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The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis
Open accessAbstract
Background: Concentrations of endogenous sex hormones fluctuate across the menstrual cycle (MC), which could have implications for exercise performance in women. At present, data are conflicting, with no consensus on whether exercise performance is affected by MC phase. Objective: To determine the effects of the MC on exercise performance and provide evidence-based, practical, performance recommendations to eumenorrheic women. Methods: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four databases were searched for published experimental studies that investigated the effects of the MC on exercise performance, which included at least one outcome measure taken in two or more defined MC phases. All data were meta-analysed using multilevel models grounded in Bayesian principles. The initial meta-analysis pooled pairwise effect sizes comparing exercise performance during the early follicular phase with all other phases (late follicular, ovulation, early luteal, mid-luteal and late luteal) amalgamated. A more comprehensive analysis was then conducted, comparing exercise performance between all phases with direct and indirect pairwise effect sizes through a network meta-analysis. Results from the network meta-analysis were summarised by calculating the Surface Under the Cumulative Ranking curve (SUCRA). Study quality was assessed using a modified Downs and Black checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group. Results: Of the 78 included studies, data from 51 studies were eligible for inclusion in the initial pairwise meta-analysis. The three-level hierarchical model indicated a trivial effect for both endurance- and strength-based outcomes, with reduced exercise performance observed in the early follicular phase of the MC, based on the median pooled effect size (ES 0.5 = − 0.06 [95% credible interval (CrI): − 0.16 to 0.04]). Seventy-three studies had enough data to be included in the network meta-analysis. The largest effect was identified between the early follicular and the late follicular phases of the MC (ES 0.5 = − 0.14 [95% CrI: − 0.26 to − 0.03]). The lowest SUCRA value, which represents the likelihood that exercise performance is poor, or among the poorest, relative to other MC phases, was obtained for the early follicular phase (30%), with values for all other phases ranging between 53 and 55%. The quality of evidence for this review was classified as “low” (42%). Conclusion: The results from this systematic review and meta-analysis indicate that exercise performance might be trivially reduced during the early follicular phase of the MC, compared to all other phases. Due to the trivial effect size, the large between-study variation and the number of poor-quality studies included in this review, general guidelines on exercise performance across the MC cannot be formed; rather, it is recommended that a personalised approach should be taken based on each individual's response to exercise performance across the MC.
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![Fig. 1 Schematic displaying the hormonal fluctuations across an idealised 28-day menstrual cycle, with ovulation occurring on day 14 Adapted from Pitchers and Elliott-Sale [8]](/paper-figures/b46ddc4dd55e42ccacd9fd05b1b440ce/the-effects-of-menstrual-cycle-phase-on-exercise-performance-in-eumenorrheic-figure-1.jpg)




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“A Bayesian approach was selected because it estimates the full probability distribution of treatment effects rather than relying on binary significance testing, allowing more informative interpretation of effect sizes and associated uncertainty [40, 41].”
From The Effect of Different Psychological Interventions on Athletes' Competitive Anxiety: A Systematic Review and Bayesian Network Meta-Analysis. (2026) · cites this paper as [41]
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“23 Rather than fully adopting this “trend,” the current study’s results suggest that it may be advantageous for athletes to avoid high-intensity activity during ovulation (Figure 3).”
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“…menstruation, with low levels of oestrogen and progesterone) followed by the late follicular phase (i.e., oestrogen rises and peaks prior to ovulation), ovulation (i.e., the release of an egg from an ovary), and the luteal phase (i.e., a second, smaller rise in oestrogen and peak progesterone) [9].”
Meixner, F., & Herbert, C. (2021) · Frontiers in Physiology · doi:10.3389/fphys.2021.680149 · Cited by 11
“Between T3 and T4, participants completed the experimental HisMine paradigm measuring emotional evaluation of self-related emotional stimuli (Herbert et al., 2011a,b, 2018; Winter et al., 2015, 2018; Weis and Herbert, 2017; Meixner and Herbert, 2018; Meixner et al., 2019).”
BackgroundHamer, J., Desbrow, B., & Irwin, C. G. (2022) · International Journal of Sports Science & Coaching · doi:10.1177/17479541221140188 · Cited by 8
“A greater number of trained female coaches will likely improve communication on menstrual health, supporting athlete health.(54,57) In maledominated coaching environments, an immediate strategy could involve prioritising opportunities to increase female representation within the training environment (e.”
BackgroundSandbakk, S. B., Tønnessen, E., Haugen, T. A., & Sandbakk, Ø. (2022) · German Journal of Sports Medicine · doi:10.5960/dzsm.2022.549 · Cited by 7
Pérez‐López, A., Garriga‐Alonso, L., Montalvo‐Alonso, J. J., del Val‐Manzano, M., Valadés, D., Vila, H., & Ferragut, C. (2024) · European Journal of Sport Science · doi:10.1002/ejsc.12233 · Cited by 7
“The physiological differences in hormones (McNulty et al., 2020), energy metabolism (Benton et al., 2020; Roepstorff et al., 2002), and body composition between sexes addressed the necessity to investigate female - specific nutritional needs in a sports performance context.”
Seddik, M., Bouzouraa, M. M., Ceylan, H. İ., Hamaidi, J., Ghouili, H., Chtourou, H., Guelmami, N., Dergaa, I., Muntean, R. I., & Souissi, N. (2025) · BMC Sports Science Medicine and Rehabilitation · doi:10.1186/s13102-025-01117-2 · Cited by 12
A hypoenergetic diet with decreased protein intake does not reduce lean body mass in trained females
Pearson, A. G., Alexander, L., Witard, O. C., Coughlin, T. E., Tipton, K. D., & Walshe, I. H. (2020) · European Journal of Applied Physiology · doi:10.1007/s00421-020-04555-7 · Cited by 8
Brown, D., Cappozzo, F., Roeck, D. D., Zariwala, M. G., & Deb, S. K. (2021) · Frontiers in Nutrition · doi:10.3389/fnut.2021.678105 · Cited by 7
Shalfawi, S. A. I., & Kailani, G. E. (2021) · Sports · doi:10.3390/sports9090130 · Cited by 7
“Females between the age of 13 and 50 experience fluctuations in endogenous sex hormones: among others, estrogen and progesterone [1,2].”
BackgroundInfluentialNAGAHORI, H., & Shida, N. (2022) · Physical Therapy Research · doi:10.1298/ptr.e10173 · Cited by 7
Feuerbacher, J. F., Dragutinovic, B., Jacobs, M. W., & Schumann, M. (2023) · International Journal of Sports Physiology and Performance · doi:10.1123/ijspp.2022-0377 · Cited by 8
The Effects of Space Flight and Microgravity Exposure on Female Astronaut Health and Performance
Strock, N. C., Rivas, E., & Goebel, K. (2023) · IEEE Aerospace Conference · doi:10.1109/aero55745.2023.10115765 · Cited by 4
“Recent systematic reviews and meta-analyses indicate both aerobic and strength performance are minimally impacted by menstrual cycle phase [61, 62] with trivial reductions during the early follicular phase (effect size=0.”
BackgroundTaipale, R. S., Ihalainen, J. K., Davis-Wilson, H. C., & Hackney, A. C. (2023) · Springer eBooks · doi:10.1007/978-3-031-21881-1_1 · Cited by 9
Mathy, A., Wessner, B., Haider, P., Tschan, H., & Triska, C. (2024) · Frontiers in Physiology · doi:10.3389/fphys.2024.1305895 · Cited by 8
Johnson, K. A., & Shields, R. K. (2024) · Orthopaedic Journal of Sports Medicine · doi:10.1177/23259671241251720 · Cited by 6
“The body of evidence indicating a potential influence of the menstrual cycle on ACL injury, 21,22,46 exercise performance, 40 and adaptations to resistance training 51 is growing but remains limited by the low quality and low quantity of research in these areas.”
BackgroundMethodInfluentialHemmati, H., Alkasasbeh, W. J., Hemmatinafar, M., Salesi, M., Pirmohammadi, S., Imanian, B., & Rezaei, R. (2024) · Frontiers in Physiology · doi:10.3389/fphys.2024.1426872 · Cited by 6
Gurton, W. H., Dabin, L., & Marshall, S. J. (2024) · International Journal of Sports Physiology and Performance · doi:10.1123/ijspp.2023-0535 · Cited by 8
The Effect of Proximity‐To‐Failure on Perceptual Responses to Resistance Training
Refalo, M. C., Helms, E. R., Hamilton, D. L., & Fyfe, J. J. (2025) · European Journal of Sport Science · doi:10.1002/ejsc.12266 · Cited by 8
Power in the flow: how menstrual experiences shape women's strength training performance
Augustsson, S. R., & Findhé-Malenica, A. (2025) · Frontiers in Sports and Active Living · doi:10.3389/fspor.2025.1519825 · Cited by 6
Docter, H., Taylor, M., Müller, A. L., de Koning, J. J., Sandbakk, Ø. B., Osborne, J. O., & Noordhof, D. A. (2025) · Scandinavian Journal of Medicine and Science in Sports · doi:10.1111/sms.70050 · Cited by 9
Donnelly, J. E., Valentin, S., Easton, C., White, A. C., & Forrest, L. J. (2025) · Science and Medicine in Football · doi:10.1080/24733938.2025.2476485 · Cited by 6
“…high-lighted that very high-intensity running distances were greater during the luteal phase compared to the follicular phase in elite football players, a greater volume of high-quality evidence is required to support these findings and for a general consensus to be made (McNulty et al. 2020).”
Rating of perceived exertion in continuous sports: a scoping review with evidence gap map
Torres, G., Maia, F., Nakamura, F. Y., Neiva, H. P., & Sousa, A. (2025) · Frontiers in Sports and Active Living · doi:10.3389/fspor.2025.1553998 · Cited by 6
Howatson, G., Russell, S., Pedlar, C. R., & Halson, S. L. (2025) · Sports Medicine · doi:10.1007/s40279-025-02246-x · Cited by 8
“Given the rise in popularity of women’s football, there is an increasing physical demand on these athletes [7] and concurrent increases in off-pitch demands that include opposition analysis, media involvements, travel to unfamiliar venues, fixture congestion, family and caring responsibilities, and…”
Mikkonen, R. S., Ihalainen, J. K., Bruinvels, G., Mkumbuzi, N. S., Smith‐Ryan, A. E., Kaikkonen, M., Kasongo, M., & Hackney, A. C. (2025) · Sports Medicine · doi:10.1007/s40279-025-02338-8 · Cited by 7
“That is, current evidence suggests that strength/endurance performance does not markedly change over the menstrual cycle [149] or hormonal contraceptive cycle [150]; however, the quality of research behind these findings is relatively low [149, 150], thus limiting our ability to draw robust…”
Stitelmann, A., Bruyneel, A.-V., Enéa, C., & Boisseau, N. (2026) · Sports Medicine · doi:10.1007/s40279-026-02412-9 · Cited by 6
“Indeed, cyclical fluctuations in estrogen and progesterone have traditionally been viewed as the main drivers of exercise performance variation [16, 17]; however, findings remain inconsistent in systematic reviews and meta-analyses [18–21].”
Nardon, M., Venturelli, M., Ruzzante, F., Longo, V. D., & Bertucco, M. (2022) · European Journal of Applied Physiology · doi:10.1007/s00421-021-04867-2 · Cited by 6
Ekenros, L., Rosen, P., Solli, G. S., Sandbakk, Ø. B., Holmberg, H., Hirschberg, A. L., & Fridén, C. (2023) · International Journal of Sports Science & Coaching · doi:10.1177/17479541231216403 · Cited by 7
Iacono, A. D., Watson, K., & Jukić, I. (2024) · International Journal of Sports Physiology and Performance · doi:10.1123/ijspp.2023-0357 · Cited by 6
Wang, P., Jiang, G., Ju, W., Cai, Y., Wang, J., & Wu, F. (2021) · Evidence-based Complementary and Alternative Medicine · doi:10.1155/2021/8624414 · Cited by 6
RetractedYamagishi, T., Saito, A., & Kawakami, Y. (2022) · PLoS ONE · doi:10.1371/journal.pone.0262507 · Cited by 6
“We could obtain the completed questionnaires from 14 out of 19 athletes, and the phases of their cycles were as follows: 1 early follicular, 3 late follicular, 1 ovulatory, 3 early luteal, and 4 late luteal phases [23].”
MethodBella, L. D., Doma, K., Sinclair, W. H., & Connor, J. D. (2023) · International Journal of Sports Physiology and Performance · doi:10.1123/ijspp.2022-0320 · Cited by 6
Morenas‐Aguilar, M. D., Ruiz‐Alias, S. A., Blanco, A. M., Lago‐Fuentes, C., García‐Pinillos, F., & Pérez‐Castilla, A. (2023) · The Journal of Strength and Conditioning Research · doi:10.1519/jsc.0000000000004542 · Cited by 6
“The rise of women ’ s sports may benefit from female physiology – specific research on performance, being the menstrual cycle (MC) as one of the most explored topics (23).”
BackgroundAron, V., Strul, D., Vægter, H. B., Pitance, L., & Armijo-Olivo, S. L. (2024) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2023-0104 · Cited by 6
Menstrual pattern and contraceptive choices of Portuguese athletes
Coutinho, F., Rebelo‐Marques, A., Andrade, R., Espregueira‐Mendes, J., Bombas, T., & Moura, P. (2021) · The European Journal of Contraception & Reproductive Health Care · doi:10.1080/13625187.2021.1879780 · Cited by 6
“Despite the increasing number of publications on the influence of menstrual cycle and contraception in sports performance [7,10], there are no relevant publications for the Portuguese population.”
BackgroundDeshayes, T. A., Daigle, N., Jeker, D., Lamontagne-Lacasse, M., Perreault-Briere, M., Claveau, P., Simoneau, I. L., Chamoux, E., & Goulet, E. D. B. (2021) · Nutrients · doi:10.3390/nu13124477 · Cited by 6
“However, (1) the menstrual cycle phase seems to have no or trivial effect on endurance performance [53,54] but (2) may impact internal temperature differently [55].”
BackgroundCritical power, W′ and W′ reconstitution in women and men
Bourgois, G., Mucci, P., Boone, J., Colosio, A. L., Bourgois, J., Pogliaghi, S., & Caen, K. (2023) · European Journal of Applied Physiology · doi:10.1007/s00421-023-05268-3 · Cited by 10
“Although the physiological responses to exercise performance can slightly differ across the menstrual cycle (McNulty et al. 2020), it has been shown ) in the lower panel that the power–duration relationship did not vary across the menstrual cycle in eumenorrheic women (James et al. 2022).”
Background
Metadata
- Authors
- McNulty, K. L., Elliott-Sale, K. J., Dolan, E., Swinton, P. A., Ansdell, P., Goodall, S., Thomas, K., & Hicks, K. M.
- Affiliations
- Northumbria University (GB)
- Nottingham Trent University (GB)
- Universidade de São Paulo (BR)
- Robert Gordon University (GB)
- Corresponding author
- Elliott-Sale, Kirsty Jayne
- ORCID
- Venue
- Sports Medicine
- Published
- 2020-07-13
- Volume
- 50
- Issue
- 10
- Pages
- 1813-1827
- ISSN
- 0112-1642 (ISSN-L)
- 1179-2035
- PMC
- PMC7497427
- OpenAlex
- W3038797657
- Cited by
- 812
- References
- 127
- Citations by year
- 2026: 183 · 2025: 181 · 2024: 153 · 2023: 136 · 2022: 72 · 2021: 70 · 2020: 17
- FWCI
- 14.50
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Sports Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Nottingham Trent University's Institutional Repository (Nottingham Trent Repository) (acceptedVersion)
- Northumbria Research Link (Northumbria University) (acceptedVersion)
- Open Access Institutional Repository at Robert Gordon University (Robert Gordon University) (submittedVersion, cc-by)
- Funders
- Fundação de Amparo à Pesquisa do Estado de São Paulo (19/05616-6, 2019/, 2019/05616)
- Topics
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
- Health Sciences › Medicine › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
- Keywords
- menstrual cycle phases, exercise performance, eumenorrheic women, sex hormones, follicular phase, luteal phase, endurance performance, strength performance
- MeSH terms
- Female, Humans, Menstrual Cycle, Exercise, Athletic Performance
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