Written evidence submitted by Dr Georgie Bruinvels, Professor Charles Pedlar and Professor Jamie North
About us:
We are part of a research team with a primary focus on female physiology and how hormonal changes e.g., across the menstrual cycle, can influence the health and performance of female athletes. Our primary aim is to better understand the needs of female athletes, so we can support them optimally. We have conducted research across the whole performance spectra, from some of the best athletes in the world, to in UK schools at the grassroots level. Dr Bruinvels and Professor Pedlar also work for Orreco, a sports science company. Through Orreco’s female athlete programme, we provide support in the form of consultancy for many professional athletes and teams (including the Lionesses) so have seen first-hand, on a global level the insufficient education and support delivered around female health. We fundamentally believe this needs to be addressed as a matter of priority to keep girls and women in the game.
The gender gap in participation in sport is well established (Guthold et al. 2020). Key timepoints for drop out from sport are associated with significant hormonal changes that can affect physical and mental wellbeing (e.g., puberty, menopause). These hormonal fluctuations can also result in anatomical and physiological changes that alter the way girls and women can feel during exercise, yet education in this space is sparse. Research from our group has repeatedly shown that 70-80% of female athletes have not received education about female health and the menstrual cycle in particular. This is compounded by the lack of education in schools, as we have recently established (Brown et al. 2022).
The pubertal transition is an important time where life-long behaviours and beliefs are likely to be formed (Lau et al. 2019). We recently conducted a large research study that collected data from over 16,000 exercising females from 7 different countries in partnership with STRAVA, the exercise tracking app. We aimed, in part, to better understand the relationship between exercise participation, the menstrual cycle and female health education (Bruinvels et al. 2020). We found that women in the UK and Ireland were more likely to reduce or stop exercising during puberty than those in other countries (France, Germany, USA, Brazil, Spain), and were almost twice as likely to do so than participants from Germany, USA, France and Brazil. There were multiple reasons for this, but factors such as poor self-confidence, feelings of inadequacy, the effects of puberty and menstruation being a barrier were all notable. Significantly, those who reported having received education about their menstrual cycle were less likely to stop or decrease exercise during puberty. We believe female health education needs to be a fundamental focus where girls should be empowered and supported to understand more about their bodies and the importance of physical activity, good nutrition and sleep, and ultimately encouraging lifelong behaviours, keeping more girls and women in sport and in the game.
Our recent work in elite women’s football has also revealed some concerning findings (unpublished data), with large numbers of players ‘suffering in silence’, not feeling able to discuss their menstrual cycle and associated symptomology with their coaches or other members of support staff and even, on occasions, their teammates. On average, 65-70% of elite female players who contributed data to our research (from professional football leagues) feel that their menstrual cycle stops them from performing at their best. However, only 10% of these have discussed this perceived performance effect with their coach. More positively though, our research has shown that after receiving education and support around female health, which crucially includes understanding what happens across the menstrual cycle, highlighting what is normal, and what is abnormal, when to seek help, and how to work with and manage their unique symptoms (both positive and negative), we have seen fundamental changes in player wellbeing and symptomology with players subsequently reporting that they feel more supported and in control, with a better understanding of how to support their body. Ultimately players report feeling that they able to play and perform better at all times in their cycle following the educational intervention and support.
In youth pathways in women’s football we have also identified a lack of awareness around female health and wellbeing. Many health myths seem to exist, for example many believe it normal to not menstruate if you exercise regularly, while there appears to be a systemic culture of dosing up with medication (e.g. non-steroidal anti-inflammatories) or using hormonal contraception to reduce symptoms or ‘regulate’ cycles, and finally it is often accepted that having bad symptoms is just bad luck and something that has to be dealt with. There are, however, so many proactive actions and natural solutions available to manage and alleviate these menstrual cycle symptoms. In scenarios where a female experiences significant menstrual cycle symptoms, players have reported having to make up an excuse to get out of training because they do not want to mention menstruation. Equally, reports of being fearful about leaking through to light-coloured playing kit are common, yet these players, along with coaches, parents and other potential members of their support team are not well educated in these issues, making discussion and management very challenging. It is extremely challenging for a male coach of a 15-year-old female player to feel empowered to have a discussion about the menstrual cycle when they themselves have not been educated on these issues.
Adverse menstrual cycle symptomology is compounded by other factors too, such as players not fuelling well (if at all) after training, having compromised sleep because their training times are so late, and/or dealing with other lifestyle stressors alongside training such as doing school exams. These are all scenarios which are seen on a frequent basis and ultimately increase risk of injury, illness and drop out, while also clearly preventing optimal performance. Yet these scenarios are largely avoidable if resources and education were made available and accessible to educate and empower players, parents, and practitioners.
Providing female health support is an area that the England Lionesses have embraced with open arms. The primary aim has been to empower players to work with their bodies as female athletes. However, it should not be that this information is only accessible to the elite few. At present, there is almost a survival of the fittest scenario, with only those who have overcome or navigated the many barriers faced to make it to the top. A fundamental cultural shift is needed. The historical sex bias in research is well established, but must not be accepted. While progress is being made in this area, this needs to continue and a concerted approach of prioritising better understanding of the needs of female players and then most importantly, translating this into practice. At present, we believe we are only just scratching the surface of how good female players can be.
On the basis of this, we conclude that:
Dr Georgie Bruinvels
Prof Charles Pedlar
Prof Jamie North
Brown N, Williams R, Bruinvels G, Piasecki J, Forrest LJ. Teachers' Perceptions and Experiences of Menstrual Cycle Education and Support in UK Schools. Front Glob Womens Health. 2022 Feb 14;3:827365. doi: 10.3389/fgwh.2022.827365. PMID: 35237766; PMCID: PMC8882726.
Bruinvels G, Goldsmith E, Blagrove R, et al. 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. British Journal of Sports Medicine 2021;55:438-443.
Guthold R, Stevens GA, Riley LM, Bull FC. Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1·6 million participants. Lancet Child Adolesc Health. 2020 Jan;4(1):23-35. doi: 10.1016/S2352-4642(19)30323-2. Epub 2019 Nov 21. PMID: 31761562; PMCID: PMC6919336.
Lau EY, Riazi NA, Qian W, Leatherdale ST, Faulkner G. Protective or risky? The longitudinal association of team sports participation and health-related behaviours in Canadian adolescent girls. Can J Public Health. 2019 Oct;110(5):616-625. doi: 10.17269/s41997-019-00221-4. Epub 2019 May 28. PMID: 31140144; PMCID: PMC6964404.