Female athlete health: Where is all the research?

If women account for 40% of all participants in sport, then why is only 6% of sports science research exclusively done on females? 

Sport science and medical research is failing to mirror the groundbreaking rise and professionalism of women’s sport. Despite media coverage improving in recent years, female athletes continue to be underrepresented within sports and exercise science.

Research is heavily skewed towards male athletes meaning female athletes are following health guidelines based on data from the opposite sex. Considering the anatomical differences between men and women, this creates a huge disadvantage for female athletes in terms of their athletic performance, training, injury prevention, and rehab.

Previous studies have highlighted this alarming imbalance of research between male and female athletes. A study in 2014 analysed 1382 sports and exercise medicine journal articles over a three-year period, and results revealed that female athletes were significantly underrepresented, with female’s only accounting for 39% of the total participants. 

Looking more specifically at research examining performance supplements, data has shown that only 23% of the participants used were female athletes.

Additionally, researcher Kelly Lee McNulty revealed that in 2020 only 6% of sports science research was conducted exclusively on female athletes. 

This signifies the alarming sex-data gap in sport, hindering our knowledge surrounding athlete health specific to females. Important topics including menstrual health, menopause, and the contraceptive pill are all areas of women’s health that have been overlooked and understudied.

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New research published by the BBC revealed that nearly two-thirds of elite British female athletes said their menstrual cycle affected their performance or caused them to miss training or competition. And just over a third of these athletes said they would not feel comfortable discussing menstrual issues with their coaches. 

Aligning with an increasingly topical issue in women’s sport, the study also found that nearly a quarter of athletes have experienced a link between their menstrual cycle and injury. With the ACL crisis dominating women’s football, this is an area that urgently needs further research, and fast. 

Although limited, data has suggested that during different phases of their cycle, females are more susceptible to suffering an injury. When oestrogen levels peak in the ovulatory phase, it can affect the stability of tendons and ligaments, making them looser and more vulnerable to injury.

Moreover, a 2023 review concluded that ovulation was associated with changes in laxity, neuromuscular control, and body temperature - potentially exposing female athletes to a higher risk of injury. 

While these findings are incredibly valuable, the considerable lack of research makes it very difficult to reach any solid conclusions.

Leading sportswomen, Dame Jessica Ennis-Hill and Dina Asher-Smith, are therefore calling for more research around the effects of menstrual cycles on athletic performance. Since retiring, Jessica Ennis-Hill has released ‘Jennis’ a menstrual-cycle mapping app, after she revealed she could have been a better athlete if she strategically trained around her periods. 

Whilst research remains scarce, data has suggested that menstrual symptoms can affect training and performance.

A 2024 study found that 77% of British elite athletes believe their cycle negatively impacts their performance, experiencing common symptoms such as bloating, lower back and pelvic pain. However, cycles vary from person to person with some females experiencing more severe symptoms, including vomiting and fainting. 

One of the recommendations to combat symptoms is for females to take oral contraception e.g., the combined pill, which prevents or reduces ovulation. 

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Research released by the BBC revealed that a quarter of athletes said they take a contraceptive pill specifically to control the impact their period has on their performance. Despite the insufficient high-quality data addressing the effects of the pill on female athlete performance, it is interesting to note a considerable number of athletes are continuing to take it. 

The contraceptive pill is predominantly used for protection against pregnancy, but many athletes revealed they use it to time their bleed or to even skip their bleed. Usually you take the pill for 21 days followed by a 7-day bleed break, but some athletes would skip these breaks taking it continuously for months. The pill is also used by athletes to reduce menstrual symptoms, specifically cramping and abdominal pain. 

There has been some suggestion that taking a contraceptive pill offers a nearly 20% reduction of injury risk. This is due to the suppression of ovulation, removing peaks in oestrogen levels. However due to the sheer absence of research, the strength of the evidence remains significantly low. 

But despite the pill managing periods to help optimise athletic performance, it also comes with the heavy price that athletes may experience unwanted side effects like anxiety, mood swings, and bodily changes. Or in some cases, the very small risk of developing serious health issues such as blood clots and cancer.  

One of the athletes in the BBC study claimed that taking the pill ‘wasn’t really worth it’. Although it prevented an oestrogen release giving her more confidence regarding injury risk, it also brought her mood down and increased anxiety levels. 

It almost seems like athletes are faced with the tough decision of choosing between their physical or mental health. And neither scenario is ideal.

The extent to which the menstrual cycle and contraceptives impact performance is highly variable and incredibly complex. But given the lack of research we are essentially failing to maximise the performance potential of female athletes.  

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So why is there no research?

Finances

Studies require money and women’s sport is still very much playing catchup. Until female athletes have the investment and equal access to the resources that men have, we can’t expect to see the same amount of time and effort going into female medical research. 

Communication

Despite the conversation gradually changing, topics surrounding women's health are still not openly spoken about due to old fashioned stigmas. This ‘communication gap’ means many women still don’t understand their individual health and how it impacts their athletic performance.

Physiological differences

Women’s health is far more variable than mens due to their fluctuating hormonal status. It is extremely challenging to perform reliable research as controlling for hormonal differences further complicates the experimental design - so we need more female participants making the research more expensive. 

Numbers

Women are less likely to volunteer for research due to not having done so before. And at an elite level, many athletes are too busy to take part in research projects, as highlighted in the recent BBC study. Although the survey was sent to 615 athletes in 28 different sports, they only received 143 responses. This could be because governing bodies and clubs are failing to share opportunities with players, but even so, if the call for research isn’t even reaching or interesting athletes, then any potential for future change slips further away.

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The absence of scientific research continues to sideline women’s sport, depriving female athletes of fair and proper treatment. 

As much as women’s sport is booming, the lack of investment into female-specific research will inevitably cause the momentum to slow down.

Therefore, more research is vital.

But it's not just about increasing the quantity of research, but also producing higher quality research so we can reach more accurate conclusions about female physiology. 

Moving forward we must work towards closing the sex-data gap in medical research and creating female-specific guidelines to optimise athlete performance.

If we can achieve this, then women’s sport is better positioned for many more years of exceptional growth. 

Link to the BBC Elite British Sportswomen's Study 2024 results: https://www.bbc.co.uk/sport/68534081