









































ANNALES KINESIOLOGIAE • 16 • 2025 • 1

5

Original scientific article        DOI: https://doi.org/10.35469/ak.2025.484
received: 2024-11-26          UDC: 796.071.2-055.2:612.662.1

MENSTRUAL SYMPTOMS IN DIVISION I FEMALE 
ATHLETES: A PROSPECTIVE OBSERVATIONAL STUDY

Jennifer A. BUNN1, Gabrielle MARCHELLI2, Hannah HUMPHRIES2

1 College of Health Sciences, Sam Houston State University, Huntsville, TX, USA
2 College of Osteopathic Medicine, Sam Houston State University, Conroe, TX, USA

Corresponding author: 
Jennifer A. BUNN, 

College of Health Sciences, Sam Houston State University, 1900 Ave I, Box 2301, 
Huntsville, TX 77341, USA

Phone: 1-936-294-2393
E-mail: jab229@shsu.edu,

ABSTRACT

Purpose: To quantify the frequency of menstrual cycle (MC) symptoms experienced 
by Division I female lacrosse athletes and to discover if the symptoms were different 
among those who were taking a hormone contraceptive (HC) compared to those who 
were not (non-HC). 

Methods: As part of a daily wellness survey, athletes (non-HC = 10, HC = 11) were 
asked if they were menstruating. If they were, they were asked to identify any symptoms 
they were experiencing. The symptoms were recorded for each day of menstruation 
during their four-month competitive season. Reported symptoms were categorized as 
frequently, sometimes, rarely, or never. The frequencies of symptoms were tabulated in 
total and per cycle for each group. 

Results: The most frequently reported symptom was cramps with 90.4% of athletes 
reporting experiencing it at least once. Headaches (66%), back pain, and skin problems 
(57% each) were also frequently reported. HC users (0.7 ± 1.4 times/cycle) reported 
mood swings more frequently than non-HC users (0.03 ± 0.08, p = 0.029), but there 
were no other group differences for symptoms. 

Conclusions: Tracking symptoms associated with MC can help athletes and coach-
es be aware of patterns and incorporate methods for mitigating or alleviating the symp-
toms. Symptom tracking can also help athletes mentally prepare for the effects of their 



6

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

MC on training and performance. More research is needed before recommending HC 
use as a management strategy for menstrual symptoms. 

Keywords: menstrual cycle, team sport, hormone contraceptive

MENSTRUALNI SIMPTOMI PRI ŠPORTNICAH DIVIZIJE I: 
PROSPEKTIVNA OPAZOVALNA RAZISKAVA

IZVLEČEK

Namen: Kvantificirati, kako pogosto doživljajo simptome menstrualnega cikla 
(MC) igralke lakrosa divizije I, in primerjati, ali se simptomi razlikujejo med športni-
cami, ki uporabljajo hormonsko kontracepcijo (HK), in tistimi, ki je ne (ne-HK). 

Metodologija: V okviru dnevne ankete o počutju so morale športnice (ne-HK = 10, 
HK = 11) vsak dan odgovoriti, ali menstruirajo. Če so odgovorile pritrdilno, so bile 
pozvane k opisu simptomov. Simptome so zapisovale vsak dan menstruacije v štirime-
sečnem obdobju tekmovalne sezone. Poročani simptomi so bili razvrščeni v kategorije 
pogosto, občasno, redko ali nikoli. Pogostost simptomov je bila predstavljena v tabe-
larni obliki, in sicer skupno ter na cikel za vsako skupino posebej. 

Rezultati: Najpogostejši simptom, o katerem so poročale športnice, so bili krči in 
kar 90,4 % športnic je navedlo, da so ta simptom doživele vsaj enkrat. Pogosto so 
poročale tudi o glavobolih (66 %), bolečinah v hrbtu in težavah s kožo (oboje 57 %). 
Uporabnice HK (0,7 ± 1,4-krat/cikel) so pogosteje opažale nihanje razpoloženja od 
tistih, ki ne uporabljajo HK (0,03 ± 0,08, p = 0,029), pri čemer ni bilo drugih razlik 
glede simptomov med skupinama. 

Zaključki: Spremljanje simptomov, povezanih z MC, lahko športnicam in trenerjem 
pomaga prepoznati vzorce ter v delo vključiti načine za ublažitev ali lajšanje simpto-
mov. Poleg tega se lahko športnice s spremljanjem simptomov psihično pripravijo na 
to, kako njihov MC vpliva na trening in zmogljivost. Potrebnih je več raziskav, preden 
bo mogoče HK priporočati kot strategijo za obvladovanje menstrualnih simptomov. 

Ključne besede: menstrualni cikel, ekipni šport, hormonska kontracepcija



ANNALES KINESIOLOGIAE • 16 • 2025 • 1

7

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

INTRODUCTION

The menstrual cycle (MC) is broken down into three phases: 1) the fol-
licular phase, 2) the ovulatory phase, and 3) the luteal phase. The follicular 
phase begins with the onset of menses and concludes when estrogen levels 
rise to begin the ovulatory phase. The ovulatory phase concludes when estro-
gen levels decline and progesterone levels increase to begin the luteal phase. 
The MC has been shown to affect thermoregulatory, respiratory, metabolic, and 
cardiovascular parameters with equivocal effects on endurance performance 
(Julian, Hecksteden, Fullagar, & Meyer, 2017). The MC is also accompanied 
by a variety of physiological, physical, and emotional symptoms. The proposed 
mechanisms for these symptoms include alterations in the central nervous sys-
tem (Yonkers & Simoni, 2018), changes in the release of inflammatory markers 
(Puder et al., 2006), reactive oxygen species (Ma et al., 2013), and hormone 
sensitivities and fluctuations (Gaskins et al., 2012). 

Two recent reviews showed that the effects of the MC on exercise perfor-
mance were equivocal across several performance characteristics, including: 
aerobic capacity, anaerobic power, muscular strength, speed, and muscular 
power (Carmichael, Thomson, Moran, & Wycherley, 2021; Vogel, Larsen, 
McLellan, & Bird, 2024). However, most of the studies focused on controlled 
laboratory exercise tests instead of training or game performance. How an ath-
lete performs on a laboratory test may not directly carry over to game day per-
formance. Gasperi, Sansone, Gómez-Ruano, Lukonaitienė, and Conte (2023) 
showed evidence that basketball players experienced improved shooting and 
rebounding during the follicular phase, further suggesting that exercise perfor-
mance and game performance are not the same. The use of microtechnology 
allows for evaluation of performance during training and games, and evidence 
shows no overall difference in college athletes when menstruating (Humphries, 
Marchelli, & Bunn, 2024). However, there is some concern about the reduced 
performance of hormone contraceptive (HC) users. Bozzini, McFadden, Elliott-
Sale, Swinton, and Arent (2021) assessed Division I soccer players weekly 
throughout their 15-week competitive season and found that HC users consist-
ently had a lower external load and energy expenditure compared to non-HC 
users. Humphries et al. (2024) also showed that HC users had a 1-5% decline in 
game day performance during their withdrawal bleed. This was not a statistical 
difference, but it would likely still be impactful in relation to game performance 
(Thornton, Figueroa, Davis, & Bunn, 2023). 

The MC is also believed to have a psychological effect on athletes, which 
may subsequently affect performance. Athletes across competitive levels 



8

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

believe that their MC has impacted their training or performance (Bruinvels 
et al., 2021; Findlay, Macrae, Whyte, Easton, & Forrest, 2020; Martin, Sale, 
Cooper, & Elliott-Sale, 2018; Oester et al., 2024). Symptoms include a per-
ceived negative effect on performance, fatigue, mood disturbances, poor coor-
dination, reduced motivation, feeling tearful and emotional, feelings of agita-
tion, and poor concentration (Brown, Knight, & Forrest, 2021; Findlay et al., 
2020; Marchelli, Humphries, & Bunn, 2025; O’Brien, Rapkin, Dennerstein, & 
Nevatte, 2011). Professional rugby players have perceived a loss of strength, 
appetite, and focus, as well as heightened emotions and fatigue (Hayward, 
Akam, Hunter, & Mastana, 2024), and nutritional strategies may be useful in 
mitigating these symptoms (Brown et al., 2024). Qualitative studies have also 
shown that athletes feel worry and fear in relation to experiencing menstrual 
flooding during competition and training (Findlay et al., 2020). Athletes also 
feel increased anxiety with standardized uniforms that may be revealing or in-
clude white shorts or pants (Findlay et al., 2020). Avoiding harm, adjusting 
energy, awareness and acceptance, and self-care were identified as coping strat-
egies to mitigate the effects of MC (Modena, Bisagno, Schena, Carazzato, & 
Vitali, 2022). To date, longitudinal studies have shown no differences in sleep 
quality, sleep duration, muscle soreness, nutrition, and health across MC phases 
in collegiate and elite-level athletes (Marchelli et al., 2025; Scott, Bruinvels, 
Norris, & Lovell, 2024). 

These perceptions are often linked to the physical symptoms experi-
enced by female athletes during their pre-menstrual phase and during men-
ses. Physical symptoms typically include abdominal cramping/pain, skin 
changes, bloating, appetite changes, breast tenderness, low back pain, gas-
trointestinal disturbances, and headaches (Brown et al., 2021; Bruinvels et 
al., 2021; Findlay et al., 2020; Martin et al., 2018; McKay et al., 2024; Roffler, 
Fleddermann, de Haan, Krüger, & Zentgraf, 2024; Taim et al., 2023). Affective 
symptoms such as mood changes, sleep disturbances, fatigue, and difficulties 
concentrating have also been reported (Taim et al., 2023). Most of these symp-
toms are reported during the initial days of menstruation (Martin et al., 2018; 
Taim et al., 2023). The Menstrual Symptoms index (MSi) was created to help 
evaluate the frequency of these symptoms (Bruinvels et al., 2021). The MSi 
categorizes the symptoms by frequency of experience for non-HC users and the 
scores range from zero to 54. The mean MSi score in general female exercisers 
was 22.9, and a higher MSi was associated with missing/changing a training 
session or sporting event, missing work, and use of pain medication (Bruinvels 
et al., 2021). This aligns with research on elite athletes indicating a negative 
correlation between the perceived performance and the presence of menstrual 



ANNALES KINESIOLOGIAE • 16 • 2025 • 1

9

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

cycle symptoms (Antero et al., 2023). Helping athletes recognize and manage 
symptoms has been recognized as a prudent approach to ensuring the readiness 
of athletes to train and compete (McGawley et al., 2023; McNamara, Harris, & 
Minahan, 2022; Taim et al., 2023). 

Approximately 40–50% of female athletes use HCs with varying hormone 
levels and types (Martin et al., 2018). There are two main types of oral contra-
ceptives: the combined pill (which contains both estrogen and progestin) and 
the mini pill (which contains only progestin) (Powell, 2017). These are typical-
ly taken daily for three weeks, followed by a week off each month. Other con-
traceptive options include implants, hormonal intrauterine devices (IUDs), and 
injections, all of which contain only progestin (Powell, 2017). Contraceptive 
patches and vaginal rings release both estrogen and progesterone (Martin et al., 
2018). Martin et al. (2018) reported that 77% of HC users experience negative 
symptoms associated with their MC, and the reported positive effects of HC 
use includes regular periods, less frequent periods, reduced bleeding, the ability 
to predict or change their cycle date, and improved skin (Martin et al., 2018). 
Common reported negative side effects of HC use include weight gain, irregular 
periods, poor skin, and mood changes (Martin et al., 2018). McKay et al. (2024) 
examined the difference in MC symptoms for non-HC and HC users during a 
high-performance camp. The results showed no difference in the symptoms 
reported in the groups, except that non-HC athletes had a higher prevalence of 
acne than the HC users. Roffler et al. (2024) tracked the menstrual symptoms of 
professional volleyball athletes and calculated the MSi, finding that the average 
number of symptoms reported per cycle was 11.8 ± 17.7 (Bruinvels et al., 2021; 
Roffler et al., 2024). Roffler calculated the MSi for both HC users and naturally 
cycling athletes, and the results showed a mean MSi of 12.5 ± 10.7 for non-HC 
users and 11.1 ± 4.7 for HC users. 

With the recent focus on the MC and female athletes, research has provided 
equivocal evidence about exercise performance and that MC symptoms affect 
the athlete both physically and psychologically (McKay et al., 2024; Roffler 
et al., 2024). However, there is little evidence comparing these concepts be-
tween HC and non-HC users. This is especially important as there is a gap 
in addressing female-specific health issues in athlete preparticipation exams 
(Schulz, Pohlod, Myers, Chung, & Thornton, 2024), and because many ath-
letes seek to use HCs to mitigate their MC symptoms or gain control over the 
timeliness of their menses (Martin et al., 2018). The purpose of this study was 
to quantify the frequency of MC symptoms experienced by Division I female 
lacrosse athletes and to see if the symptoms were different among those who 
were and were not taking a HC. We hypothesized that abdominal cramps would 



10

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

be the most frequently reported symptom and that non-HC users would experi-
ence more symptoms than HC users.

MATERIALS AND METHODS

Study Design

This was a prospective observational study. Data were collected during the 
competitive season in Division I women’s lacrosse for 3.5 months. All the data 
were self-reported by the participants. All the participants completed an in-
formed consent prior to study participation. This study was approved by the 
institutional review board (CUIRB-705) and conducted in accordance with the 
Declaration of Helsinki.

Participants

Athletes were included in this study if they were members of the varsity 
women’s lacrosse team at a given university and had been cleared for play. 
Athletes were excluded if they did not experience menses or a withdrawal 
bleed during the time of the study (n = 6) or missed significant time during 
the study due to injury or illness (n = 2). The athletes completed a shortened 
menstrual status questionnaire to indicate their status as an HC user or not 
(Bozzini et al., 2021; Humphries et al., 2024). There were 10 non-HC ath-
letes and 11 HC users, with 10 taking an oral contraceptive and one using an 
intrauterine device. The mean age of the 21 athletes included in the study was 
20.3 ± 1.4 years.

Measurements

Athletes were asked each morning via a smartphone survey (Metrifit, Louth, 
Ireland) whether or not they were menstruating. If they were not menstruat-
ing, no further information was gathered. If they were menstruating, they were 
asked to identify any symptoms they were experiencing in relation to their MC. 
The athletes could select as many symptoms as they wanted from the following 
list: cramping, headache, skin problems, bloating, back pain, nausea, fatigue, 



ANNALES KINESIOLOGIAE • 16 • 2025 • 1

11

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

mood swings, stress, and tenderness. This survey accompanied their daily 
wellness survey (data not included in the present study), and compliance was 
tracked daily by the research personnel. 

The Metrifit system tracked the menstruation cycles of each athlete for the 
duration of the season and calculated the average length of their cycle and the 
average number of days they menstruated per cycle. 

Symptoms were tabulated as a total for each group and by average per MC 
of the athlete. The symptoms were also categorized as occurring “often” if they 
appeared in each MC (3 points), “sometimes” if the symptoms appeared every 
two cycles (2 points), “rare” if the symptom appeared fewer than two times 
(1 point), and “never” if the symptom never appeared (0 points) (Bruinvels 
et al., 2021). This method is similar to that used for calculating the MSi, but the 
MSi uses 18 symptoms, and the present study only included ten. 

Data Analysis

The frequency of the symptoms reported by all the athletes and for each 
group were tabulated in total and per cycle. The mean length of the MC, the 
number of days menstruating, and the number of cycles observed were calcu-
lated per group. A Shapiro-Wilk test determined that the data were not normally 
distributed, so the group differences in the number of cycles, cycle length, num-
ber of days menstruating, and the symptoms reported per cycle were determined 
via Mann-Whitney U tests with an alpha level of 0.05. Cohen’s d effect sizes 
were calculated to determine the magnitude of the differences and interpreted 
as small (0.2), moderate (0.5), and large (0.8) (Cohen, 1988). Comparing symp-
toms in HC and non-HC users is fairly new, thus we did not use a Bonferroni 
correction. Instead, groups were determined to be different if the p-value was 
below the alpha level and had at least a moderate effect size. 

RESULTS

More cycles were observed from HC users (3.6 ± 0.5 cycles) than non-
HC users (2.8 ± 0.8 cycles) during the observed time (U = 26.0, p = 0.031, 
d = 0.527, moderate). The cycle length for the HC users was 27.8 ± 4.0 days 
and 33.0 ± 10.2 days for the non-HC users (U = 31.0, p = 0.098, d = 0.436, 
moderate), and 80% of the non-HC users were eumenorrheic. The number of 



12

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

menstruating days for the HC users was 5.7 ± 1.5 days and 6.2 ± 2.5 days 
for the non-HC users (U = 51.0, p = 0.805, d = 0.073, small). Table 1 shows 
the frequency of symptoms reported per athlete per cycle for each group. The 
HC users experienced mood swings more frequently than the non-HC users 
(U = 33.0, p = 0.029, d = 0.400, moderate), but there were no other group dif-
ferences for the other symptoms reported. 

Figure 1 shows the percentage of athletes who reported each symptom 
at least once. Cramps and headaches were the two most frequently reported 
symptoms for all the athletes at 90.4% and 66.6%, respectively. Nausea and 
tenderness were reported with the lowest frequency, with only 23.8% of ath-
letes reporting them. Two athletes, one HC user and one non-HC user, did not 
report any symptoms related to menstruation during the study. Figure 2 shows 
the percentage of athletes, regardless of group, reporting each symptom and 
the frequency of the categories for “often”, “sometimes”, “rare”, and “never”. 
Cramps were experienced often by 42.9% of the athletes, followed by back 
pain for 33.3% of the athletes. Skin breakouts were experienced “sometimes” 
by 42.9% of the athletes, and headaches were experienced “rarely” by 28.6% of 
the athletes. Tenderness, nausea, mood swings, fatigue, and bloating were never 
experienced by two-thirds or more of the athletes.  

Table 1: The frequency (mean ± standard deviation) of symptoms experienced 
per athlete per cycle. The results of the inference tests and effect sizes are also 
provided. * indicates a difference between the groups, p < 0.05.

HC User Non-HC 
User U (sig) Effect size

Cramps 1.9 ± 1.5 2.4 ± 2.8 52.5 (0.444) 0.046 (small)

Headache 0.6 ± 0.8 1.1 ± 1.1 42.0 (0.834) 0.236 (small)

Skin breakouts 0.5 ± 1.1 1.1 ± 1.8 46.0 (0.758) 0.164 (small)

Bloating 0.7 ± 1.7 1.1 ± 1.7 47.0 (0.762) 0.146 (small)

Back pain 1.4 ± 1.5 1.2 ± 2.2 41.5 (0.170) 0.246 (small)

Nausea 0.5 ± 0.8 0.1 ± 0.2 40.0 (0.086) 0.273 (small)

Fatigue 0.4 ± 0.7 0.6 ± 1.2 53.5 (0.467) 0.027 (small)

Mood swings* 0.7 ± 1.4 0.03 ± 0.08 33.0 (0.029) 0.400 (moderate)

Stressed 0.6 ± 1.0 0.7 ± 1.5 50.0 (0.358) 0.091 (small)

Tenderness 0.6 ± 1.5 0.5 ± 1.2 52.0 (0.407) 0.055 (small)



ANNALES KINESIOLOGIAE • 16 • 2025 • 1

13

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

Figure 2: The percentage of athletes reporting symptoms in the frequency cat-
egories of often, sometimes, rarely, and never

Figure 1: The prevalence of symptoms reported at least once by an athlete dur-
ing the observed time period. 



14

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

DISCUSSION

This study aimed to quantify the frequency of MC symptoms experienced 
by Division I female lacrosse athletes and to discover whether the symptoms 
were different among those who were taking HCs versus those who were not. 
Approximately 95% of the athletes experienced symptoms of some form in re-
lation to their menses or withdrawal bleed. This aligns with previous literature 
indicating that 90% of women from the general female population experience 
symptoms associated with menses (Mauvais-Jarvis, Clegg, & Hevener, 2013). 
Cramps, headaches, skin breakouts, and back pain were among the most fre-
quently noted symptoms, and tenderness and nausea were seen least frequently. 
Cramps occurred in each cycle for 43% of the athletes, and only 9.5% of the 
athletes did not experience cramps during the four-month observation period. 
Mood swings were mostly experienced by HC users, with two athletes expe-
riencing them often, one experiencing them sometimes, and four experiencing 
them rarely. The one non-HC user who experienced mood swings indicated it 
as a symptom that only occurred rarely. These findings support current research 
indicating that both HC users and non-users experience negative symptoms re-
lated to withdrawal bleeds and menstruation, respectively (McKay et al., 2024; 
Oxfeldt, Dalgaard, Jørgensen, & Hansen, 2020; Parker, Elliott-Sale, Hannon, 
Morton, & Close, 2022; Roffler et al., 2024). However, the specific differences 
in symptoms experienced by both groups vary across the studies (McKay et al., 
2024; Oxfeldt et al., 2020; Parker et al., 2022). 

Of the ten symptoms included in this study, only mood swings showed a 
difference between HC and non-HC users. The other nine symptoms were not 
different between groups, and all had small or trivial effect sizes. Estrogen has 
been shown to be neuroprotective and modulate neurotransmitters like seroto-
nin and dopamine, while progesterone has a negative effect on mood through 
pathways that ultimately reduce serotonin (Mu & Kulkarni, 2022). The link 
between HC use and mood remains controversial, but it is believed that the 
amount and type of progesterone in the HC probably negatively affect the 
serotonin levels (Mu & Kulkarni, 2022). Previous literature has reported that 
non-HC users have a greater frequency of acne and skin-related issues with no 
other difference between the groups (McKay et al., 2024). McKay et al. (2024) 
reported that a higher percentage of non-HC users experienced mood swings 
(13.7%) compared to HC users (5.4%), but this was not statistically different. 
In a large cross-sectional study, Martin et al. (2018) showed that HC users and 
non-HC users experienced mood swings at approximately the same rate, 4.2% 
and 4.1%, respectively. Bruinvels et al. (2021) reported that mood changes 



ANNALES KINESIOLOGIAE • 16 • 2025 • 1

15

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

were the most frequently reported symptom (90.6%) of non-HC users. The par-
ticipants included exercising women from seven countries, but they were not 
specifically athletes participating in competition. Furthermore, the study was 
conducted via a cross-sectional survey. Future studies should include both HC 
and non-HC users with prospective data collection, as there are very few in the 
current literature. Prospective studies also improve the accuracy of symptom 
reporting.

Overall, 100% of athletes studied have experienced negative symptoms as-
sociated with the MC (Oester et al., 2024), which may be useful information 
to incorporate into athlete preparticipation examinations (Schulz et al., 2024). 
Martin et al. (2018) surveyed participants about both negative and positive 
aspects of the MC and found that many HC users positively viewed having 
regular periods, the cessation of or less frequent periods, and reduced bleed-
ing. The present study focused only on the negative side effects of menses and 
withdrawal bleeding. Cramps were the most frequently cited symptom in the 
present study, regardless of HC use, aligning with previous literature about 
various sports (Brown et al., 2021; Bruinvels et al., 2021; Martin et al., 2018; 
Roffler et al., 2024). The high frequency of headaches (Martin et al., 2018; 
McKay et al., 2024; Roffler et al., 2024), skin breakouts (Martin et al., 2018; 
McKay et al., 2024), and back pain (Martin et al., 2018; McKay et al., 2024) 
are also regularly reported in the literature. However, other symptoms such as 
fatigue/disturbed sleep and weight gain have also been reported with high fre-
quency (Martin et al., 2018; Roffler et al., 2024). The present study did not in-
quire about either of these symptoms as a negative effect of the MC. However, 
Marchelli et al. (2025) found that athletes from a similar population reported no 
differences in sleep quality or duration during menses or by HC use. 

Previous literature has only used the MSi for non-HC users, and the tradi-
tional MSi includes 18 variables for a high score of 54 (Bruinvels et al., 2021; 
Roffler et al., 2024). The present study only included ten symptoms; thus, com-
parisons can only be made with frequencies and not with an overall MSi score. 
The present study reported that 90.5% of the participants experienced cramps 
compared to 100% of the participants in Roffler et al. (2024) and 80% of the 
participants in Bruinvels et al. (2021). Between the three studies, 30-47% of 
the participants report experiencing cramps often. Notably, Bruinvels et al. 
(2021) reported the low-end range from a large-scale cross-sectional analy-
sis of older female exercisers (38.3 ± 8.7 years) who were not taking HCs. 
Whereas the present study and Roffler et al. (2024) showed a higher percentage 
experiencing cramps and collected data for each MC in their younger competi-
tive athletes (18 to 27.7 years) and included some HC users. All three studies 



16

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

indicated that approximately 20% of the participants experienced headaches 
often, but Bruinvels et al. (2021) indicated that 70% of their participants expe-
rienced them at any frequency, and both Roffler (2024) and the present study 
ranged from 60-67% of the athletes. Fatigue was the third and fourth most fre-
quently reported symptom for Roffler et al. (2024) and Bruinvels et al. (2021), 
respectively, but ranked seventh in the present study. The percentage of athletes 
reporting fatigue often and sometimes was similar in the present study and 
Roffler et al. (2024) (13-14%), but 35% of the participants in the Bruinvels 
study (2021) cited fatigue as occurring often. It is difficult to ascertain the rea-
son for these differences, but prospective studies evaluating each MC provide 
more reliable data than the cross-sectional information presented by Bruinvels 
(2021). Further, differences may exist between the studies due to the age dif-
ferences noted and comparisons between competitive athletes and recreational 
exercisers. Future research should consider these components to provide more 
robust comparisons between groups.   

Limitations of the present study include evaluating only one team, limited 
comparisons with the MSi, only collecting symptoms on the days of reported 
menstruation and withdrawal bleed, and variations of the HCs used in the par-
ticipants. Women experience symptoms outside of menses and future research 
should consider collecting each day that women experience any MC-related 
symptoms (McKay et al., 2024). We also did not ask the athletes if they thought 
their performance was affected by their MC symptoms, and this would be a 
valid question to include as 51-93% of athletes indicate that they perceive a 
negative effect of their symptoms on their performance (Bruinvels et al., 2021; 
Findlay et al., 2020; Martin et al., 2018). The self-report survey used in the pre-
sent study is an accepted athlete monitoring tool, but it has not been assessed 
for validity and reliability. The present study also did not inquire how training 
or performance affected their MC symptoms, positively or negatively. There 
is evidence that some exercise may reduce menstrual discomfort (Kannan, 
Chapple, Miller, Claydon, & Baxter, 2015; Vaghela, Mishra, Sheth, & Dani, 
2019) and further investigation is warranted. We also did not control whether 
non-HC users had used HCs prior to the study. This study also had a small n-
size for group comparisons. While the variation in HC use in this study reduces 
the internal validity of the work, the study does have strong external validity for 
many female teams. Teams typically consist of women using a variety of HCs, 
including those using none, and must still be expected to coordinate training 
and deliver high performance in games. The present study provides practical 
use for this information when collecting these data with team athletes. 



ANNALES KINESIOLOGIAE • 16 • 2025 • 1

17

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

CONCLUSIONS 

There is wide variation in the frequency of MC-related symptoms that ath-
letes experience. Tracking symptoms associated with MC can help athletes and 
coaches be aware of patterns and incorporate methods for mitigating or allevi-
ating the symptoms. Symptom tracking can also help athletes mentally prepare 
for the effects of their MC on training and performance. Tracking may also as-
sist with communication of discomfort and fatigue between athletes and coach-
es. Providing education to athletes and coaches about the physiological effects 
of the MC and the use of different HCs would also be beneficial. Understanding 
individual responses to the MC and HC use can help coaches plan training and 
workload. Further research is needed to help determine the most prudent strate-
gies for tracking and pattern recognition, to determine appropriate intervention 
strategies, and to include a large and diverse population. These data indicate 
that athletes who experience menses or withdrawal bleeds are very likely to 
have symptoms associated with this event, regardless of HC use. HC users 
experiencing a high frequency of certain symptoms should speak with their 
healthcare provider and consider alternatives to their HC.

Author Contributions

JAB conceptualized the study, participated in the study design, data collec-
tion, data analysis, and manuscript writing. MG and HH conceptualized the 
study, participated in the study design, and edited the manuscript.

Competing Interests

The authors declare that they have no competing interests.



18

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

REFERENCES

Antero, J., Golovkine, S., Niffoi, L., Meignié, A., Chassard, T., Delarochelambert, 
Q., … Toussaint, J. F. (2023). Menstrual cycle and hormonal contraceptive phases’ 
effect on elite rowers’ training, performance and wellness. Frontiers in Physiology, 
14, 1110526. https://doi.org/10.3389/fphys.2023.1110526

Bozzini, B. N., McFadden, B. A., Elliott-Sale, K. J., Swinton, P. A., & Arent, S. 
M. (2021). Evaluating the effects of oral contraceptive use on biomarkers and 
body composition during a competitive season in collegiate female soccer play-
ers. Journal of Applied Physiology, 130(6), 1971-1982. https://doi.org/10.1152/
japplphysiol.00818.2020

Brown, N., Knight, C. J., & Forrest (Née Whyte), L. J. (2021). Elite female ath-
letes’ experiences and perceptions of the menstrual cycle on training and sport per-
formance. Scandinavian Journal of Medicine & Science in Sports, 31(1), 52-69. 
https://doi.org/10.1111/sms.13818

Brown, N., Martin, D., Waldron, M., Bruinvels, G., Farrant, L., & Fairchild, 
R. (2024). Nutritional practices to manage menstrual cycle related symptoms: 
A systematic review. Nutrition Research Reviews, 37(2), 352–375. https://doi.
org/10.1017/S0954422423000227

Bruinvels, G., Goldsmith, E., Blagrove, R., Simpkin, A., Lewis, N., Morton, K., … 
Pedlar, C. (2021). Prevalence and frequency of menstrual cycle symptoms are as-
sociated with availability to train and compete: A study of 6812 exercising women 
recruited using the Strava exercise app. British Journal of Sports Medicine, 55(8), 
438-443. https://doi.org/10.1136/bjsports-2020-102792

Carmichael, M. A., Thomson, R. L., Moran, L. J., & Wycherley, T. P. (2021). The 
impact of menstrual cycle phase on athletes’ performance: A narrative review. 
International Journal of Environmental Research and Public Health, 18(4), Article 
4. https://doi.org/10.3390/ijerph18041667

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed). L. 
Erlbaum Associates.

Findlay, R. J., Macrae, E. H. R., Whyte, I. Y., Easton, C., & Forrest (Née Whyte), L. 
J. (2020). How the menstrual cycle and menstruation affect sporting performance: 
Experiences and perceptions of elite female rugby players. British Journal of Sports 
Medicine, 54(18), 1108-1113. https://doi.org/10.1136/bjsports-2019-101486

Gaskins, A. J., Wilchesky, M., Mumford, S. L., Whitcomb, B. W., Browne, R. W., 
Wactawski-Wende, J., … Schisterman, E. F. (2012). Endogenous reproductive 
hormones and C-reactive protein across the menstrual cycle: The BioCycle study. 
American Journal of Epidemiology, 175(5), 423–431. https://doi.org/10.1093/aje/
kwr343

Gasperi, L., Sansone, P., Gómez-Ruano, M.-Á., Lukonaitienė, I., & Conte, D. 
(2023). Female basketball game performance is influenced by menstrual cycle 
phase, age, perceived demands and game-related contextual factors. Journal of 
Sports Sciences, 43(1), 117–124. https://doi.org/10.1080/02640414.2023.2285119

Hayward, E., Akam, L., Hunter, D., & Mastana, S. (2024). Role of the menstrual cy-
cle on performance and injury risk: A survey of female professional rugby players in 

https://doi.org/10.3389/fphys.2023.1110526 
https://doi.org/10.1152/japplphysiol.00818.2020 
https://doi.org/10.1152/japplphysiol.00818.2020 
ttps://doi.org/10.1111/sms.13818 
https://doi.org/10.1017/S0954422423000227 
https://doi.org/10.1017/S0954422423000227 
https://doi.org/10.1136/bjsports-2020-102792 
https://doi.org/10.3390/ijerph18041667 
https://doi.org/10.1136/bjsports-2019-101486 
https://doi.org/10.1093/aje/kwr343
https://doi.org/10.1093/aje/kwr343
https://doi.org/10.1080/02640414.2023.2285119


ANNALES KINESIOLOGIAE • 16 • 2025 • 1

19

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

the United Kingdom. International Journal of Environmental Research and Public 
Health, 21(2), 150. https://doi.org/10.3390/ijerph21020150

Humphries, H., Marchelli, G., & Bunn, J. A. (2024). The influence of menstruation 
and hormonal birth control on the performance of female collegiate lacrosse play-
ers. Sports, 12(11), 297. https://doi.org/10.3390/sports12110297

Julian, R., Hecksteden, A., Fullagar, H. H. K., & Meyer, T. (2017). The effects of 
menstrual cycle phase on physical performance in female soccer players. PloS One, 
12(3), e0173951. https://doi.org/10.1371/journal.pone.0173951

Kannan, P., Chapple, C. M., Miller, D., Claydon, L. S., & Baxter, G. D. (2015). 
Menstrual pain and quality of life in women with primary dysmenorrhea: Rationale, 
design, and interventions of a randomized controlled trial of effects of a treadmill-
based exercise intervention. Contemporary Clinical Trials, 42, 81–89. https://doi.
org/10.1016/j.cct.2015.03.010

Ma, H., Hong, M., Duan, J., Liu, P., Fan, X., Shang, E., … Tang, Y. (2013). Altered 
cytokine gene expression in peripheral blood monocytes across the menstrual cycle 
in primary dysmenorrhea: A case-control study. PloS One, 8(2), e55200. https://doi.
org/10.1371/journal.pone.0055200

Marchelli, G., Humphries, H., & Bunn, J. A. (2025). An analysis of wellness respons-
es in female lacrosse athletes throughout their menstrual cycle. Exercise, Sport, and 
Movement, 3(3), e00049. https://doi.org/10.1249/ESM.0000000000000049

Martin, D., Sale, C., Cooper, S. B., & Elliott-Sale, K. J. (2018). Period prevalence 
and perceived side effects of hormonal contraceptive use and the menstrual cycle in 
elite athletes. International Journal of Sports Physiology and Performance, 13(7), 
926–932. https://doi.org/10.1123/ijspp.2017-0330

Mauvais-Jarvis, F., Clegg, D. J., & Hevener, A. L. (2013). The role of estrogens 
in control of energy balance and glucose homeostasis. Endocrine Reviews, 34(3), 
309–338. https://doi.org/10.1210/er.2012-1055

McGawley, K., Sargent, D., Noordhof, D., Badenhorst, C. E., Julian, R., & Govus, 
A. D. (2023). Improving menstrual health literacy in sport. Journal of Science and 
Medicine in Sport, 26(7), 351–357. https://doi.org/10.1016/j.jsams.2023.06.007

McKay, A. K. A., Minahan, C., Harris, R., Mccormick, R., Skinner, J., Ackerman, 
K. E., & Burke, L. M. (2024). Female Athlete Research Camp: A unique model for 
conducting research in high-performance female athletes. Medicine & Science in 
Sports & Exercise, 56(4), 706-716. https://doi.org/10.1249/MSS.0000000000003354

McNamara, A., Harris, R., & Minahan, C. (2022). ‘That time of the month’ … for 
the biggest event of your career! Perception of menstrual cycle on performance 
of Australian athletes training for the 2020 Olympic and Paralympic Games. 
BMJ Open Sport & Exercise Medicine, 8(2), e001300. https://doi.org/10.1136/
bmjsem-2021-001300

Modena, R., Bisagno, E., Schena, F., Carazzato, S., & Vitali, F. (2022). How do elite 
female athletes cope with symptoms of their premenstrual period? A study on Rugby 
Union and football players’ perceived physical ability and well-being. International 
Journal of Environmental Research and Public Health, 19(18), 11168. https://doi.
org/10.3390/ijerph191811168

Mu, E., & Kulkarni, J. (2022). Hormonal contraception and mood disorders. 
Australian Prescriber, 45(3), 75–79. https://doi.org/10.18773/austprescr.2022.025

https://doi.org/10.3390/ijerph21020150
https://doi.org/10.3390/sports12110297
https://doi.org/10.1371/journal.pone.0173951
https://doi.org/10.1016/j.cct.2015.03.010
https://doi.org/10.1016/j.cct.2015.03.010
https://doi.org/10.1371/journal.pone.0055200
https://doi.org/10.1371/journal.pone.0055200
https://doi.org/10.1249/ESM.0000000000000049
https://doi.org/10.1123/ijspp.2017-0330
https://doi.org/10.1210/er.2012-1055
https://doi.org/10.1016/j.jsams.2023.06.007
 https://doi.org/10.1249/MSS.0000000000003354 
https://doi.org/10.1136/bmjsem-2021-001300
https://doi.org/10.1136/bmjsem-2021-001300
https://doi.org/10.3390/ijerph191811168
https://doi.org/10.3390/ijerph191811168
https://doi.org/10.18773/austprescr.2022.025


20

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

ANNALES KINESIOLOGIAE • 16 • 2025 • 1

O’Brien, S., Rapkin, A., Dennerstein, L., & Nevatte, T. (2011). Diagnosis and man-
agement of premenstrual disorders. BMJ, 342, d2994. https://doi.org/10.1136/bmj.
d2994

Oester, C., Norris, D., Scott, D., Pedlar, C., Bruinvels, G., & Lovell, R. (2024). 
Inconsistencies in the perceived impact of the menstrual cycle on sport perfor-
mance and in the prevalence of menstrual cycle symptoms: A scoping review of 
the literature. Journal of Science and Medicine in Sport, 27(6), 373-384. https://doi.
org/10.1016/j.jsams.2024.02.012

Oxfeldt, M., Dalgaard, L. B., Jørgensen, A. A., & Hansen, M. (2020). Hormonal 
contraceptive use, menstrual dysfunctions, and self-reported side effects in elite 
athletes in Denmark. International Journal of Sports Physiology and Performance, 
15(10), 1377–1384. https://doi.org/10.1123/ijspp.2019-0636

Parker, L. J., Elliott-Sale, K. J., Hannon, M. P., Morton, J. P., & Close, G. L. 
(2022). An audit of hormonal contraceptive use in Women’s Super League soc-
cer players; implications on symptomology. Science & Medicine in Football, 6(2), 
153–158. https://doi.org/10.1080/24733938.2021.1921248

Powell, A. (2017). Choosing the right oral contraceptive pill for teens. Pediatric Clinics 
of North America, 64(2), 343–358. https://doi.org/10.1016/j.pcl.2016.11.005

Puder, J. J., Blum, C. A., Mueller, B., De Geyter, C., Dye, L., & Keller, U. (2006). 
Menstrual cycle symptoms are associated with changes in low-grade inflam-
mation. European Journal of Clinical Investigation, 36(1), 58–64. https://doi.
org/10.1111/j.1365-2362.2006.01591.x

Roffler, A., Fleddermann, M.-T., de Haan, H., Krüger, K., & Zentgraf, K. (2024). 
Menstrual cycle tracking in professional volleyball athletes. Frontiers in Sports and 
Active Living, 6, 1408711. https://doi.org/10.3389/fspor.2024.1408711

Schulz, J. M., Pohlod, L., Myers, S., Chung, J., & Thornton, J. S. (2025). Are fe-
male athlete specific health considerations being assessed and addressed in prepar-
ticipation examinations? A scoping review and proposed framework. Journal of 
Sport and Health Science, 14, 100981. https://doi.org/10.1016/j.jshs.2024.100981

Scott, D., Bruinvels, G., Norris, D., & Lovell, R. (2024). The dose-response in elite 
soccer: preliminary insights from menstrual-cycle tracking during the FIFA Women’s 
World Cup 2019. International Journal of Sports Physiology and Performance, 
19(4), 331–339. https://doi.org/10.1123/ijspp.2022-0282

Taim, B. C., Ó Catháin, C., Renard, M., Elliott-Sale, K. J., Madigan, S., & Ní 
Chéilleachair, N. (2023). The prevalence of menstrual cycle disorders and men-
strual cycle-related symptoms in female athletes: A systematic literature review. 
Sports Medicine (Auckland, N.Z.), 53(10), 1963–1984. https://doi.org/10.1007/
s40279-023-01871-8

Thornton, A. R., Figueroa, Y., Davis, P., & Bunn, J. A. (2023). Comparision of game 
data between halves and quarters in Division I women’s lacrosse. Journal of Science 
in Sport and Exercise. https://doi.org/10.1007/s42978-023-00260-x

Vaghela, N., Mishra, D., Sheth, M., & Dani, V. B. (2019). To compare the effects of 
aerobic exercise and yoga on Premenstrual syndrome. Journal of Education and 
Health Promotion, 8(1), 199. https://doi.org/10.4103/jehp.jehp_50_19

https://doi.org/10.1136/bmj.d2994
https://doi.org/10.1136/bmj.d2994
https://doi.org/10.1016/j.jsams.2024.02.012
https://doi.org/10.1016/j.jsams.2024.02.012
 https://doi.org/10.1123/ijspp.2019-0636
 https://doi.org/10.1080/24733938.2021.1921248
https://doi.org/10.1016/j.pcl.2016.11.005
 https://doi.org/10.1111/j.1365-2362.2006.01591.x
 https://doi.org/10.1111/j.1365-2362.2006.01591.x
 https://doi.org/10.3389/fspor.2024.1408711
 https://doi.org/10.1016/j.jshs.2024.100981
 https://doi.org/10.1123/ijspp.2022-0282
 https://doi.org/10.1007/s40279-023-01871-8
 https://doi.org/10.1007/s40279-023-01871-8
 https://doi.org/10.1007/s42978-023-00260-x
 https://doi.org/10.4103/jehp.jehp_50_19


ANNALES KINESIOLOGIAE • 16 • 2025 • 1

21

Jennifer A. BUNN, Gabrielle MARCHELLI, Hannah HUMPHRIES: MENSTRUAL SYMPTOMS IN DIVISION I FEMALE ATHLETES ..., 5–21

Vogel, K., Larsen, B., McLellan, C., & Bird, S. P. (2024). Female athletes and the 
menstrual cycle in team sports: Current state of play and considerations for future 
research. Sports, 12(1), 4. https://doi.org/10.3390/sports12010004

Yonkers, K. A., & Simoni, M. K. (2018). Premenstrual disorders. American 
Journal of Obstetrics and Gynecology, 218(1), 68–74. https://doi.org/10.1016/j.
ajog.2017.05.045

https://doi.org/10.3390/sports12010004 
https://doi.org/10.1016/j.ajog.2017.05.045
https://doi.org/10.1016/j.ajog.2017.05.045

	_Hlk199018774
	_heading=h.r98mwvimp51m
	_heading=h.c5xxoosmfb0
	_heading=h.ra86sy5uuqai
	_heading=h.8hg10f48zyt5
	_heading=h.pqcczyy4e2pg
	_heading=h.4m30s8od8tub
	_heading=h.pg55g25d2nd
	_heading=h.a8srg11uwxxg
	_heading=h.4i4blvd56uvj
	_heading=h.req9hpvv0x60
	_Hlk201317441
	_Hlk60736358
	_Hlk62755260
	_Hlk62755317
	_Hlk62755341
	_Hlk175663888
	_Hlk203037924
	_Hlk207193304

