Introduction
The menstrual cycle (MC) is a fundamental biological rhythm that shows significant cyclic changes in endogenous sex hormones, including oestrogen and progesterone. Although these hormones are primarily fluctuated to assist reproduction, recent research on female athletes has indicated that muscular strength, aerobic, anaerobic, and endurance performances are either enhanced or impaired by MC’s follicular, luteal, and ovulatory phases (Carmichael et al., 2021). Additionally, there appears to be an association between certain phases of the MC and the likelihood of injury in female athletes, including anterior cruciate ligament ruptures (Hewett et al., 2007).
Apart from that, Carmichael et al.’s (2021) review found that female athletes perceive the MC to hurt their training and competition (50–71% and 49–65% of female athletes, respectively). Certain phases of the MC, such as early follicular and late luteal phases, change athletes’ perceived speed, power ratings, and strength. Several studies have indicated that the decline of perceived performance in these phases is associated with menstrual-related symptoms, such as pain and tiredness (Chen & Hu, 2019; Schoep et al., 2019), mood changes (Samy et al., 2019), fatigue, lethargy, and bleeding (Bruinvels et al., 2016; Findlay et al., 2020).
A precise understanding of MC’s physiological and psychological effects on sporting performance is critical for coaches and sports professionals to ensure the appropriate training prescription and the well-being and health of female athletes. However, mixed findings have been reported, which hinder the ability of researchers to develop evidence-based guidelines for female athletes (Elliott-Sale et al., 2021). To date, it is recommended that a personalized approach be taken based on fluctuations in exercise performance throughout the menstrual cycle. However, with individual experiences, beliefs, and attitudes towards the MC being influenced by normative expectations, stereotypes, and myths about the MC (Chrisler, 2008), more investigation is warranted to understand how the MC is perceived to impact training and competition among female athletes from different populations and cultures.
Previously, Saudi Arabia had laws and regulations that restricted the participation of women in sports because of socio-cultural beliefs and practices; however, on a positive note, that changed in 2018 in line with Vision 2030, which encourages full empowerment of women, including active participation in sporting activities in Saudi Arabia (Sayyd et al., 2020). The Saudi government started licensing female fitness centres to support female athletes and reduce physical inactivity and cases of obesity among women in Saudi Arabia. This paradigm shift means female Saudi athletes can now actively participate in sporting activities and get adequate training. They no longer have to worry about restrictive policies and a lack of training facilities that were previously the major impediments to their active involvement in sports.
It is essential to note that, unlike many parts of the world where women have been involved in sports for several decades, Saudi Arabia faces a distinct challenge. It was not until 2018 that females in Saudi Arabia were allowed to engage in major sporting events. It means that males still dominate this field as coaches and promoters. It has been suggested that male coaches in Saudi Arabia cannot fully understand and appreciate the pain and discomfort associated with period pain. They cannot find a proper solution to the problem due to their lack of experience (Clarke et al., 2021).
Communication is another barrier that the sporting community faces. It has been suggested that female athletes in Saudi Arabia find it difficult to address problems related to their MC’s physiological challenges directly. Saudi sportswomen have struggled for many years to access the same opportunities as sportsmen, with gender segregation as a reason (Alruwaili et al., 2020). Therefore, gender as a barrier to the conversation has remained a significant issue among these female athletes. However, it is impossible to discount the fact that female athletes want to prove their ability and determination in various sports.
The Saudi Vision 2030 envisages a society where women are fully empowered in all aspects of life. The programme acknowledges that long-time women in Saudi Arabia have been denied the opportunity to explore their talents and achieve their full sporting potential due to cultural beliefs and practices (Sadeghi, 2019). Athletics is one area where Saudi women have made significant strides over the past few years.
The present paper focuses on assessing how menstrual cycle challenges, directly and indirectly, affect the performance of female athletes in SA. This investigation is intended to identify the unique challenges female athletes in SA face, the steps taken to manage MC, and possible gaps that still need further attention. This paper will further explore how Saudi female athletes communicate with their coaches and support staff regarding their menstrual cycles, despite existing cultural impediments (Sayyd et al., 2020).
It will propose ways the athletic community can utilize internationally approved methods to help these women overcome MC’s challenges. As Findlay et al. (2020) observed, it is not enough for the government to eliminate laws prohibiting women from engaging in sports. It is equally important to identify and eliminate all impediments that may deny them an equal opportunity to participate actively in sports.
This study examines female athletes’
- MC status characteristics,
- MC perceived impact concerning training and competition performances, and
- openness to a conversation with coaches, trainers, and allied support personnel about their MC.
This information can help the local athletic community in Saudi Arabia adhere to international best practices in addressing menstrual challenges among female athletes.
Methods
Design
The present study is designed as a survey similar to the one conducted in Australia by Armour et al. (2020). Refer to (Appendix A). It is worth noting that the lead researcher in Armour et al. (2020) granted permission for the use of the survey questionnaire and its adaptation to the Saudi context. With slight modifications to accommodate the peculiarities of the Saudi context, this study was organized to quantify the extent to which female athletes in Saudi Arabia experience MC and its perceived impact on training and competition. The online survey method was also considered appropriate because it can be distributed to a large population across the country, despite the current COVID-19 pandemic, which has restricted the movement and interaction of people over the recent past.
All questionnaires were forward-translated by two independent translators from English into Arabic and combined into a final version to ensure reliability, validity, and appropriateness for the Saudi population. All translators had Arabic as their mother language and were fluent in English. Additionally, a small sample pilot (n=29) was conducted to help determine the survey’s clarity and validity. All participants in the pilot test indicated that the questionnaire was clear and appropriate. However, minor edits were made to the survey wording based on their feedback.
Participants
Following institutional ethical approval, the researcher needed to contact the targeted population and inform them about the study. Social media platforms provided the best avenue for reaching out to these participants. Using Instagram, Snapchat, and Twitter to reach the targeted audience was effective because these young athletes spend considerable time communicating and entertaining themselves on these platforms.
The recruitment strategy led to a sample size of 149 valid responses. The total number of responses was 181, but 32 were excluded from the analysis. Eight respondents were excluded because they did not provide their consent, and 24 respondents were excluded because they did not participate in a primary sport. Participants were athletes involved in athletics, football, volleyball, basketball, and boxing, among other popular sports in the SA.
Although the preliminary investigation conducted indicated that female sports are yet to be fully explored in the Saudi local context because of policies that, for a long time, denied women the opportunity to engage in sports, therefore, at this stage of research, the exact number of semi-professional and professional athletes in SA is not known. Participants were considered to be an adequate representation of active female athletes involved in various sports in SA. It is essential to note that the article by Armour et al. (2020) served as a crucial guide in this study due to its high number of participants and a confidence level of 95%, which made it a reliable source.
Inclusion Exclusion Criteria
It was essential to define the inclusion/exclusion criteria in this study. Participants had to be athletes currently residing in Saudi Arabia. Armour et al. (2020, p. 318) define an athlete as “someone who engages in strenuous and specialised training for competition against other peers in the same sport at club level or above.” Those who failed to meet the criteria were excluded from the study.
The participants had to be aged 18 to 45, older athletes who are currently experiencing less regular period pain, and those who are suppressing the pain through the use of oral contraceptive pills and other forms of therapy were included in the study. Since Saudi Arabian athletes were only recently allowed to participate in competitive sports, participants had to be active current athletes, including Individuals who identified as recreational, club, national, and international athletes.
Data Collection
For reliability in collecting the needed information, all questionnaire was developed adopting aspects of previous studies, including menstrual characteristics (i.e., assessment of menstrual flow heaviness), menstrual cycle perceived impact (i.e., perceived impact on training sessions), and openness to the conversation around menstrual cycle with coaches, trainers, and support staff.
An anonymous 31-item questionnaire was published using JISC online surveys. Kumar (2014) explains that it is often advisable to ensure the anonymity of participants, especially when the issue under investigation is controversial. Protecting the identity of the participants ensures that they are not subjected to criticism or any form of verbal or physical attacks because of their views, which may differ from those of the majority.
The menstrual cycle remains a sensitive issue, especially in Saudi Arabia, and many women may not be willing to talk about it freely. As such, making the survey anonymous gives them the best opportunity to discuss sensitive issues related to the menstrual cycle without revealing their identity. All respondents were invited to complete the study within three weeks (July 1st-21st, 2021).
Informed consent was obtained via a compulsory “yes” or “no” selection at the start of the questionnaire, which was presented following a participant information page. Those who responded “no” to the consent statements were excluded from the analysis. Most questions required a compulsory answer; however, respondents who selected “other” for their responses were given the option to provide a more detailed explanation. Moreover, twenty-eight participants responded to an optional open-ended question about details related to MC alterations in training sessions.
Statistical Analyses
When gathering data, the researcher was interested in obtaining specific information about the topic that could be coded and statistically processed. A descriptive statistical analysis focused on interquartile and median ranges for not normally distributed data and percentages for categorical data. The Mann-Whitney U test was used for group comparisons and to assess pain severity.
Differences between groups were assessed by the frequency of responses using the chi-square test (χ²), and nominal data were analyzed using the Chi-square test for classification, with a statistical significance level of p < 0.05. No missing data were replaced. To compare athletes’ level of competition, the researcher considered ‘elite’ athletes to be those competing at national and international levels, whereas ‘non-elite athletes are those competing at club and recreational levels.
Results
Of the 149 responders, 119 participants (79.9%) were classified as “non-elite,” and 30 participants (20.1%) were classified as “elite” based on their level of competition, which included reactional, national, club, and international athletes, respectively.
Demographics
Participants ranged in age from 18 to 45, with the most common reported ages falling between 18 and 24 and 25 and 35. The most commonly reported sport or exercise categories included team sports (land-based) and individual sports (land-based) (39.6% and 43.6%, respectively).
MC Status Characterises
The overall majority of female athletes reported regular MC. There was a significant association between competition level and menstrual regularity (χ²(2, N = 149) = 7.629, p =.023), with 73.9% and 53.3% reporting regular MC, 19.3% and 43.3% reporting not regular MC, and 6.7% and 3.3% reporting not sure, respectively, in non-elite athletes and elite athletes.
Heavy menstrual bleeding (HMB) was not common among female athletes (2.7%), nearly one-third of female athletes reported that they had been diagnosed with anemia before age 43 (28.9%), and 33 (22.1%) reported that they are currently taking iron supplements. There was no significant association between athletic level and HMB (χ²(2) = 1.70, p =.427). PMS, such as breast tenderness, headaches, and mood swings, was commonly reported, with almost 87% of female athletes suffering from pre-menstrual symptoms.
Athletes experienced moderate period pain, with a median intensity of 6, measured on a 0–10 numeric rating scale (NRS), occurring during every period (36.2%); most periods, 19.5%; and occasionally, 23.5%. 61% of athletes indicated they engaged in a variety of pharmaceutical strategies for menstrual management, including Brufen, Panadol, stan, Aleve, and Brufen.
The most commonly reported medications were Brufen and Panadol (22.1% and 19.9%, respectively). The use of hormonal oral contraceptives (HOC) was not common among female athletes, with only 9.4% using HOC. The most common reasons for using HOC were reported to be: to regulate MC and contraceptive reasons. There was no significant association between oral contraceptive use and athletic level, as Fisher’s exact shows (Exact, p =.482).
Perceived Impact
Most female athletes acknowledged that the MC undermines their performance during training sessions and competitions (45%, 28.9%). More than two-thirds of the sample reported that the onset of menstruation is the most affected part of their MC (67.4%). The most common negative impact reported was a decrease in energy level, observed in 76.1% of training sessions and 65.1% of competition performances, respectively.
Other negative reported symptoms were:
- strength (47.8%, 37.2%);
- coordination (28.4%, 39.5%);
- endurance (59.7%, 58.1%);
- ability to maintain focus (7.5%, 14.0%);
- vision (4.5%, 7.0%); speed (52.2%, 51.2%);
- and concerns related to bleeding (38.8%, 53.5%),
in training and competition performance, respectively.
MC-related modifications and alterations to training sessions did not mirror perceptions, as 71.1% of female athletes didn’t make any MC-related alterations. There was no significant association between alteration practices and athletic level, as indicated by Fisher’s exact test (Exact, p = 0.759) (χ²(2, N = 149) = 2.06, p = 0.545). There was a significant association between the perceived impact on training sessions and athletic level (χ²(2, N = 149) = 10.014, p = 0.008), with 38.7% and 70% of participants perceiving a negative impact, and 46.2% and 26.7% perceiving no impact, in non-elite and elite groups, respectively.
Openness to Conversation and Potential Barriers
Almost 40% reported being unwilling to discuss their MC with their coaching, training, and support personnel, while 33.9% stated that they didn’t see the need to do so. Of the female athletes who reported talking about their MC (34.9%), gender was a clear condition, as above half of the sample reported that they would talk to only a female coach, trainer, and support staff (53.8%). There was no significant association between openness to conversation and coach gender (χ²(1, N = 149) = 0.150, p = 0.845).
The assumption of this study was partially met, as there were higher overall numbers of female coaches and trainers; however, the elite athlete had more male coaches. There was a significant association between coach gender and athletic level (χ²(1, N = 109) = 22.658, p = 0.00). 76.7% and 26.6% male coaches and 23.3% and 73.4% female coaches for elite and non-elite, respectively
Discussion
In contrast to many regions of the world where women have participated in sports for decades, women in Saudi Arabia were only permitted to participate in major sporting events beginning in 2018. This study was conducted as a preliminary investigation into female athletes in Saudi Arabia, focusing on their current status and perceptions regarding the menstrual cycle (MC) in relation to training and competition, as well as their openness to, and barriers in, discussing MC-related symptoms with coaching staff, trainers, and auxiliary personnel.
The findings revealed that menstrual pain and other pre-menstrual symptoms—such as headaches, mood swings, and breast tenderness—were common among participants. Another notable result was the considerable variation in how athletes perceived the negative impact of the MC on training and competition performance, along with inconsistencies in how training sessions were adjusted to address these challenges. Regarding openness, the study found that Saudi female athletes often felt uncomfortable discussing menstrual-related issues, particularly with male staff, while being more at ease with trainers, female coaches, and support personnel.
Prior studies that have noted the importance of adopting an individual approach when working with female athletes draw our attention to the importance of considering the perceived impact of the menstrual cycle on sports performance. For instance, Bruinvels et al (2016) indicated that 51.1% of elite British female runners and rowers felt their menstrual cycle had somehow impacted their sporting performance. Armour et al. 2020 recently reported that Australian female athletes perceive the menstrual cycle phase to adversely affect their training and competition by 50% and 56.5%, respectively.
However, it was essential to identify the unique challenges that female athletes face in the Saudi local context. Previous research has noted that how women perceive the MC is influenced by cultural norms, stereotypes, and myths surrounding the MC. This will help inform and influence best practices provided by coaches and practitioners in the local context of Saudi Arabia.
The results of this study indicate that the physiological and psychological challenges of pre-menstrual and dysmenorrhea symptoms were a prevalent feature among female athletes in Saudi Arabia. In line with this study, Armour et al. (2020) indicated that over 90% of Australian female athletes have reported primary dysmenorrhea as a significant impediment to their training and competition. These symptoms of MC have been observed in athletes and the general population. It has also been reported that women who are involved in regular physical exercise experience reduced period pain and other associated effects.
However, surprisingly, a minority of participants (9%) indicated that they are currently using OCP to manage the number of conditions, with only one participant choosing to use the OCP to reduce period pain, and one participant choosing to use the OCP to shift their MC. In other words, the present study’s reported coping strategies to manage these symptoms were predominantly limited to anti-inflammatory medication.
Olympic athletics happen in all phases of the cycle. OCP is an available option used to control the timing of menstruation, to prevent the onset of symptoms, or the inconvenience of bleeding and associated anxiety or distraction of leaking while performing. Most female athletes believed the menstrual cycle negatively affected their game-day performance and training sessions. These findings further support the importance of understanding female athletes’ perceptions of the MC.
This study supports evidence from prior observations by scholars such as Armour et al. (2020). However, despite the perceived negative influence of the MC on training sessions, most female athletes did not consider altering or modifying their training sessions. These findings suggest limited awareness of the menstrual cycle’s impact on training and the potential benefits of adjusting training.
Despite the reported PMS and dysmenorrhea, female athletes in the present study frequently reported no impact on training sessions and game-day performance. Self-awareness is the first step for preparing and managing the MC, and it is essential. Identifying management strategies that align with monitoring symptoms to prevent this may be essential.
Inter-individual variation in reported symptoms was observed, and the perceived impact can enhance understanding and inform best practices for coaches and practitioners working with female athletes. A key aspect of the findings is that one approach cannot be applied to all female athletes, whether for addressing symptoms and management, training, competition, or increasing comfort and openness in conversations. For example, a few female athletes reported. Previous research has been contrasting in relation to the physiological impact of the menstrual cycle on sports performance and adaptation; however, as established from the current results, this may be due to the individual variability in the timing of and symptoms experienced by each individual.
The influence of psychological determinants such as motivation and levels of lethargy should also be considered throughout the cycle in relation to performance, as stated by multiple female athletes within this study; this has not previously been considered within the literature yet we know the impact of motivation on performance, those athletes who display high motivational profiles have been shown to obtain the highest levels of performance.
One consistently reported element was the distraction of leaking or blood showing through clothing, which was a common occurrence across all sports. This aligns with previous findings in which the trauma of staining clothing or leaking through underwear was deemed the most embarrassing event that could happen while menstruating. This element should be addressed within the sport, advising athletes on menstrual products and considering the clothes women must wear for competition.
Findings indicated that athletes expressed varying degrees of comfort in addressing MC-related symptoms with coaching staff, trainers, and support personnel. Contrary to expectations, the coach’s gender did not significantly influence this openness. These findings are somewhat surprising given the fact that other research shows women still conceal menstruation issues, and the culture and social media have enhanced this and coach gender.
However, more than half of the female athletes who indicated an openness to talk about menstrual-related issues chose to talk to only a female coach, trainer, or support staff. It can thus be suggested that coach gender played a role in the comfort level of openness to the conversation among female athletes in SA. This is consistent with prior literature in female athletes, where coach gender was mentioned as a factor in considering talking about MC-related issues.
Another notable finding is the considerable variation in reported reasons for athletes’ discomfort in discussing MC-related issues with coaches, trainers, and support staff. About 17% of these reasons were linked to perceptions of male gender, such as feeling embarrassed because the coach is male, believing men would not understand, or assuming they would not care. These insights further reinforce the study’s findings and raise essential questions about the level of awareness male coaches in Saudi Arabia have regarding the impact of the menstrual cycle on performance, particularly given that women have only recently been permitted to participate in sports. Although beyond the scope of the present study, future research should investigate male coaches’ comfort and knowledge regarding the menstrual cycle and its impact on athletic performance.
With the majority of reported reasons, 33.9% were “don’t think they need because they don’t perceive the MC to have an impact on training”. Knowledge about the MC and how it might impact the performance can help the athlete manage and modify training sessions to reach her best potential. This finding underscores the importance of discussion and open dialogue regarding the MC and its potential impact on performance. These findings suggest a role for coaches, instructors, and support team members in creating an environment where women can discuss their MC by promoting open dialogue, especially with male coaches. This can help share knowledge and understanding.
Limitation
Saudi Female Athlete
At the time of research number of Saudi athletes was not known, therefore, in this study, it was open for female athletes currently participating in sport in Saudi Arabia, so it is possible that not only Saudi athletes but other nationalities participated in the study and for future research, it will be better if only Saudi so we can generalise the results on Saudi population.
Region
Also, it would be better if we ask for “what part of Saudi Arabia are you from” because of its cultural and social influences on the perceptions of MC. It opens the conversation around issues related to MC and myths around MC.
Age
The inclusion criteria (due to ethical approval) were individuals above 18 years old; it is possible that the number of teens who couldn’t participate in the study and their perceptions would be helpful. Self-reported: All measures were self-reported; therefore, athletes may have had issues such as anemia that had not been discussed or diagnosed by a medical practitioner, or conversely, may have considered themselves to have heavy bleeding, but not meet the criteria for this.
Recruitment Strategy
Our recruitment strategy, which utilizes social media and professional networks, may have overlooked athletes who do not use social media or are not involved in the targeted sporting groups. This may be a factor in why very few respondents were involved in water-based sports, preventing comparisons between different types of sports.
Practical Application and Conclusion
This paper highlights the importance of increasing awareness and education among coaches and trainers; they need to be aware of the menstrual cycle and start to consider the effects when working with female athletes in the same light as other physiological functions. Additionally, an environment where female athlete can discuss their cycles is essential; open dialogue around the MC can help ensure the right strategies and training alterations for the athlete.
Menstrual cycle tracking is essential to develop tailor-made guidelines for managing performance across the MC, including inter-individual variability in the reported impact of hormonal fluctuation in a prior study and the present study (that’s why). Instead, it is advised that a personalized approach be adopted, tailored to each individual’s exercise performance patterns during the menstrual cycle.
It means that female athletes and those who work with them need to be aware that the time of MC performance might be reduced, so that early follicular phase or in the entire MC phases, but they should be tailored to and informed by the individual response to work on a case-by-case basis. Moreover, further problems or issues relating to MC among Saudi female athletes are yet to be explored in the Saudi context. Initially, the right help and support for the athlete’s needs can be provided by referring the athlete to a doctor.
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