex hormones have different functions, and the effects of their interactions on different physiological processes may be different. Both have a potential effect on exercise performance through their influence on individual systems. Figure 1 shows that the difference between estrogen and progesterone levels is mainly observed during EF (low estrogen and low progesterone), LF (high estrogen and low progesterone), and ML (high estrogen and high progesterone). Therefore, the effects of EF, LF, and ML on exercise performance become increasingly complicated, and more studies have focused on these three phases than on other phases (10).

1.2 Accurately framing methods for confirming MC phases

At present, several methods for confirming MC phases (Table 1) exist: vaginal ultrasound scans can directly distinguish whether ovulation is occurring to determine whether the MC is in the OVU phase. However, due to its invasiveness, expensive equipment, and high technical requirements, it is not accepted by all subjects and researchers. Determining the MC phase on the basis of dates is simple and easy. This method is conducted on the premise that all subjects experience regular MCs and ovulation. The specific phase is estimated by determining the number of days in the whole cycle. If the MC is normal but the LP is shorter than 9 days, determining whether ovulation has occurred on the basis of dates is impossible, and LP deficiency (LPD) cannot be excluded. In addition, the change rate of the number of days in the FP is higher than that in the LP^[9]. Phase estimation is also prone to errors. Confirming the MC phase on the basis of the change in basal body temperature (BBT) is also a common method. The morning body temperature of subjects is measured by a thermometer with an accuracy of 0.05°C. In general, body temperature fluctuates at approximately 36.5°C during the FP, reaches its lowest point on ovulation day, rises by 0.3°C to 0.5°C during the LP, and is maintained for 12 to 16 days (9). However, body temperature is easily affected by numerous factors, such as mood, environment, sleep disorders, and temperature. Therefore, the accuracy of this method is inadequate. MC phase can also be determined on the basis of urine luteinizing hormone (LH). This method is usually started on the eighth day of the MC (or the entire MC can be considered as the collection period). The morning urine of the subjects is collected, and the LH peak is determined by using a urine LH test paper, which shows positive results, or a laboratory test. Ovulation usually occurs 14 h to 26 h after the LH peak and lasts for 24–36 h. Some studies have shown that the incidence of LPD is as high as 30% in subjects with positive urine LH test strips (11). In addition, women with luteinized unruptured follicle syndrome may also have a normal MC and LH surges but may not have normal ovulation because the follicle cannot be discharged and follicular luteinization may occur (12). The MC is characterized by fluctuations in estrogen and progesterone. The main ways for determining the MC phase include measuring these two hormones in saliva and blood. The advantage of the saliva test is that it is noninvasive and convenient. However, sex hormones show fluctuations in saliva. Salivary estrogen fluctuates within a 60–90 min cycle (13). Moreover, the level of hormones in saliva accounts for a small amount of total estrogen in serum (14): estrogen and progesterone account for only 1%–2% and 1-3% due to their small amounts. The small differences in hormones at different times have an effect on the accuracy of the results. The serum hormone test method is more accurate than the saliva test method and is considered as the gold standard for determining the MC phase. In this method, venous serum samples (approximately 8 ml) are collected after the same time of fasting in the morning, centrifuged and stored at −80°C, and then detected by using ELISA kits or laboratory tests. However, this method has disadvantages, and continuous blood collection throughout the MC is hindered in actual operation. The use of a single method has certain advantages and disadvantages. For example, vaginal ultrasound scanning or urine LH can only confirm OVU and can only estimate other phases. Therefore, Schaumberg et al. (11) proposed a three-step method for the determination of MC phases. Integrating three methods is recommended. First, the bleeding time and menstrual days of the first 3 months are recorded and counted. After EF, a urine LH test paper strip is used for determination. If it is positive, OVU is occurring. Blood is collected from the 6th day to the 12th day after ovulation with an interval of 1 day or 2 days. This method minimizes intrusion and damage and can accurately confirm OVU and ML. The accuracy of the MC phase determination method affects the accuracy of the analysis of the difference in exercise performance. During preparation for competition, the use of the blood hormone method to determine the MC phase is recommended if the time is sufficient because it is highly accurate. Before the competition, the three-step method, which combines tests based on dates, urine, and blood, is recommended to determine the MC phase quickly with minimal invasiveness and regulate the MC.

Table 1

Table 1. Methods for confirming MC phases.

2 Methods

A literature search was conducted in the following databases Web of Science, SpringerLink, PubMed Embase, Medline, BMJ (final search 1 November 2025). Keywords included athlete, MC, exercise performance, physical fitness, strength, and menstrual symptoms. The search strategy contained terms related to the MC and performance. A summary table of all included literature information in this study is available in the Supplementary Materials (Supplementary Table 1) and an overview of the search and screening process is provided in Figure A.

Results from the database searches were imported in EndNote X9 (Clarivate Analytics), where duplicates were removed before screening occurred. One author conducted article screening to identify relevant articles, first based on whether the title and abstract was related to exercise performance over the menstrual cycle, followed by a full-text screening. Articles were included in this narrative review if they were published in English and included populations of women. Participants were considered athletes if they were referred to solely as “athletes” or if specific competitive sports were indicated by the authors. Participants must also have been described as Participants must also have been described as eumenorrheic or having regular menstruation and were not currently using any form of hormonal contraceptives. No exclusion criteria were applied based on participants’ age.

Articles meeting the inclusion criteria must also have reported objective test results of participants, including outcomes from exercise performance tests (maximal tests for measuring exercise performance, such as countermovement jump tests, time trials, or maximal voluntary contraction tests) and applied physiological tests (maximal or submaximal tests for measuring physiological variables related to exercise performance, such as maximal oxygen uptake tests).

Articles must also have compared exercise performance in at least two phases of the MC. To standardize he results from the included articles, where possible, the phases were defined using the MC model established by Redman LM et al. (17) consisting of the early follicular (days 1-5), late follicular (days 6-12), ovulatory (days 13-15), early luteal (days 16-19), mid luteal (days 20-23) and late luteal (days 24-28) phases.

After relevant articles were identified, one author extracted the following information, presented in Tables 2, 3, 4: Author, year of publication, participant information (sample size and sport level), phases investigated, and the findings of the study. A narrative review was then conducted to summarize the findings and identify the gaps within the literature.

Table 2

Table 2. Related research on aerobic exercise ability at different phases of menstrual cycle.

Table 3

Table 3. Related research on anaerobic exercise ability at different phases of menstrual cycle.

Table 4

Table 4. Related research on the maximum strength at different phases of the menstrual cycle.

3 Differences in exercise performance at different MC phases and possible mechanisms

3.1 Aerobic performance

Sixteen relevant studies were included, a summary of the findings and characteristics of the included studies is provided in Table 2. In a study on the female population, Gordon et al. (15) found that in women with normal MC, hormone fluctuations did not affect oxygen uptake (VO2max), maximum heart rate, and maximal stroke volume; this finding was consistent with previous results (16–19). A study on LT (17–19) also found no effect. However, different views also exist. Some studies determined the MC phase by using salivary progesterone and found that aerobic performance during ML was lower than that during other phases. For example, Brutsaert et al. (20) found that VO2max during ML had reduced by 2% relative to that during LF. Freemas et al. (21) discovered no change in absolute VO2 and volume ventilation and HR by in 8 km bicycle test. However, compared with that during LF, average power was worse during ML, and negative emotions and RPE before exercise increased.

A study on female athletes showed that the VO2max of triathlon (22), rowing (23), middle-distance running, and football athletes (24) was unaffected by the MC. However, early studies discovered fluctuations in VO2max. For example, in 1995, Lebrun et al. (25) demonstrated that absolute VO2max was greater during EF than during ML but found no change in relative VO2max and time to exhaustion. By conducting the lactate threshold (LT) test on seven endurance athletes in 2005, Forsyth et al. (26) discovered that the LT level during LF was higher than that during ML.

In addition to maximum VO2max and LT, aerobic performance can be estimated by intermittent endurance tests (IETs). The YOYO test showed that high-level football players performed on IET better during EF than during ML (27) and their intermittent recovery test (IRT) results did not change (28). The YOYO test of nine ordinary athletes also found that IET performance during the FP was better than that during the LP (29). Twenty 5 s power bicycle sprint tests were performed on handball players. The percentage of peak power reduction from the first to the 20th cycle was greater during LL than during LF and ML (30).

The inconsistency in findings from studies on women’s aerobic performance in relation to body mass and exercise may be associated with exercise continuity. The results of continuous exercise on maximal oxygen uptake only partially supported that aerobic performance was affected by the MC, whereas tests on intermittent exercise showed that intermittent endurance and sprint performance were affected by the MC. In general, studies indicating that aerobic performance is affected by MC tend to support that aerobic performance is higher during the FP than the LP. Although progesterone can increase excitability by reducing the threshold of the medullary respiratory center (31), the increase in ventilation affects respiration. In substrate metabolism, estrogen and progesterone have different effects on sugar storage and utilization and lipid metabolism. In terms of glycogen storage, estrogen promotes insulin sensitivity and may increase glycogen storage, whereas progesterone promotes insulin resistance (32). In glycogen utilization, estrogen reduces carbohydrate oxidation rates by reducing muscle glycogen utilization and muscle glucose uptake (33). In lipid metabolism, estrogen can increase the availability of free fatty acids as energy substrates during exercise and promote lipid oxidation in skeletal muscle, whereas progesterone antagonizes the effect of estrogen by inhibiting lipid oxidation (34). Therefore, high levels of estrogen during the FP may improve endurance performance by changing carbohydrate, fat, and protein metabolism. Although progesterone is antagonistic, its level during the FP is low. In addition to estrogen and progesterone, exercise intensity, nutritional status, exercise level, and individual hormone differences all affect the rate of substrate oxidation. This influence may explain the differences in the results of aerobic performance studies. In addition, studies have demonstrated that glucose intake can minimize the effect of MC on glucose metabolism (35) and reduce the effect on aerobic performance.

3.2 Anaerobic performance

Sixteen of the included studies examined at least one anaerobic performance outcome; most of these studies (n = 6) determined that MC phase had no effect and only one studies demonstrated at least one anaerobic performance outcome fluctuated with MC phase (Table 3).

Studies on the female population showed that Wingate peak power, average power (36), and maximal accumulated oxygen deficit (37) did not significantly differ between the FP and ML. However, after repeated sprints during the LP, serum progesterone significantly reduced. Nonathletes subjected to high-intensity tests during the LP exerted poor emotional and perceptual efforts (38), resulting in a low level of motivation and ultimately different research results.

Studies on female athletes (triathlon (39), rowing (40), middle- and long-distance running, football, and skiing (41)) found no significant difference in Wingate anaerobic power test results between the EF and ML phases. In addition, the results of lactic acid accumulation, average power (40), and constant load test (25) after five groups of 15-second bicycle sprints (interval 2 minutes) were unaffected by the MC. However, Yapic et al. (42) tested 15 athletes and found that Wingate peak power and average power results were better during OVU than during EF.

Anaerobic exercise derives energy through phosphate and anaerobic glycolysis in muscle. There is a lack of research examining the impact of the menstrual cycle (MC) on phosphate utilization. However, Harber et al. (43) compared endurance athletes with amenorrhea and normal MC and found that after plantar flexion training, the recovery of creatine phosphate in athletes with amenorrhea was slow, indicating that the hormone level of the ovary may affect the recovery of phosphate.

The inconsistent results of anaerobic performance research may be related to the determination method of exercise levels and MC phases but tend to support the conclusion that anaerobic performance is unaffected by the MC. Untrained eumenorrheic women has not received long-term anaerobic training, and their level of anaerobic performance itself is low. Therefore, finding differences in studies conducted during different MC phases is difficult. Among four-item studies on athletes (25, 39–41), only the work of Lebrun et al. (25) used blood hormones to determine the MC phase. Given that the methods based on dates, body temperature, and urine utilized in other studies are inaccurate, different conclusions were obtained. The use of blood hormones is recommended in future experiments to increase the accuracy of conclusions.

3.3 Muscle strength

3.3.1 Maximal strength

A total of twenty-one relevant studies were incorporated, with a synopsis of their key findings and attributes presented in Table 4. In studies on untrained eumenorrheic women, six scholars tested the flexion and extension of the knee joint of the lower body through isokinetic muscle strength (44, 46, 49) or maximum voluntary contraction (45, 47, 48, 50) tests and found that the maximum strength of the lower body was unaffected by the MC. No significant difference in upper body grip strength at different times was found (51, 52). However, two scholars believe that maximum strength fluctuates during the menstrual period (53, 54). Phillips et al. (53) believed that the upper body grip strength is higher during the FP than during other phases. Rodrigues et al. (54) found through the 45° pedal test of the lower body that the maximum strength of the lower body during EF was higher than that during LL, and the maximum strength of the lower body was greater during the premenstrual period than during the postmenstrual period. The results of both studies suggested that strength performance is best during the FP. However, different conclusions were also reached (52, 55). Ansdell et al. (55) believed that the muscle strength of the lower body was highest during OVU. In the isokinetic test on the knee joints of ordinary college students, Ekenros et al. (52) found that strength during EF was less than that during ML.

The results of research on female athletes are also inconsistent. Some studies have shown no significant change in the maximum strength of the lower body in different time phases (25, 56–60). Some studies have also illustrated that the maximum voluntary contraction strength of the knee extensor muscle group is lower during LF and ML than during LL^[30]. Dos Santos et al. (60) tested the knee muscle strength of football players during the FP and LP and found that the ratio of hamstring to quadriceps strength of nondominant legs was greater during the LP than during the FP but found no significant difference in dominant legs. In terms of upper body muscle strength, Shahraki et al. (61) tested upper body shoulder strength (abduction, internal rotation, and external rotation) and reported that strength was higher during OVU than during EF and ML and grip strength was best during the FP (62).

The results of studies on the effect of MC on maximum strength showed that when estrogen level was high, maximum strength also increased. Maximum strength was worst during the LP likely because in the physiological cycle, estrogen gradually decreased after OVU, whereas progesterone gradually increased and peaked during ML. The specific mechanism of the effect of the fluctuating relationship between estrogen and progesterone on maximum strength remains unclear. However, the two hormones can affect the physiological factors of maximum strength, such as nerve excitability and the contraction coupling of muscle fibers. Estradiol and progesterone have opposite effects on nerve excitation. Specifically, estradiol can increase glutamate-mediated neuronal excitability and reduce the neuronal excitation threshold; the neurosteroid metabolites of progesterone can bind to the γ-aminobutyric acid (GABA) receptor complex, enhance its activity via an allosteric mechanism, reduce neuronal excitability, and elevate the neural excitation threshold (63). In terms of muscle contraction, estrogen promotes the improvement in myosin function by acting on estrogen receptors, thereby affecting the binding of myosin to actin (64). Experiments on rodents and humans have shown that estrogen can promote strength by changing muscle mass (64). In addition, female endogenous testosterone (T) also fluctuates during the MC. Such fluctuations are manifested by the gradual increase in serum total and free T during the FP; serum total T and free T then peak during OVU and gradually decrease during the LP (65). A study examined the relationship between endogenous testosterone (T) concentration in females and muscle mass, strength, and surface muscle performance (66). It found that quadriceps muscle mass and maximal stretching strength increased as levels of free testosterone or bioavailable testosterone rose (66). During the FP, estrogen and T are high, and the positive effects of both hormones on nerves and muscles account for the optimal maximum muscle strength during this phase.

Exploring the potential of physiological cycle characteristics to inform strength training planning may hold practical value. According to Kissow et al. (67), resistance training during the FP was observed to promote muscle strength and increase muscle volume to a greater extent than during the LP in their study. In training practice, adjusting the frequency of strength training during the FP might be a viable approach to explore for optimizing training outcomes.

3.3.2 Power strength

Studies on untrained eumenorrheic women found no significant differences in various jump performance metrics across menstrual phases: squat jump (SJ) and multiple jump tests (maximum power and height) during EF, LF, and ML (68); countermovement jump (CMJ), drop jump (reaction strength index) (69), and vertical jumps (height and power) during EF, LF, and LL (70); and single-leg jump distances during EF and LP (52). However, different results were also obtained (42, 69). Aysegul et al. (42) showed that CMJ performance during OVU was better than that during EF, and Felipe et al. (69) reported that SJ height during the LP was higher than that during EF.

The results of studies on female athletes are also inconsistent (62, 71, 72). Tsolakis et al. (71) used Boso Ergo jump test equipment to test the CMJ, SJ, and repeated jump performances of 10 international fencing athletes and found no significant differences in lower body power strength during EF, LF, and LL; the CMJ and SJ test results of handball players during EF, LF, and the LP also showed no significant differences (72). However, when Tasmektepligil et al. (62) used Takei jump test equipment on 30 athletes (including basketball, football, and judo) during the same three phases, they found that CMJ was better during LL than during EF.

Research exploring the relationship between lower-body power and the MC remains limited. Power strength is not only affected by physiological factors, such as age, weight, body fat, muscle volume, and nervous system regulation, but also by training factors. Various factors must be included and comprehensively considered when considering the influence of MC on power strength.

4 Related factors affecting the difference in exercise ability during different MC phases

4.1 MC-related symptoms

The MC is a unique biological rhythm of women. The psychological and physiological symptoms associated with menstruation have a negative effect on the daily life and work of women. More than 100 potential psychological changes, such as anxiety and depression, exist. Physiologically, MC manifests as lower abdominal colic, abdominal distension, fatigue, drowsiness, and severe premenstrual syndrome (PMS) (9). Martin et al. (73) found that 77% of female athletes (N = 430) had conditions, such as pain, cramps, headache, or migraine and even PMS. Heavy menstrual bleeding (HMB) can also lead to fatigue, anxiety, and other negative emotions and has a negative effect on life. A survey found that the incidence of HMB in the sports population is higher than that in the general population, and the incidence of HMB in elite athletes reached 37% (74). The incidence of exercise-associated menstrual disorders in female athletes has also increased annually (75).

In a cross-sectional survey of elite female athletes by Ergin et al. (76), 70% of female athletes (N = 430) reported that EF-related symptoms affected their participation in competition or training. A four-phase follow-up survey of six college athletes (77) revealed that self-perception strength and speed were poor during ML and LL, and explosive power was poor during EF, ML, and LL. The above results in elite or ordinary athletes support that women perform worst during EF and LL and better during other phases. This finding is consistent with the proneness to fatigue, drowsiness, and pain during EF and LL.

4.2 Body weight and composition

Many women state that their weight fluctuates throughout the MC. This condition may affect exercise performance. Although some studies on female athletes and untrained eumenorrheic women showed that no remarkable change in body weight and body fat occur throughout the MC (25), some have shown that body weight decreases gradually from EF to LF and then increases continuously from EF to the LP. This change may be due to the increase in extracellular water (78). It may also be due to the increase in progesterone and decrease in insulin during the LP, resulting in increased appetite and food intake (79). Hormonal fluctuations during the MC have been suggested to not affect weight and body water changes; it may instead affect distribution rather than the body’s retention or exclusion of water (80).

4.3 BBT

Most studies support that the BBT fluctuates during the MC, that is, the BBT is high during the LP likely in relation to the increase in progesterone. Studies have shown that estrogen and progesterone may interact in a complex manner to regulate body temperature through the central and peripheral systems. Progesterone acts on thermosensitive neurons in the preoptic area of the hypothalamus to increase heat production or reduce heat loss, whereas estrogen promotes heat loss or heat production reduction. Estrogen and progesterone may also feed back to the hypothalamus through the effect of the peripheral vasomotor state to further regulate body temperature (81). However, the BBT during the LP is only 0.3°C–0.5°C higher than that during other phases. Studies have illustrated that sufficient warm-up activities can offset the difference in BBT caused by different phases without affecting exercise performance during different phases (82).

5 Attitudes of athletes and coaches toward MC

Although reports related to the female MC are increasing and deepening, the MC may remain an obscure term for the eumenorrheic women. The MC is considered a shameful and embarrassing topic. A survey shows that stigma continues to surround the MC. One in four women states they are overwhelmed at the time of menarche, and 48% of women say they are ashamed when they talk about the MC (83). This situation also exists in female athletes. According to a survey of elite athletes, some athletes are reluctant to communicate MC problems with their coaches or medical staff because they are ashamed or because of gender differences and believe that communicating with them will not help (84).

Communication between coaches and female athletes is equally important. Most coaches emphasize sports-related techniques and tactics, teaching methods, athlete management, and nutrition and pay little attention to the MC of athletes and its effect on exercise performance (85). The attitudes of male and female coaches toward the MC differ. Male coaches think that the regularity of the MC is unimportant, do not understand relevant knowledge, and find communicating about the MC with female athletes inconvenient (86). Although female coaches have a natural gender advantage in terms of the MC of athletes, most female athletes’ coaches are male (87). This situation increases the difficulty of communication between coaches and female athletes. Coaches’ neglect of the MC-related needs of athletes may lead to the athletes’ inability to leverage their exercise performance fully due to the effect of the MC, which in turn affects competition results. The important role of the coach’s identity in the athlete’s entire sports career is not fully reflected. Therefore, further improving athletes’ own understanding of the MC, improving coaches’ attitude towards athletes’ MC, and increasing communication between coaches and athletes are recommended to reduce the negative effect of the MC on exercise performance.

6 Conclusion

Although a considerable proportion of female athletes believe that their exercise performance is affected by the MC, some differences may be due to small sample sizes, lack of blood hormone–based methods to determine the MC phase, poor control of confounding factors, and nonrandomization of experiments. No significant difference in exercise performance during different phases of the MC have been observed in the present study. Existing research examining differences in exercise performance has produced conflicting conclusions. Anaerobic performance generally appears unaffected by variations in MC phases, though ovarian hormones may influence post-exercise energy recovery. Aerobic performance tends to be greater during FP than LP, with glucose intake potentially mitigating the impact of MC-related hormonal fluctuations on this performance. Maximum strength performance tends to be relatively lower during the LP. Nevertheless, the patterns of hormonal fluctuations throughout the MC may offer potential insights for refining strength training approaches to support muscle strength enhancement. The difference in explosive power during different phases of the MC remains controversial.

In recent years, due to the increase in women’s participation in sports, the research on the exercise performance of women has also increased. Many methods for determining the phase of the female MC, an important step in this kind of research, exist. Some inaccuracies, except for blood estrogen and progesterone, were observed. Although some scholars used a combination of methods, adding blood estrogen and progesterone (including post hoc) measurement is recommended to enhance accuracy. In addition, current research usually provided a cross-sectional test or questionnaire to untrained eumenorrheic women or athletes. The comparison of the differences between untrained eumenorrheic women and elite athletes is scarce, and whether differences among female athletes at different sports levels exist are unclear. Studies on exercise ability focused on aerobic, anaerobic, and strength parameters, whereas research on speed, sensitivity, and flexibility is lacking. Further research is needed to quantify the exercise performance during different phases of the MC and determine the relevant factors affecting the change in exercise performance to understand women’s exercise performance fully. Such research provides help to athletes in regulating their physiological cycle before games and ensuring their full performance during competition.

Clarifying the effect of MC on various exercise performance is crucial for sports researchers and coaches to formulate training plans rationally, ensure athletes’ physical health, improve exercise performance, and extend sports careers. Therefore, further studying the influence of MC on sports ability and its potential mechanism is necessary. In some cases, the related problems of athletes’ MC should be discussed in the same important position as other training loads and skills that affect exercise performance. The communication between athletes and coaches should be increased, open discussion and analysis should be conducted with a positive attitude, and more women should be encouraged to participate in sports.

Author contributions

YW: Writing – original draft. BG: Writing – review & editing. RW: Writing – review & editing. CZ: Conceptualization, Writing – review & editing.

Funding

The author(s) declared that financial support was received for this work and/or its publication. This study was supported by Shanghai Key Laboratory of Human Performance (11DZ2261100).

Conflict of interest

The authors declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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The author(s) declared that Generative AI was not used in the creation of this manuscript.

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fendo.2025.1448686/full#supplementary-material

Supplementary Figure | Summary of the search and screening methods implemented in this narrative review.

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