Programming For Menstruating Women: How We Get The Best Results
There is a lot of misinformation and confusion surrounding the menstrual cycle and in my personal experience it is not talked about enough by exercise professionals and their clients. Since the majority of personal training clients are women, we should each have a good understanding of their physiology to help support our clients in navigating and understanding their own bodies in order to get the most out of their training. This article will discuss the impact the menstrual cycle may have on resistance training and what we can do to get the most out of training despite challenges presented to female athletes by their unique physiology.
Women are subject to constantly fluctuating steroid hormones as a result of the menstrual cycle so it is important to consider how these may impact training (Thompson et al., 2020). The menstrual cycle is split in to two distinct phases: the follicular phase starting on the first day of bleeding and finishing approximately two weeks later when ovulation occurs, and the luteal phase which starts with ovulation and ends with the beginning of the next menstrual period (Brown, Knight & Forrest, 2021). The early follicular phase begins with low progesterone and oestrogen. The late follicular phase occurs when oestrogen increases to high levels whilst luteinising hormone upsurges as ovulation approaches. After ovulation, the luteal phase begins with luteinising hormone returning to baseline levels as high levels of oestrogen and progesterone are observed (Blanca Romero-Moraleda et al., 2019). Around 90% of women experience menstrual symptoms (Bruinvels et al., 2021). These symptoms include pain, cravings, low mood, energy and motivation, lethargy and increased anxiety, amongst others. It is common that training sessions or competitions are missed by menstruating women due to menstrual pain (Bruinvels et al., 2021). Menstrual symptoms can be experienced throughout the month with the majority reported around menstruation at the late luteal/early follicular phase (Jarvis & McCabe, 1991). These are suggested anecdotally to be the times associated with the poorest performance (Giacomoni et al., 2000).
Although it appears that maximal strength, force and lifting velocity likely doesn’t change much throughout the menstrual cycle (Blanca Romera-Moraleda et al., 2019) the research is mixed (Rodrigues et al., 2019). A larger study of 100 women over a minimum of six months found that grip strength was significantly higher and reported fatigue was significantly lower in the follicular phase (Pallavi, Souza & Shivaprakest, 2017). A review by Pereira, Larson and Bemben (2020) found that out of sixteen studies, only four found a statistically significant difference in maximal strength between stages of the menstrual cycle. That said, it has been observed in some studies that training around the menstrual cycle yields greater increases in strength. By biasing the majority of training sessions into the follicular phase of the cycle and reducing the number of training sessions in the luteal phase greater strength increases were observed than a more typical and even distribution of sessions throughout the month (Reis at al., 1995). Furthermore, when this follicular based model was compared to the opposite layout where more sessions are performed in the luteal phase than in the follicular (Sung et al., 2015) similar findings were reported – the follicular based training groups still seemed to get better results from their training. This implies that energy and effort may be better spent in the follicular phase when trying to increase strength. The mechanism for this remains unclear although it seems likely that the presence of these symptoms may contribute to the better training sessions occurring in the follicular phase. Given that menstrual symptoms seem to be concentrated around the late luteal phase, it seems likely and natural that exercise quality and/or consistency may suffer during this phase of the cycle.
With this in mind, how can we interpret the evidence to get the best results for female clients?
Tracking the menstrual cycle can help our clients to better understand her own cycle and symptoms and when energy levels, concentration and mood are best. This can help us understand where to place heavy training sessions or new/skills based work in the menstrual cycle to achieve best results. It can help women who find themselves distracted, lethargic, tired or in pain regularly at any given stage of the cycle get the most out of the training and have the best chance of leaving the workout feeling accomplished and not defeated. However, it is important to consider that tracking menstrual symptoms may be a moving target for many women as they change throughout the life time and although there are likely to be some patterns, no two cycles are likely to be identical (Allshouse et al., 2018). Women with irregular cycles my be especially subject to unpredictable fluctuations and although tracking may help, it is likely that tracking the cycle is likely to benefit some women more than others.
Although it appears unlikely that maximal strength is reduced at any stage in the menstrual cycle, more traditional approach to programming that assumes a client’s ability to perform at a given percentage of their one repetition maximum may still not be the best approach when symptoms are at their worst. Asking a client who is anxious and in pain, regardless of the reason, to perform at her usual level may be off putting to the client (arguably making them more likely to skip training) and potentially detrimental to motivation by impacting her perception of her progress. To prevent missed sessions (Bruinvels, et al., 2020) and the loss of motivation, results and revenue, it seems logical that we as trainers should be taking some steps to adapt sessions to ensure the client is able to train as consistently as possible and get the most from her efforts.
An alternative to this more traditional method is the use of autoregulation. Monitoring subjective intensity of sets allows us to adapt training intensity to reflect the recovery status of our client on any given day (Helms, 2017; Larsen et al., 2021) and takes into consideration the individual rate that each person adapts to training (Shattock & Tee, 2022). There are a number of ways to implement autoregulation but the best known is probably using rate of perceived exertion (RPE) scales to monitor lifting intensity. However, this method has been more recently adapted to better fit resistance training. Repetitions in reserve (RIR) has been shown to be fairly accurate at higher intensities (Zourdos et al., 2021) and an easy to implement tool to use for this purpose. It works by asking clients to communicate how many additional repetitions they could have done after the set finished and using this data to adapt the weight to the intended intensity. Since the energy levels of our female clients are likely to fluctuate throughout the menstrual cycle, autoregulation may allow for greater performance when energy is good and better recovery when needed by ensuring that subjective intensity matches the intended intensity. Autoregulation has been shown in many cases to be more effective than fixed load programming for increasing strength (Zhang et al., 2021) and using RIR to monitor subjective intensity is likely to be a practical way to enhance maximal strength (Larsen et al., 2019).
In conclusion, our female clients are not small men. Understanding how a person’s unique physiology impacts them can ensure than training is as sustainable and as beneficial is possible. Tracking the cycle of our clients, maintaining good communication and listening to them may be key for ensuring they get the most out of their training, even when their menstrual cycle makes training more challenging. Supporting athletes in getting to understand their bodies can only help them feel empowered and get the most from their sessions as well as helping coaches support their clients when training gets especially tough. Taking into consideration subjective intensities when lifting and adapting weights accordingly can help to enhance strength whilst facilitating better recovery when needed. This arguably helps make resistance training more sustainable when clients are not feeling their best due to menstrual symptoms. Taking into account the current situation a client is in will help cultivate trust, buy-in and strengthen the coaching relationship.
References
Allshouse, A., Pavlovic, J., & Santoro, N. (2018). Menstrual Cycle Hormone Changes Associated with Reproductive Aging and How They May Relate to Symptoms. Obstetrics and Gynecology Clinics of North America, 45(4), 613-628.
Brown, N., Knight, C. J., & Forrest, née W. L. J. (2021). Elite female athletes’ experiences and perceptions of the menstrual cycle on training and sport performance. Scandinavian Journal of Medicine & Science in Sports, 31(1), 52–69.
Bruinvels, G., Goldsmith, E., Blagrove, R., Simpkin, A., Lewis, N., Morton, K., Suppiah, A., Rogers, J. P., Ackerman, K. E., Newell, J., & Pedlar, C. (2021). Prevalence and frequency of menstrual cycle symptoms are associated with availability to train and compete: A study of 6812 exercising women recruited using the strava exercise app. British Journal of Sports Medicine, 55(8), 438-443.
Giacomoni, M., Bernard, T., Gavarry, O., Altare, S., & Falgairette, G. (2000). Influence of the menstrual cycle phase and menstrual symptoms on maximal anaerobic performance. Medicine and science in sports and exercise, 32(2), 486-492.
Helms, E. (2017). Using the Repetitions in Reserve-based Rating of Perceived Exertion Scale to Autoregulate Powerlifting Training (Doctoral dissertation, Auckland University of Technology).
Jarvis, T. J., & McCabe, M. P. (1991). Women's experience of the menstrual cycle. Journal of psychosomatic research, 35(6), 651-660.
Julian, R., Skorski, S., Hecksteden, A., Pfeifer, C., Bradley, P. S., Schulze, E., & Meyer, T. (2021). Menstrual cycle phase and elite female soccer match-play: Influence on various physical performance outputs. Science and Medicine in Football, 5(2), 97-104.
Larsen, S., Kristiansen, E., & van den Tillaar, R. (2021). Effects of subjective and objective autoregulation methods for intensity and volume on enhancing maximal strength during resistance-training interventions: a systematic review. PeerJ, 9, e10663.
Pallavi, L. C., D Souza, U. J., & Shivaprakash, G. (2017). Assessment of Musculoskeletal Strength and Levels of Fatigue during Different Phases of Menstrual Cycle in Young Adults. Journal of clinical and diagnostic research : JCDR, 11(2), CC11–CC13.
Read, P., Mehta, R., Rosenbloom, C., Jobson, E., & Okholm Kryger, K. (2021). Elite female football players’ perception of the impact of their menstrual cycle stages on their football performance. A semi-structured interview-based study. Science and Medicine in Football, (just-accepted).
Reis, E., Frick, U., & Schmidtbleicher, D. (1995). Frequency variations of strength training sessions triggered by the phases of the menstrual cycle. International journal of sports medicine, 16(08), 545-550.
Rodrigues, P., de Azevedo Correia, M., & Wharton, L. (2019). Effect of menstrual cycle on muscle strength. Journal of Exercise Physiology Online, 22(5), 89-96.
Romero-Moraleda, B., Del Coso, J., Gutiérrez-Hellín, J., Ruiz-Moreno, C., Grgic, J., & Lara, B. (2019). The influence of the menstrual cycle on muscle strength and power performance. Journal of human kinetics, 68, 123.
Shattock, K., & Tee, J. C. (2022). Autoregulation in resistance training: a comparison of subjective versus objective methods. Journal of Strength and Conditioning Research, 36(3), 641-648.
Sung, E., Han, A., Hinrichs, T., Vorgerd, M., Manchado, C., & Platen, P. (2014). Effects of follicular versus luteal phase-based strength training in young women. Springerplus, 3(1), 1-10.
Thompson, B., Almarjawi, A., Sculley, D. et al. The Effect of the Menstrual Cycle and Oral Contraceptives on Acute Responses and Chronic Adaptations to Resistance Training: A Systematic Review of the Literature. Sports Med 50, 171–185 (2020).
Zhang, X., Li, H., Bi, S., Luo, Y., Cao, Y., & Zhang, G. (2021). Auto-regulation method vs. fixed-loading method in maximum strength training for athletes: a systematic review and meta-analysis. Frontiers in Physiology, 244.
Zourdos, M. C., Goldsmith, J. A., Helms, E. R., Trepeck, C., Halle, J. L., Mendez, K. M., ... & Byrnes, R. K. (2021). Proximity to failure and total repetitions performed in a set influences accuracy of intraset repetitions in reserve-based rating of perceived exertion. The Journal of Strength & Conditioning Research, 35, 158-165.