Guidelines for sport and physical activity

• AIS High Performance Pregnancy Guidelines (October 2021). The AIS has developed these guidelines to assist pregnant athletes, athletes planning to become pregnant, and their sports to make safe and informed decisions in relation to HP programs. These guidelines are also designed to inform athletes and their sport of their obligations around matters such as discrimination and inclusion.
• Physical activity and exercise during pregnancy – guidelines, Australian Government - Department of Health, (May 2021). Being active during and after pregnancy is essential for the good health and wellbeing of both you and your baby. You should continue to follow the guidelines for adults, and add pelvic floor exercises. But you might need to modify the exercises you do as your body changes during pregnancy.

Sport specific policies and guidelines

Information about pregnancy policies/requirements for most Australian National Sporting Organisations (NSOs) is included in the sports' Member Protection Policy. While all of these policies highlight that there is zero tolerance for discrimination some, due to specific safety requirements of the sport, may recommend or require pregnant players to obtain medical advice before beginning/continuing to play. Some sports have also developed stand-alone policies:

• Pregnancy and participation in motorsport policy, Motorsport Australia, (May 2020).
• Pregnancy in Netball Policy, Netball Australia, (October 2016)
• Pregnancy guidelines, Softball Australia, (March 2016).
• Pregnancy Policy, Australian Flying Disc Association, (revised 16 September 2014).
• Athlete and coach (Basketball Australia National Teams) pregnancy and parental management policy, Basketball Australia, (2014)
• Guidelines for participation regarding pregnancy and basketball, Basketball Australia (2009)

International examples

• 2019 Canadian guideline for physical activity throughout pregnancy, Canadian Society for Exercise Physiology, (October 2018). New evidence-based guideline outlines the right amount of physical activity women should get throughout pregnancy to promote maternal, fetal, and neonatal health. Physical activity is now seen as a critical part of a healthy pregnancy. Following the guideline can reduce the risk of pregnancy-related illnesses such as depression by at least 25%, and the risk of developing gestational diabetes, high blood pressure and preeclampsia by 40%. Unless contraindicated pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week over a minimum of three days per week; however, being active in a variety of ways every day is encouraged.
• Pregnancy guidelines, International Netball Federation, (July 2014). These pregnancy guidelines have been developed by INF to provide information and guidance for all those participating in netball at international level (including, in particular, players, umpires, bench officials and team officials).

• Female Performance and Health Initiative (FPHI), Australian Institute of Sport, (accessed 11 January 2022). The FPHI was established in October 2019, to improve female athlete specific knowledge and systems of support. The initiative will benefit Australian athletes, coaches, parents, sporting organisations and support staff in the sport sector and will raise awareness and understanding to key female athlete performance and health considerations, including but not limited to: the menstrual cycle and associated dysfunction including endometriosis and Polycystic ovary syndrome (PCOS); Medical conditions impacting female athletes; Pelvic floor health and incontinence; Breast health; Pregnancy and return to sport.
• The Mum-Alete Project, Australian Institute of Sport, (accessed 11 January 2022). An Australian first, this study is being conducted by AIS Medicine in collaboration with the AIS Female Health Performance Initiative, to enhance our understanding of high performance athletes’ sport experiences during and post-pregnancy.
• This Mum Moves is an initiative aimed at supporting pregnant women and new mums to be active. It looks to do this in two key ways: Providing healthcare professionals with the tools and training to knowledgeably and confidently discuss physical activity; and, providing women with further information on the benefits of being active, and activities to try.
  • ukactive kicks off This Mum Moves project with first insights from mothers and healthcare professionals, ukactive, (25 April 2019). A survey of more than 400 healthcare professionals’ showed that 27% did not know whether pregnant women should continue to engage in 150 minutes of moderate-intensity physical activity every week, as recommended in specific guidance introduced by the Chief Medical Officer in 2017. This is in keeping with recommendations for the general adult population. However, 97% said they would be interested in further training to support their practice. The findings were consistent with existing literature in this area that shows there is a lack of knowledge and confidence in providing physical activity advice and guidance during pregnancy and the postnatal period.

• Exercising too much could affect fertility in young, healthy women, expert warns, Amanda Shalala, ABC News, (30 August 2020).So, why would young, healthy women who keep their body in peak physical shape struggle to conceive? Well, it's complicated.
• Fertility and Elite Female Athletes, Jenny Sinclair, Netball Scoop, (2020). A series of case study reports based on the experiences of three elite female netball players who have used assisted reproduction to try and address fertility issues, some of which are particularly relevant to elite sports women. The trailblazers hope that by sharing some of their more intimate details, that people might gain a wider understanding of the problems they faced, and why all active females should consider their health as well as their sporting careers.
  • Part One: Barriers to Fertility
  • Part Two: How can female athletes be better supported
  • Part Three: Geva Mentor – I retrieved my eggs
  • Part Four: Natalie Medhurst – pregnant after fertility treatment
  • Part Five: Sonia Mkoloma – multiple miscarriages
• FIFA outlines new maternity rules for women's football, Dan Palmer, Inside the Games, (19 November 2020). The world governing body said it was bringing in new "global minimum standards" for women's football. New rules include mandatory maternity leave of at least 14 weeks, at a minimum of two thirds of contracted salary. When players return to their clubs, they must be fully reintegrated and provided with medical and physical support.
• Infographic: Guidance for medical, health and fitness professionals to support women in returning to running postnatally, Donnelly GM, Rankin A, Mills H, et al., British Journal of Sports Medicine, Volume 54(18), pp.1114-1115, (2020). Profound physical and physiological changes accompany pregnancy,2 and subsequent tissue healing following childbirth is understood to take 4–6 months.3 These healing timescales should be considered to support a successful return to running postnatally.
• Infographic. Prenatal physical activity: baby steps for better health, Margie H Davenport, Trevor Horbachewsky, Michael Brown, et al., British Journal of Sports Medicine, Volume 54(6), pp.360-361, (2020). Based on the 2019 Canadian guideline for physical activity throughout pregnancy this infographic aims to provide women with pertinent information on the benefits of being active throughout the pregnancy and empower medical professionals to advise patients on physical activity throughout pregnancy with confidence and clarity.
• Is vigorous exercise safe during the third trimester of pregnancy? Kassia Beetham, Exercise Physiology Lecturer, Australian Catholic University, The Conversation, (16 September 2019). Expectant mothers receive an avalanche of information about potential risks to their baby. There’s a growing list of foods, toxins and environmental threats to avoid. It’s normal for this to lead to an increased level of anxiety. As a result, some women believe it’s safer to avoid any risks in pregnancy, no matter how small. Vigorous exercise may be considered one of these risks. But we’ve recently reviewed the research and found vigorous exercise is safe during pregnancy, including in the third trimester. And not only is it safe; it’s healthy, too.
• Physical activity throughout pregnancy: A prescription for improved maternal/fetal health, Margie H. Davenport, Wellspring, (1 November 2018). Being physically active throughout pregnancy can be beneficial for both mother and baby. But how much and at what intensity is recommended? This WellSpring highlights the new 2019 Canadian Guideline for Physical Activity throughout Pregnancy which provides a specific prescription to engage in physical activity that is both safe and beneficial for mothers and babies.
• 'Physically and emotionally I wasn't ready': Hockeyroo Jodie Kenny on returning to sport after pregnancy, Amanda Shalala, ABC News, (2 October 2020). Hockeyroo Jodie Kenny was back playing elite sport nine months after giving birth to her son.
• Pregnancy and Players Agreements, Katrina Nissen, Netball Scoop, (8 January 2020). When considering the fact that netball is consistently rated as the highest female-dominated team sport in the country, it is little wonder that other sports turn to Netball Australia when looking for ways to improve their player’s parenting provisions. So, what do netball’s provisions look like? And, how have they shaped the playing future for female athletes across the country?
• When pregnancy spells the end of a career, Pearce L, The Age (6 July 2015). Many sportswomen's career prospects disappear when they become pregnant. This news item presents the stories of several success Australian sportswomen and how they have managed their sporting career and personal commitments.

• Evidence-based physical activity guidelines for pregnant women, Brown WJ, Hayman M, Haakstad LAH, Mielke GI et al., Report for the Australian Government Department of Health, (March 2020). As part of the suite of national physical activity and sedentary behaviour guidelines for Australians, the Australian Government, in 2018, commissioned a review and synthesis of the evidence to inform the development of practical and safe physical activity guidelines for pregnant Australian women (“the guidelines”). The main purpose of these guidelines is to provide evidence-based best practice recommendations on physical activity/exercisea during pregnancy for Australian women and those who provide healthcare during pregnancy. A five-stage approach, which involved critical ‘umbrella’ reviews of the scientific evidence, and adaptation of recommendations included in recently published guidelines and position statements, was used to develop the Guidelines. The proposed Guidelines and Supporting Information are presented on pages 9-14 of this report.
• Physical activity during pregnancy 2011–12, Australian Institute of Health and Welfare, (2 May 2019). Currently, little is known about how much, and what types of, physical activity pregnant women undertake in Australia. This short report investigates the types and amount of physical activity undertaken by women during pregnancy, with comparisons made between pregnant and non-pregnant women of the same age, and against Australia’s Physical Activity and Sedentary Behaviour Guidelines for adults. The report found that only one third of pregnant women met the Australian physical activity guideline of at least 150 minutes per week of moderate to vigorous activity [compared to around 50% in the general female population as reported in other AIHW reports].

• Benefits of Physical Activity during Pregnancy and Postpartum: An Umbrella Review, Dipietro, Loretta,Evenson, Kelly, Bloodgood, Boony, et al. for the 2018 Physical Activity Guidelines Committee, Medicine and Science in Sports and Exercise, Volume 51(6), pp.1292-1302, (2019). This study aimed to summarize the evidence from the 2018 Physical Activity Guidelines Advisory Committee Scientific Report, including new evidence from an updated search of the effects of physical activity on maternal health during pregnancy and postpartum. The reviewers concluded that the gestational period is an opportunity to promote positive health behaviors that can have both short- and long-term benefits for the mother. Given the low prevalence of physical activity in young women in general, and the high prevalence of obesity and cardio metabolic diseases among the U.S. population, the public health importance of increasing physical activity in women of childbearing age before, during, and after pregnancy is substantial.
• Considerations for the Postpartum Runner, Kate Mihevc Edwards, Strength and Conditioning Journal, Volume 42(1), pp.45-52, (2020). According to Running USA, today there are over 35 million runners in the United States and greater than half are women. The psychological, physiological and biomechanical differences between male and female runners are well cited however, there is little guidance provided to healthcare providers including running and strength coaches about how to transition runners back to running postpartum. This article can serve as a reference for understanding the unique challenges female runners face postpartum and give clinicians the knowledge to manage the athlete’s expectations and training progression.
• Elite Athletes and Pregnancy Outcomes: A Systematic Review and Meta-analysis, Jenna Wowdzia, Tara-Leigh McHugh, Jane Thornton, et.al., Medicine and Science in Sport and Exercise, Volume 53(3), pp.534-542, (2021). The purpose of this systematic review was to evaluate fetal and maternal pregnancy outcomes of elite athletes who had participated in competitive sport immediately before conception. There is “low” certainty of evidence that elite athletes have reduced odds of experiencing pregnancy-related low back pain and “very low”certainty of evidence that elite athletes have increased the odds of excessive weight gain compared with active/sedentary controls. More research is needed to provide strong evidence of how elite competitive sport before pregnancy affects maternal and fetal outcomes.
• Elite athletes get pregnant, have healthy babies and return to sport early postpartum, Jorunn Sundgot-Borgen, Christine Sundgot-Borgen, Grethe Myklebust, et.al., BMJ Open Sport and Exercise Medicine, Volume 5(1), (November 2019). 34 Norwegian elite athletes (33.1 years) and 34 active controls (31.5 years) were asked about training and competitive history, pregnancy-related issues, injuries, body dissatisfaction (BD), drive for thinness (DT), eating disorders (ED) and practical experiences, through a questionnaire and interview. The results showed that both elite athletes and active controls got pregnant easily, delivered healthy babies and decreased training during pregnancy and the first postpartum periods compared with prepregnancy. Most athletes and every third control returned to sport or exercise at week 0–6 postpartum. Athletes reported stress fractures and increased BD and DT, but decreased ED postpartum. However, since relatively few athletes were included these findings need further investigation.
• Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1—exercise in women planning pregnancy and those who are pregnant, Bo K, Aertal R, Barakat R, et.al., British Journal of Sports Medicine, Volume 50(10), pp.571-589, (2016). The IOC assembled an international expert committee to review the literature on physical activity and exercise (1) during pregnancy and (2) after childbirth, using rigorous systematic review and search criteria. Part 1 focuses on the effects of training during pregnancy and on the management of common pregnancy-related symptoms experienced by athletes.
• Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2—the effect of exercise on the fetus, labour and birth, Bø K, Artal R, Barakat R, et al., British Journal of Sports Medicine, Volume 50(21), pp.1297-1305, (2016). This evidence statement, based on a systematic literature search, examines how strenuous exercise affects the fetus. It also addresses issues relating to birth, such as risk of preterm birth, prolonged labour and mode of delivery, including injuries to the pelvic floor muscles and the perineum.
• Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3—exercise in the postpartum period, Bø K, Artal R, Barakat R, et.al., British Journal of Sports Medicine , Volume 51(21), pp.1516-1525, (2017). The aims of this paper are to present (1) the findings from a systematic review of the scientific literature on factors related to returning to exercise after childbirth in recreational and elite athletes, and (2) the prevalence, risk factors and evidence for prevention and treatment of common postpartum conditions that may affect sport performance and overall quality of life.
• Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC expert group meeting, Lausanne. Part 4—Recommendations for future research, Bø K, Artal R, Barakat R, et al., British Journal of Sports Medicine , Volume 51(24), pp.1724-1726, (2017). In Part 4, we recommend future research based on Parts 1–3. The systematic reviews, on which the previous Parts were based, revealed many gaps in knowledge relating to strenuous exercise during pregnancy and in the postpartum period, in both regular recreational exercisers and elite athletes. Important research questions are listed below, in relation to the foci of Parts 1–3, under the following headings: exercise during pregnancy, exercise related to birth outcomes and exercise in the postpartum period.
• Exercise and pregnancy in recreational and elite athletes: 2016/2017 evidence summary from the IOC expert group meeting, Lausanne. Part 5. Recommendations for health professionals and active women, Bø K, Artal R, Barakat R, et al., British Journal of Sports Medicine, Volume 52(17), pp.1080-1085, (2018). Summarises the recommendations for exercise during pregnancy and after childbirth in recreational exercisers and elite athletes experiencing healthy pregnancies. Part 5 also serves as a background for healthcare personnel to advise women who wish to stay active at a high level.
• Exercise Benefits and Recommendations for the 6-Week Postpartum Period, Loewen, Brandon, Collum, Connor, Ryan, Greg A., Strength and Conditioning Journal, Volume 42(4), pp.12-21, (2020). The postpartum period is the stage after childbirth and is associated with many physical and psychological changes. Exercise has been shown to be beneficial for both the physical and psychological health of a new mother. Previous literature has examined the effect of both aerobic and resistance training in this period; however, there have been no clear guidelines and recommendations provided. Therefore, the purpose of this article is to review the benefits of exercise in the postpartum period, and to provide guidelines and a sample 6-week aerobic and resistance training program after exercise initiation after delivery and medical clearance.
• From Childbirth to the Starting Blocks: Are We Providing the Best Care to Our Postpartum Athletes? Rita E. Deering, Shefali M. Christopher, Bryan C. Heiderscheit, Journal of Orthopaedic and Sports Physical Therapy, Volume 50(6), pp.281-345, (2020). There is minimal evidence to guide return to exercise after pregnancy and childbirth, and even less information on safe return to competitive sport. The International Olympic Committee has suggested a 3-phase approach to postpartum recovery in athletes. This Viewpoint expands on that 3-phase model and incorporates a multidisciplinary approach to ensure comprehensive care of postpartum athletes to facilitate safe return to sport with optimal health and performance outcomes. Adopting a multidisciplinary approach may also open new research avenues to ameliorate the dearth of knowledge regarding musculoskeletal recovery and facilitate the development of guidelines to inform clinicians and postpartum women about safe return to exercise, particularly, high-intensity or high-impact activities.
• Postpartum exercise, Brad Roy, ACSM's Health and Fitness Journal, Volume 18(6), pp.3-4, (2014). There are numerous benefits to being physically active after pregnancy, including a reduction in fat mass, increased lean mass, improved lipid profiles, and enhanced mental outlook and acuity. All women are encouraged to begin exercising as soon as medically appropriate and to remain physically active throughout their lifetimes.
• Pregnancy and Postpartum Training: Coaching Considerations, Wise, Stephanie L., Binkley, Jean L., Binkley, Helen M., Strength and Conditioning Journal, Volume 42(4), pp.93-104, (2020). Exercise is beneficial for women to continue during pregnancy and the postpartum period. However, many women do not meet the minimum guidelines set forth by the American College of Obstetricians and Gynecologists. Strength and conditioning coaches and personal trainers working specifically with athletes and nonathletes during childbearing years should continue to encourage their clientele to exercise. Educating them on altering their current exercise program and adapting it as they progress through their pregnancy into the postpartum period is important. General recommendations for exercise and certain modifications may be needed as many physical and physiological adaptations occur within the body during this time.
• ‘Provide clarity and consistency’: the practicalities of following UK national policies and advice for exercise and sport during pregnancy and early motherhood, Eilidh H. R. Macrae, International Journal of Sport Policy and Politics , Volume 12(1), pp.147-161, (2020). This qualitative study employed a social-ecological framework to investigate the experiences of new mothers based in the UK and the practicalities of engaging in regular exercise during pregnancy and the postpartum period. Three themes were generated as recommendations to the sector. The first theme was the importance of providing ‘trusted advice’ from reputable sources. The second theme was the need for provision of ‘safe, affordable sport and exercise options’. The final theme was the need for more ‘considered postpartum support’ for exercise, through further childcare options and a range of supportive environments for women to exercise within postpartum.
• Psychological effects of exercise for pregnant women: a systematic review, Lina Anisa Nasution, Irma Darmawati, EurAsian Journal of BioSciences, Volume 14(2), pp.6983-6990, (2020). The aim of this study was to conduct a systematic mapping review of the literature that explored the psychological effect of sport in pregnant women. The search identified quantitative research studies on the psychological effect of exercise for pregnant women. Nine articles were analyzed through data extraction. The types of exercise discussed in this systematic review include supervised exercise sessions, aerobic dance, endurance training, interval stationary cycling and the intervention followed American College of Obstetricians and Gynecologists (ACOG) guidelines. Pregnant women who have exercise have improved psychological conditions such as decreased sadness, hopelessness, anxiety and the incidence of antenatal depression. Furthermore, pregnant women also showed an enjoyment to exercise. Exercise may have a positive effect on psychological state and reduce risk of psychological distress for pregnant women.
• Spotlight on the fetus: how physical activity during pregnancy influences fetal health: a narrative review, Ilena Bauer, Julia Hartkopf, Stephanie Kullmann, et.al., BMJ Open Sport and Exercise Medicine, Volume 6(1), (2020). In the current review, we aimed to comprehensively assess the evidence of beneficial and harmful effects of maternal PA, including high-performance sports, on fetal development. The different mental and body-based relaxation techniques presented here are frequently performed during pregnancy. We found a considerable number of studies addressing these issues. In general, neither low key, moderate maternal PA nor relaxation techniques were observed to have a harmful effect on the developing child. However, we identified some forms of PA which could have at least a transient unfavourable effect. Notably, the literature currently available does not provide enough evidence to enable us to make a general conclusive statement on this subject. This is due to the lack of longitudinal studies on the metabolic and cognitive effects of regular PA during pregnancy and the wide diversity of methods used. In particular, the kind of PA investigated in each study differed from study to study.
• Why can’t I exercise during pregnancy? Time to revisit medical ‘absolute’ and ‘relative’ contraindications: systematic review of evidence of harm and a call to action, Meah VL, Davies GA, Davenport MH, British Journal of Sports Medicine, Volume 54(23), pp.1395-1404, (2020). We found that the majority of medical conditions listed as contraindications were based on expert opinion; there is minimal empirical evidence to demonstrate harm of exercise and benefit of activity restriction. We identified 11 complications (eg, gestational hypertension, twin pregnancy) previously classified as contraindications where women may in fact benefit from regular prenatal physical activity with or without modifications. However, the evidence suggests that severe cardiorespiratory disease, placental abruption, vasa previa, uncontrolled type 1 diabetes, intrauterine growth restriction, active preterm labour, severe pre-eclampsia and cervical insufficiency are associated with strong potential for maternal/fetal harm and warrant classification as absolute contraindications.

• AIS Female Performance and Health Initiative resources (accessed 11 January 2022):
  • AIS High Performance Pregnancy Guidelines (October 2021). The AIS has developed these guidelines to assist pregnant athletes, athletes planning to become pregnant, and their sports to make safe and informed decisions in relation to HP programs. These guidelines are also designed to inform athletes and their sport of their obligations around matters such as discrimination and inclusion.
  • Breastfeeding as an athlete. Your milk supply, your baby's growth and development and the composition of your breastmilk is unlikely to be affected by your training.
  • Education modules. The AIS has partnered with specialist medical practitioners, high performance athletes and high performance coaches to design a suite of online learning modules for athletes, parents, coaches and medical practitioners. These modules aim to increase your knowledge about the menstrual cycle; menstrual abnormalities; puberty; hormonal contraception; bone, pelvic and breast health, body image; low energy availability and nutrition; and, considerations for coaches and medical practitioners working with female athletes.
• Pregnancy and Exercise resources, Program for pregnancy and postpartum health, (accessed 27 January 2021).
• Pregnancy exercise guide, approved by the BabyCenter Australia Medical Advisory Board (last reviewed July 2019).
• Benefits of sport for the pregnant woman, Wendy Brown, Sports Medicine Australia, (2017).
• Pregnancy and Exercise, Sports Medicine Australia, (2017).
• The risk of abdominal injury to women during sport, Associate Professor Caroline Finch, Sports Medicine Australia, (2017).
• SMA Guidelines – Participation of pregnant athletes in collision sports, Dr Marg Torode, Sports Medicine Australia, (2017).
• Exercise in pregnancy and the postpartum period, Sports Medicine Australia, (2016).

• Female Performance and Health Initiative (FPHI), Australian Institute of Sport, (accessed 27 January 2021). The FPHI was established in October 2019, to improve female athlete specific knowledge and systems of support. The initiative will benefit Australian athletes, coaches, parents, sporting organisations and support staff in the sport sector and will raise awareness and understanding to key female athlete performance and health considerations, including but not limited to: the menstrual cycle and associated dysfunction including endometriosis and Polycystic ovary syndrome (PCOS); Medical conditions impacting female athletes; Pelvic floor health and incontinence; Breast health; Pregnancy and return to sport.
• SmartHER: EIS prioritising female athlete health, Mark Jamieson, English Institute of Sport, (8 March 2019). The English Institute of Sport (EIS) has prioritised opening up conversations amongst athletes, coaches and staff in high performance sport around female athletes’ menstrual cycle and its possible effects, as well as offering expertise to help elite British female athletes be healthy, happy and deliver world class performances.

• Australian women's cricket team tracks players' periods in focus on women's health and fertility, Amanda Shalala, ABC News, (10 October 2020). The aim is to see whether players are regular, and what symptoms they might have. "If we can start to collect those types of things, hopefully down the track, we can start to look at those other facets of the menstrual cycle and how they can actually start to affect performance as well," Dr Inge says.
• Does injury incidence really change across the menstrual cycle? Highlighting a recent key study, Dr Emma Jane Lunan, BJSM blog, (5 April 2021). Part of the BJSM Knowledge translation series. This is a plain language translation of a non-BJSM article. This study aimed to assess whether the menstrual cycle phase and extended cycle length had an influence on the incidence of injuries in international footballers. This study adds further weight to the premise that monitoring athlete menstrual cycles may be useful to identify points within the cycle that athletes are at increased risk of injuries. In particular extended menstrual cycles are easily identified and it may be worthwhile modifying training during this period.
• How periods and the pill affect athletic performance, Dan Gordon, Principal Lecturer Sport and Exercise Sciences, Anglia Ruskin University, The Conversation, (22 September 2020). The menstrual cycle, the pill and their potential impact on sporting performance have long been considered a taboo subject. Yet for most females who undertake any form of exercise or high-performance sport, there are a range of challenges that can affect their athletic performance, including from their menstrual cycle and their use of contraceptive pills. But a historic lack of scientific research in these areas still means we have very limited knowledge of the specific effect that both have on athletic performance. However, what research we do have on these subjects shows both can have an impact on athletic performance – which may be especially important for elite athletes.
• The menstrual cycle and female athletic performance, Johanna Ihalainen, Mid Sweden University, (2019). In a recent study, more than half of elite female athletes reported that hormonal fluctuations during their menstrual cycle negatively affected their exercise training and performance capacity.
• Sport Science on Women, Women in Sport Science. Mujika, Iñigo; Taipale, Ritva S., International Journal of Sports Physiology and Performance, Volume 14(8), pp.1013-1-14, (2019). This editorial article discusses issues on women in sport science and sex differences in responses and adaptations to training. Some interesting comments/links to research in the text include:
  • Unique to women is the ability to legally and ethically alter their hormonal profile and menstrual cycle by using exogenous hormones (hormonal contraceptives).
  • Approximately 42% of exercising women believe that their menstrual cycle has a negative impact on exercise training and performance.
  • Approximately 50% of elite athletes are currently using hormonal contraceptives, and up to 70% have used them. Unfortunately, we still do not fully understand the effects of the menstrual cycle and hormonal contraceptives on training and performance.
  • Monitoring and reporting of menstrual-cycle phase takes a little extra time and effort but could explain “interesting” results. More research should test women in different phases of the menstrual cycle to further elucidate the possible phase effects on training responses, adaptations, and performance (instead of just testing in the follicular, or “low-hormone,” phase of the menstrual cycle, when hormonal profile is “most similar” to that of men).
  • When applicable, use of accurate measurements for determination of both ovulation and nonovulatory cycles may also be important (a menstrual bleed does not necessarily indicate ovulation).
  • Users of hormonal contraceptives should be included in research in their own group to further elucidate the possible effects of exogenous hormones on training adaptations and performance, and the type and delivery methods of hormonal contraceptives should be reported.
  • It would also be of benefit for researchers to consider the potential underlying issues that might have been a reason for using hormonal contraceptives (eg, relative energy deficiency in sport, polycystic ovary syndrome, endometriosis, etc), as these may have influenced endogenous hormone profiles prior to taking hormonal contraceptives.
• Why periods must no longer be a taboo subject in sport, Louise Lawless, The Irish Times, (25 July 2019). Athletes who incorporate menstrual cycle into preparation are reaping the benefits.

• Australian female athlete perceptions of the challenges associated with training and competing when menstrual symptoms are present. Armour, Mike; Parry, Kelly A; Steel, Kylie; et.al., International Journal of Sports Science and Coaching, Volume 15(3), pp.316- , (2020). This study aimed to investigate the strategies used by athletes to manage menstrual symptoms and the role coaches played in this process. One hundred and twenty-four valid responses from Australian athletes 16–45, with a mean age of 29 years, were received. Period pain (82%) and pre-menstrual symptoms (83%) were commonly reported and contributed to fatigue and to perceived reductions in performance during or just prior to the period (50.0% in training, 58.7% on 'game day'). Contraceptive use was reported by 42% of athletes. Those reporting heavy menstrual bleeding (29.7%) were more likely to report increased fatigue. Over three-quarters of athletes reported neither they nor their coaches altered training due to the menstrual cycle. Most athletes (76%) did not discuss menstruation with their coaches. Given the perceived negative impact on performance and potential risks with contraceptive usage during adolescence, coaches, trainers and athletes need to have a more open dialogue around the menstrual cycle.
• Bidirectional Interactions between the Menstrual Cycle, Exercise Training, and Macronutrient Intake in Women: A Review, Sílvia Rocha-Rodrigues, Mónica Sousa, Patrícia Lourenço Reis, et.al., Nutrients, Volume 13(2), (2021). Women have a number of specificities that differentiate them from men. In particular, the role of sex steroid hormones and the menstrual cycle (MC) significantly impact women’s physiology. The literature has shown nonlinear relationships between MC, exercise, and nutritional intake. Notably, these relationships are bidirectional and less straightforward than one would suppose. For example, the theoretical implications of the MC’s phases on exercise performance do not always translate into relevant practical effects. There is often a disconnect between internal measures (e.g., levels of hormone concentrations) and external performance. Furthermore, it is not entirely clear how nutritional intake varies across the MC’s phases and whether these variations impact on exercise performance. Therefore, a thorough review of the existing knowledge could help in framing these complex relationships and potentially contribute to the optimization of exercise prescription and nutritional intake according to the naturally occurring phases of the MC. Throughout this review, an emerging trend is the lack of generalizability and the need to individualize interventions, since the consequences of the MC’s phases and their relationships with exercise and nutritional intake seem to vary greatly from person to person. In this sense, average data are probably not relevant and could potentially be misleading.
• Changes in Self-Reported Physical Fitness, Performance, and Side Effects Across the Phases of the Menstrual Cycle Among Competitive Endurance Athletes, Solli, Guro S.; Sandbakk, Silvana B.; et.al., International Journal of Sports Physiology and Performance, Volume 15(9), pp.1324-1333, (2020). To investigate changes in self-reported physical fitness, performance, and side effects across the menstrual cycle (MC) phases among competitive endurance athletes and to describe their knowledge and communication with coaches about the MC. Methods: The responses of 140 participants (older than 18 y) competing in biathlon or cross-country skiing at the (inter)national level were analyzed.About 50% and 71% of participants reported improved and reduced fitness, respectively, during specific MC phases, while 42% and 49% reported improved and reduced performance, respectively. Most athletes reported their worst fitness (47%) and performance (30%) and the highest number of side effects during bleeding (compared with all other phases). The phase following bleeding was considered the best phase for perceived fitness (24%) and performance (18%). Only 8% of participants reported having sufficient knowledge about the MC in relation to training, and 27% of participants communicated about it with their coach.
• Dysmenorrhea and Heavy Menstrual Bleeding in Elite Female Athletes: Quality of Life and Perceived Stress, Silvia Vannuccini, Flavia Fondelli, Sara Clemenza, et.al., Reproductive Sciences, Volume 27, pp.888-894, (2020). In female athletes, the incidence of menstrual disorders is variable, and their impact on perceived stress and quality of life (QoL) is poorly known. A cross-sectional survey was conducted in nulliparous elite athletes of reproductive age, and the study population included 112 cases. A group of women not practising regular sport activities (n = 103) was used as control. Athletes had a significantly higher incidence of irregular periods and heavy menstrual bleeding (HMB) and a lower incidence of dysmenorrhea than controls. Furthermore, athletes had a better physical QoL (53.9 ± 5.9 vs 51.2 ± 6.0) but higher PPS level (17.3 ± 4.8 vs 13.8 ± 4.8) and a worse mental QoL (44.9 ± 9.9 vs 47.6 ± 9.0) than controls. HMB was associated with lower mental scores (39.7 ± .8.9 vs 45.6 ± 9.9) and higher PSS scores (19.8 ± .3.2 vs 17.0 ± .4.9) than those observed in athletes with normal bleeding. No difference was found in different sports regarding gynecological health, PSS level, and QoL. An increased incidence of HMB should be considered in elite athletes with increased PSS and impaired QoL.
• The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis, Kelly Lee McNulty, Kirsty Jayne Elliott-Sale, Eimear Dolan, et.al., Sports Medicine, Volume 50, pp.1813-1827, (2020). 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.
• The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis, Kirsty J. Elliott-Sale, Kelly L. McNulty, Paul Ansdell, et.al., Sports Medicine, Volume 50, pp.1785-1812, (2020). OCP use might result in slightly inferior exercise performance on average when compared to naturally menstruating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and variable across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle.
• Elite female athletes' experiences and perceptions of the menstrual cycle on training and sport performance, Brown N; Knight CJ; Forrest Née Whyte LJ, Scandinavian Journal of Medicine and Science in Sports, Volume 31(1), pp.52-69, (2021). Individual semi-structured interviews were conducted with 17 elite female athletes (25.5 ± 4.7 years) from multiple sports. Results revealed athletes' experiencing a natural menstrual cycle reported physical symptoms alongside mood disturbances and reduced motivation to train. The decision to actively control the menstrual cycle was often triggered by a desire to reduce the effect on competition, to lessen anxieties about making required weight or reduce distraction to manage during competition. Athletes indicated an openness to talk about the menstrual cycle to other females, however, there was variation in the comfort athletes experienced regarding talking to male coaches. Overall, the findings highlight the need to educate elite athletes and coaches on the menstrual cycle, considering it in the same light as other physiological functions in sport to improve health, well-being, and performance. Furthermore, providing education on how to construct positive conversations, equipping individuals with the correct terminology, and confidence to talk about the menstrual cycle will reduce some reservations identified through improved knowledge and understanding.
• Endocrine disorders in adolescent and young female athletes: impact on growth, menstrual cycles, and bone mass acquisition, Maïmoun L; Georgopoulos NA; Sultan C, The Journal of Clinical Endocrinology and Metabolism, Volume 99(11), pp.1945-7197, (2014). Puberty is a crucial period of dramatic hormonal changes, accelerated growth, attainment of reproductive capacity, and acquisition of peak bone mass. Participation in recreational physical activity is widely acknowledged to provide significant health benefits in this period. Conversely, intense training imposes several constraints, such as training stress and maintenance of very low body fat to maximize performance. Adolescent female athletes are therefore at risk of overtraining and/or poor dietary intake, which may have several consequences for endocrine function. The "adaptive" changes in the hypothalamic-pituitary-gonadal, -adrenal, and somatotropic axes and the secretory role of the adipose tissue are reviewed, as are their effects on growth, menstrual cycles, and bone mass acquisition. Young female athletes present a high prevalence of menstrual disorders, including delayed menarche, oligomenorrhea, and amenorrhea, characterized by a high degree of variability according to the type of sport. Exercise-related reproductive dysfunction may have consequences for growth velocity and peak bone mass acquisition. Recent findings highlight the endocrine role of adipose tissue and energy balance in the regulation of homeostasis and reproductive function. A better understanding of the mechanisms whereby intense training affects the endocrine system may orient research to develop innovative strategies (ie, based on nutritional or pharmacological approaches and individualized modalities of training and competition) to improve the medical care of these adolescents and protect their reproductive function.
• How the menstrual cycle and menstruation affect sporting performance: experiences and perceptions of elite female rugby players, Rebekka J Findlay, Eilidh H R Macrae, Ian Y Whyte, et.al., British Journal of Sports Medicine , Volume 54(18), pp.1108-1113, (2020). This study provides the first in-depth insight into athlete’s experiences of the menstrual cycle and perceived impact on training and competition. It highlights individual responses to menstrual ‘issues’ and emphasises the need for clinicians and support staff to undertake menstrual cycle profiling, monitoring and continue to develop awareness, openness, knowledge and understanding of the menstrual cycle.
• Inflammation and Oral Contraceptive Use in Female Athletes Before the Rio Olympic Games, Larsen B; Cox A; Colbey C; et.al., Frontiers in Physiology, (25 May 2020). This study investigated the association between synthetic ovarian hormone use [i.e., the oral contraceptive (OC) pill] and basal C-reactive protein (CRP), peripheral blood immune cell subsets, and circulating pro- and anti-inflammatory cytokine concentrations in elite female athletes. Elite female athletes (n = 53) selected in Rio Summer Olympic squads participated in this study; 25 were taking an OC (AthletesOC) and 28 were naturally hormonally cycling (AthletesNC). Venous blood samples were collected at rest for the determination of sex hormones, cortisol, CRP, peripheral blood mononuclear memory and naïve CD4+ T-cells, CD8+ T-cells and natural killer cells, as well as pro- and anti-inflammatory cytokine concentrations. C-reactive protein concentrations were elevated (p < 0.001) in AthletesOC (median = 2.02, IQR = 3.15) compared to AthletesNC (median = 0.57, IQR = 1.07). No differences were reported for cortisol, cytokines, or PBMC immune cell subsets, although there was a trend (p = 0.062) for higher IL-6 concentrations in AthletesNC. Female Olympians had substantially higher CRP concentrations, a marker of inflammation and tissue damage, before the Rio Olympic Games if they used an OC. Future research should examine the potential consequences for athlete performance/recovery so that, if necessary, practitioners can implement prevention programs.
• Iron status in athletic females, a shift in perspective on an old paradigm, Claire E. Badenhorst,Kazushige Goto, Wendy J. O’Brien, et.al., Journal of Sports Sciences, (14 February 2021). The prevalence of iron deficiency in female athletes is higher than their male counterparts and is often cited as being a result of the presence of a menstrual cycle in the premenopausal years. This review has sought to revise our current understanding of female physiology and the interaction between primary reproductive hormones (oestrogen and progesterone) and iron homoeostasis in females. The review highlights an apparent symbiotic relationship between iron metabolism and the menstrual cycle that requires additional research as well as identifying areas of the menstrual cycle that may be primed for nutritional iron supplementation.
• Methodological Recommendations for Menstrual Cycle Research in Sports and Exercise, Janse DE Jonge X; Thompson B; Han A, Medicine and Science in Sports and Exercise, Volume 51(12), pp.2610-2617, (2019). The aim of this review is to provide methodological recommendations for menstrual cycle research in exercise science and sports medicine based on a review of recent literature. Potential changes over the menstrual cycle are likely related to hormone fluctuations; however, only 44% of the selected studies measured the actual concentrations of the female steroid hormones estrogen and progesterone. It was shown that the likely inclusion of participants with anovulatory or luteal phase-deficient cycles in combination with small participant numbers has affected results in recent menstrual cycle research and, consequently, our understanding of this area. To improve the quality of future menstrual cycle research, it is recommended that a combination of three methods is used to verify menstrual cycle phase: the calendar-based counting method combined with urinary luteinizing hormone surge testing and the measurement of serum estrogen and progesterone concentrations at the time of testing. A strict luteal phase verification limit of >16 nmol·L for progesterone should be set. It is also recommended that future research should focus on the inclusion of the late follicular estrogen peak. It is envisaged that these methodological recommendations will assist in clarifying some of the disagreement around the effects of the menstrual cycle on exercise performance and other aspects of exercise science and sports medicine.
• Practice does not make perfect: A brief view of athletes' knowledge on the menstrual cycle and oral contraceptives, Larsen B; Morris K; Quinn K; et.al., Journal of Science and Medicine in Sport, Volume 23(8), pp.690-694, (2020). Australian female athletes (n=189) representing their state and/or country in their respective sport completed a questionnaire comprising questions relating to the menstrual cycle and oral contraceptives. A knowledge 'score' was calculated by allocating one point for each correct answer; the highest knowledge score that could be achieved was 14. Almost half (47.1 %) of the athletes surveyed were currently using hormonal contraception, the majority (75.3 %) of which used an oral contraceptive pill. Nevertheless, the mean knowledge score achieved by athletes on the questionnaire was 5.03±3.06, with only 8.5 % of athletes achieving a knowledge score of 10 or above. Our findings indicate that knowledge surrounding the menstrual cycle and oral contraceptives was low in most elite athletes. Further education is warranted to enable athletes to make informed decisions regarding hormonal contraception, and any educational interventions should be implemented across all athlete groups.
• 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, Georgie Bruinvels, Esther Goldsmith, Richard Blagrove, et.al., British Journal of Sports Medicine, (16 November 2020). The most prevalent menstrual cycle symptoms were mood changes/anxiety (90.6%), tiredness/fatigue (86.2%), stomach cramps (84.2%) and breast pain/tenderness (83.1%). After controlling for body mass index, training volume and age, the MSi was associated with a greater likelihood of missing or changing training (OR=1.09 (CI 1.08 to 1.10); p≤0.05), missing a sporting event/competition (OR=1.07 (CI 1.06 to 1.08); p≤0.05), absenteeism from work/academia (OR=1.08 (CI 1.07 to 1.09); p≤0.05) and use of pain medication (OR=1.09 (CI 1.08 to 1.09); p≤0.05). Menstrual cycle symptoms are very common in exercising women, and women report that these symptoms compromise their exercise participation and work capacity. The MSi needs to be formally validated (psychometrics); at present, it provides an easy way to quantify the frequency of menstrual cycle symptoms.
• Sport, exercise and the menstrual cycle: where is the research? Bruinvels G, Burden RJ, McGregor AJ, et al., British Journal of Sports Medicine, Volume 51(6), pp.487-488, (2016). We recently reported that 41.7% of exercising women believe their menstrual cycle has a negative impact on exercise training and performance. However, largely due to the dearth of sports and exercise research in women, explanations for this are lacking. Heavy menstrual bleeding with unknown or undiagnosed iron deficiency could be a cause but this is speculative.
• Use of Oral Contraceptives to Manipulate Menstruation in Young, Physically Active Women, Schaumberg, Mia A.; Emmerton, Lynne M.; Jenkins, David G.; et.al., International Journal of Sports Physiology and Performance, Volume 13(1), pp.82- (2018). Menstruation and menstrual symptoms are commonly cited barriers to physical activity in women. The delay or avoidance of menstruation through extended oral-contraceptive (OC) regimens may mitigate these barriers, yet information on menstrual- manipulation practices in young physically active women is sparse. The majority (74%) of OC users reported having deliberately manipulated menstruation at least once during the previous year, with 29% reporting having done so at least 4 times. Prevalence of menstrual manipulation (at least once in the previous year) was not different between competitive athletes, subelite recreationally active women, and recreationally active women (77% vs 74% vs 72%). The most cited reasons for manipulating menstruation were special events or holidays (rated by 75% as important/very important), convenience (54%), and sport competition (54%). Menstrual manipulation through extended OC regimens is common practice in recreationally and competitively active young women, for a range of reasons relating to convenience that are not limited to physical activity. This strategy may help reduce hormone-related barriers to exercise participation, thereby positively affecting participation and performance.
• The Young Female Athlete: Using the Menstrual Cycle as a Navigational Beacon for Healthy Development, Vicki Harber, Canadian Journal for Women in Coaching, Volume 11(3), (October 2011). “Using the menstrual cycle as an additional vital sign adds a powerful tool to the assessment of normal development and the exclusion of pathological conditions” (American Academy of Pediatrics 2006). Tracking menarche and monitoring the menstrual status of young female athletes needs to be integrated into the athlete development pathway. Developing and training young female athletes is challenging and complex; by implementing education and awareness of menstrual function, young athletes and their families will be better equipped to respond to the demands of training and competition. Menstrual status is an indicator of overall health and well-being; it provides information about energy status, risk of musculoskeletal injury, nutritional intake, metabolic and hormonal condition, recovery and other areas relevant to peak performance. In addition, with increasing use of OCP among skeletally-immature girls, coaches and parents need to be informed about the recent findings regarding bone mineral health in this population. Contains a detailed overview on menstrual cycle basics aimed at female athletes, parents, coaches, and primary care physicians highlighting that many are not aware of the usual age of menarche, normal ranges for menstrual cycle length, and other characteristics of the menstrual cycle. Also goes into further depth relating to other issues including frequency of menstrual disturbances and OCP use.

• AIS Female Performance and Health Initiative resources (accessed 11 January 2022):
  • Hormonal contraception: What are the options?
  • Understanding your menstrual cycle: What's normal, what's not?
  • Polycystic ovary syndrome.
  • Endometriosis.
  • Education modules. The AIS has partnered with specialist medical practitioners, high performance athletes and high performance coaches to design a suite of online learning modules for athletes, parents, coaches and medical practitioners. These modules aim to increase your knowledge about the menstrual cycle; menstrual abnormalities; puberty; hormonal contraception; bone, pelvic and breast health, body image; low energy availability and nutrition; and, considerations for coaches and medical practitioners working with female athletes.
• Female athletes, hormonal contraception, and bone health [infographic], Emily Kraus, Clinical Assitant Professor, Standford Children's Orthopedic and Sports Medicine, Twitter, (accessed 27 January 2021).
• FitrWoman. Free mobile app that helps track your menstrual cycle and provides personalised training and nutritional suggestions tailored to the changing hormone levels throughout your cycle. A subscription option also available called FitrCoach which allows athletes to share their data with their coach to help monitor real-time status and plan training and optimise performance throughout the athletes' menstrual cycle.
• Menstrual Cycle Tracking, (accessed 27 January 2021). Hormonal changes during the menstrual cycle impacts mood, energy levels, risk of ACL injuries and female athlete’s ability to train and perform. AthleteMonitoring.com helps you monitor menstrual phases, symptoms, load, mitigate risk, and safely maximize athletic potential.

• E-Alliance: research hub for gender and equity in sport, (accessed 2 February 2021). Created in late 2020, E-Alliance is a knowledge sharing hub made up of scholars and partner organizations from across Canada who are dedicated to gender+ equity in sport. E-Alliance is led by three co-directors, Dr. Gretchen Kerr (University of Toronto), Dr. Guylaine Demers (Université Laval) and Dr. Ann Pegoraro (University of Guelph).
• Female Performance and Health Initiative (FPHI), Australian Institute of Sport, (accessed 27 January 2021). The FPHI was established in October 2019, to improve female athlete specific knowledge and systems of support. The initiative will benefit Australian athletes, coaches, parents, sporting organisations and support staff in the sport sector and will raise awareness and understanding to key female athlete performance and health considerations, including but not limited to: the menstrual cycle and associated dysfunction including endometriosis and Polycystic ovary syndrome (PCOS); Medical conditions impacting female athletes; Pelvic floor health and incontinence; Breast health; Pregnancy and return to sport.
• SmartHER: EIS prioritising female athlete health, Mark Jamieson, English Institute of Sport, (8 March 2019). The English Institute of Sport (EIS) has prioritised opening up conversations amongst athletes, coaches and staff in high performance sport around female athletes’ menstrual cycle and its possible effects, as well as offering expertise to help elite British female athletes be healthy, happy and deliver world class performances.

• AFLW gets a kick out of new finding, Victoria University , (11 February 2021). Using a 3D motion-capture system, Dr Cust measured elite women’s foot and ball velocities, kick impact efficiency, kick movement patterns and kick strategies. The results reveal differences in movement patterns between women’s and men’s kicks: the women had a greater knee and hip range of motion, and faster knee action speeds while kicking for both their preferred and non-preferred kick legs. The women also showed less knee bend on the support leg during higher impact kicks. The study is important because of the high impact and repetitive nature of kicking in elite Australian Football, leading to athlete-specific strengthening programs to avoid injuries.
• Research to curb injury in women’s footy, La Trobe University, (7 October 2020). La Trobe sports injury researchers are working with the AFL, Medibank and other partners to reduce knee injury among female Australian football players, thanks to a grant from the National Health and Medical Research Council (NHMRC).
• Sport Science on Women, Women in Sport Science. Mujika, Iñigo; Taipale, Ritva S., International Journal of Sports Physiology and Performance, Volume 14(8), pp.1013-1-14, (2019). This editorial article discusses issues on women in sport science and sex differences in responses and adaptations to training. Some interesting comments/links to research in the text include:
  • Unique to women is the ability to legally and ethically alter their hormonal profile and menstrual cycle by using exogenous hormones (hormonal contraceptives).
  • Approximately 42% of exercising women believe that their menstrual cycle has a negative impact on exercise training and performance.
  • Approximately 50% of elite athletes are currently using hormonal contraceptives, and up to 70% have used them. Unfortunately, we still do not fully understand the effects of the menstrual cycle and hormonal contraceptives on training and performance.
  • Monitoring and reporting of menstrual-cycle phase takes a little extra time and effort but could explain “interesting” results. More research should test women in different phases of the menstrual cycle to further elucidate the possible phase effects on training responses, adaptations, and performance (instead of just testing in the follicular, or “low-hormone,” phase of the menstrual cycle, when hormonal profile is “most similar” to that of men).
  • When applicable, use of accurate measurements for determination of both ovulation and nonovulatory cycles may also be important (a menstrual bleed does not necessarily indicate ovulation).
  • Users of hormonal contraceptives should be included in research in their own group to further elucidate the possible effects of exogenous hormones on training adaptations and performance, and the type and delivery methods of hormonal contraceptives should be reported.
  • It would also be of benefit for researchers to consider the potential underlying issues that might have been a reason for using hormonal contraceptives (eg, relative energy deficiency in sport, polycystic ovary syndrome, endometriosis, etc), as these may have influenced endogenous hormone profiles prior to taking hormonal contraceptives.

• A Saddle sores among female competitive cyclists: A systematic scoping review, Keira Bury, Justine E. Leavy, Charlene Lan, et.al., Journal of Science and Medicine in Sport, Volume 24(4), pp.357-367, (2021). Saddle sores are a prominent but an under investigated health issue among female competitive cyclists. The authors found limited research investigating the prevalence, prevention and treatment of saddle sores among female competitive cyclists, although it has been described as a common occurrence by those in the cycling community. Research is required to understand its prevalence, along with trials to investigate prevention and management methods, so that evidence informed guidelines and/or protocols can be developed.
• Breast pain affects the performance of elite female athletes. Brisbine, Brooke R.; Steele, Julie R.; Phillips, Elissa J.; et.al., Journal of Sports Sciences, Volume 38(5), pp.528-533, (2020). Although breast pain is problematic for many active women, no published research has investigated breast pain experienced by elite female athletes. This study aimed to examine the extent that mastalgia and exercise-induced breast pain affected the sporting performance of elite female athletes during training and competition. Five hundred and forty female athletes competing nationally or internationally across 49 different sports participated in the survey. Sixty-three percent of respondents reported experiencing breast pain associated with their menstrual cycle and 33% reported that this pain worsened during activity. Forty-four percent of athletes reported experiencing exercise-induced breast pain during training or competition. Both types of breast pain were also reported to negatively affect sporting performance (20% and 32%, respectively). Mastalgia associated with the menstrual cycle and exercise-induced breast pain should be acknowledged as potential problems affecting the sporting performance of elite female athletes. Awareness around the impact of breast pain and the development and implementation of breast pain management strategies are essential for this population.
• Effects of Breast Motion on Lower-Body Kinematics during Running, Gibson Taylor M., Langenderfer Joseph E., Ustinova Ksenia I., International Journal of Human Movement and Sports Sciences, Volume 8(2), pp.51-56, (2020). We measured the effects of breast motion on lower-body kinematics during overground running. Thirty female participants aged 18–60 years completed two blocks of three trials each of overground running for 25 m at self-selected pace under two conditions: with and without breast support provided by a sports bra. Participants' body movements were analyzed with 18 parameters characterizing breast and lower-body kinematics. Sports bra use reduced breast motion and increased about 83% of the lower-body kinematic parameters, including running velocity; stride length; foot clearance; vertical and lateral center of mass displacement; and thorax, hip, knee, and ankle range of motion (all p < 0.05). Among the changed characteristics, the stride length, center of mass displacements, thorax and knee range of motions correlated negatively (r = –0.25 to –0.46) with the velocity of breast motion. Therefore, the reduction of breast motion may improve lower-body kinematics during running, which may influence sport and leisure performance.
• The Occurrence, Causes and Perceived Performance Effects of Breast Injuries in Elite Female Athletes, Brisbine, Brooke R.; Steele, Julie R.; Phillips, Elissa J.; et.al., Journal of Sports Science and Medicine, Volume 18(3), pp.569-576, (2019). This study aimed to investigate the occurrence, causes and perceived performance effects of breast injuries in elite female athletes across a wide range of sports. A custom-designed survey was distributed to female athletes aged over 18 years who were competing nationally or internationally in their chosen sport. The survey included questions about breast injuries sustained during training and competition and any perceived performance effects of these injuries. 504 elite female athletes from 46 different sports completed the survey. 36% of participants (n = 182) reported experiencing breast injuries and 21% (n = 37) perceived that their breast injury negatively affected their performance. Contact breast injuries were reported by significantly more athletes involved in contact or combat sports and by athletes with larger breasts or a higher body mass index. Frictional breast injuries were reported by significantly more older athletes or those with larger breasts. Less than 10% of participants who experienced breast injuries reported their injury to a coach or medical professional and only half used any prevention strategies. Athletes, coaches and medical professionals associated with women’s sport need to be made aware of the occurrence and potential negative effects of breast injuries. It is critical to normalise conversations around breast health so that athletes can be encouraged to report and, when necessary, receive treatment for breast injuries. Further research is also required to better understand factors that affect breast injuries in sport in order to develop evidence-based breast injury prevention strategies.
• Return to Sport and Reinjury Rates in Elite Female Athletes After Anterior Cruciate Ligament Rupture, Kate E. Webster, Sports Medicine, (7 January 2021). While there has been significant interest in the documentation of return to sport outcomes following anterior cruciate ligament (ACL) injury, the elite level female athlete has not been a focus of this research. This is despite women being at increased risk for ACL injury and considerable global growth in women participating in sport. Therefore, the focus of this review was to examine the available literature regarding return to sport outcomes in elite level women with an ACL injury. The topics of discussion focus on return to sport rates, timing and determinants of return to sport, longevity of play, return to sport performance, and further ACL injury. Knee health in the longer term is also briefly discussed along with the limitations of the existent literature.
• Sport-Related Concussion in Female Athletes: A Systematic Review, Neil K. McGroarty, Symone M. Brown, and Mary K. Mulcahey, Orthopaedic Journal of Sports Medicine, Volume 8(7), (2020). A total of 25 studies met the inclusion criteria. Female athletes appear to sustain more severe concussions than male athletes, due in part to a lower biomechanical threshold tolerance for head impacts. Additionally, concussions may alter the hypothalamic-pituitary-ovarian axis, resulting in worse symptoms and amenorrhea. Although females are more likely to report concussions than males, underreporting still exists and may result in concussions going untreated.

• AIS Female Performance and Health Initiative resources (accessed 11 January 2022):
  • Education modules. The AIS has partnered with specialist medical practitioners, high performance athletes and high performance coaches to design a suite of online learning modules for athletes, parents, coaches and medical practitioners. These modules aim to increase your knowledge about the menstrual cycle; menstrual abnormalities; puberty; hormonal contraception; bone, pelvic and breast health, body image; low energy availability and nutrition; and, considerations for coaches and medical practitioners working with female athletes.
  • Breast health and bra fit.
  • Endometriosis.
  • Polycystic Ovary Syndrome (PCOS).
  • Pelvic floor health.
• Exercise and breast support, Sports Medicine Australia, (accessed 27 January 2021).
• Nutrition for Active Women, Sports Medicine Australia, (2017).
• “Sports Bra” web-based app , Dr Deirdre McGhee and Professor Julie Steele, University of Wollongong, (accessed 27 January 2021). Contains evidence-based information to help choose a well-fitted, supportive sports bra. The app allows users to save information such as age range, bra size and details of the bra. Users who choose to save this information, consent to it being used for research purposes. All information is anonymous and no personal details will be accessed or saved.