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Cited by 812Sports Performance and TrainingCardiovascular and exercise physiologyMenstrual Health and Disorders

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The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis

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McNulty, Kelly Lee, Elliott-Sale, Kirsty Jayne, Dolan, Eimear, Swinton, Paul Alan, Ansdell, Paul, Goodall, Stuart, Thomas, Kevin, Hicks, Kirsty Marie·2020·Sports Medicine
DOI 10.1007/s40279-020-01319-3PMC PMC7497427
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Abstract

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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Figures

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]
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]CC BY · PubMed Central
Fig. 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines flow chart for literature search and study selection
Fig. 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines flow chart for literature search and study selectionCC BY · PubMed Central
Fig. 3 Quality rating of outcomes from all included studies (n = 78). Each bar represents the proportion of studies assigned a “high,” “moderate,” “low,” or “very low” quality rating. The x-axis represents the different stages of the quality appraisal process, with question one (Q. 1) and question two (Q. 2) indicating the questions asked to determine menstrual cycle phase identification and verification in each study, with the final bar representing the proportion of studies assigned to each quality rating category
Fig. 3 Quality rating of outcomes from all included studies (n = 78). Each bar represents the proportion of studies assigned a “high,” “moderate,” “low,” or “very low” quality rating. The x-axis represents the different stages of the quality appraisal process, with question one (Q. 1) and question two (Q. 2) indicating the questions asked to determine menstrual cycle phase identification and verification in each study, with the final bar representing the proportion of studies assigned to each quality rating categoryCC BY · PubMed Central
Fig. 4 Bayesian Forest Plot of multilevel meta-analysis comparing performance measured during the early follicular phase with all other menstrual cycle phases. The study-specific intervals represent individual effect size estimates and sampling error. The circle represents the pooled estimate generated with Bayesian inference along with the 95% credible interval (95% CrI). Negative values favour all other menstrual cycle phases (late follicular, ovulation, early luteal, mid-luteal and late luteal) compared to the early follicular phase. High and moderate quality studies are indicated with an asterisk (*)
Fig. 4 Bayesian Forest Plot of multilevel meta-analysis comparing performance measured during the early follicular phase with all other menstrual cycle phases. The study-specific intervals represent individual effect size estimates and sampling error. The circle represents the pooled estimate generated with Bayesian inference along with the 95% credible interval (95% CrI). Negative values favour all other menstrual cycle phases (late follicular, ovulation, early luteal, mid-luteal and late luteal) compared to the early follicular phase. High and moderate quality studies are indicated with an asterisk (*)CC BY · PubMed Central
Fig. 5 Network diagram illustrating the pairwise effect sizes calculated across the six menstrual cycle phases (early follicular, late follicular, ovulation, early luteal, mid-luteal and late luteal). The analysis included direct and indirect pairwise effect sizes from 73 studies. The relative size of nodes and relative thickness of connecting lines illustrate the frequency of outcomes measured in a given menstrual cycle phase and the number of direct comparisons between two phases, respectively
Fig. 5 Network diagram illustrating the pairwise effect sizes calculated across the six menstrual cycle phases (early follicular, late follicular, ovulation, early luteal, mid-luteal and late luteal). The analysis included direct and indirect pairwise effect sizes from 73 studies. The relative size of nodes and relative thickness of connecting lines illustrate the frequency of outcomes measured in a given menstrual cycle phase and the number of direct comparisons between two phases, respectivelyCC BY · PubMed Central

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Research works printed but not linked: 3

  1. Cohen J. Statistical power analysis for the social sciences. 2nd ed. New Jersey: Lawrence Erlbaum Associates; 1988.
  2. Grucza R, Pekkarinen H, Hanninen O. Cardiorespiratory responses to bicycle incremental exercise in women taking oral contraceptives. Biol Sport. 2002;19(3):267–79.
  3. Masterson G. The impact of menstrual phases on anaerobic power performance in collegiate women. J Strength Cond Res. 1999;13(4):325–9.

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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
Publisher
Springer Science and Business Media LLC
Published
2020-07-13
Volume
50
Issue
10
Pages
1813-1827
ISSN
  • 0112-1642 (ISSN-L)
  • 1179-2035
DOI
10.1007/s40279-020-01319-3
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
Licence
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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