“No, that is not normal”: Psychosocial lived experiences of Elite Athletes living and performing with Menstrual Dysfunctions

“No, that is not normal”: Psychosocial lived experiences of Elite Athletes living and performing with Menstrual Dysfunctions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “No, that is not normal”: Psychosocial lived experiences of Elite Athletes living and performing with Menstrual Dysfunctions Ritu Verma, Sahen Gupta This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4782294/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background With the increasing representation of women in sports, addressing menstrual health issues, specifically menstrual dysfunctions (MDs), has gained significance. This study aimed to gain a comprehensive understanding of the experiences of athletes living with MDs and how they manifest in their sports performance and psychological well-being Methods Ten female athletes (mean age = 24.5, SD = 5.20), active and retired, living with MDs, including endometriosis, polycystic ovary syndrome (PCOS), primary dysmenorrhea, and premenstrual dysphoric disorder (PMDD), for a minimum of one year, were engaged in semi-structured interviews. Data analyses utilized Braun and Clarke's (2019) six-phase guide for reflexive thematic analysis, which incorporated a three-step coding process (Moghaddam, 2006 ) for an in-depth exploration. Results A two-phase thematic analysis highlighted six key themes: medical impact, health impact, psychological impact, socio-cultural impact, social support, and suggestions. These themes illuminate how their physical symptoms led to psychological challenges and underscore the inadequate support received from sporting and medical professionals. In the second phase we identified several barriers and facilitators as illustrated from the lived experience with MDs. These are then synthesised into reccomendations that the athletes suggest themselves which offer insights that can benefit other athletes with MDs and guide coaches and medical practitioners in providing effective support. Conclusions Study findings highlight athletes' daily experiences living with menstrual dysfunctions (MDs) both in and out of sport, including their thoughts on how MDs affect their sports participation, sense of self and personal well-being. Future studies can adopt a more longitudinal approach, delving into various MDs individually for a deeper understanding and conduct focus groups with medical personnel, support staff and athletes for improved support provisions. We recommend an education programme for athletes and coaches in an asynchronous format for access to information and CPD for holistic support for pathway athletes. MDs menstrual cycle coaches medical professionals self-perception Female athlete Figures Figure 1 Figure 2 Introduction Menstrual dysfunctions (MDs) are a prevalent concern among women of reproductive age and is a prominent cause for gynecological consultations worldwide (Bahamondes & Ali, 2015). Dovom et al., (2016) define regular menstrual cycles, or eumenorrhea, as those lasting fewer than 35 days but no longer than 23 days, with an ideal duration of three to seven days for normal bleeding. MDs deviate from the regular menstrual cycle and typically become apparent one to two years after the initiation of the first menstrual period (Rani et al., 2016). MDs can serve as indicative symptoms of conditions, such as polycystic ovarian syndrome (PCOS) and endometriosis (Abdelmoty et al., 2015). If left undiagnosed or untreated can lead to substantial long-term consequences, including reduced quality of life due to worsening symptoms, the potential for infertility, negative self-perceptions of body image, an increased susceptibility to comorbidities like depression and anxiety, and significant financial burden caused by increased healthcare expenses (Agarwal et al., 2019; Fernandez et al., 2021). Prevalence of Menstrual Dysfunctions (MDs) in Female Sport Statistics indicate 30–70% women, experience MDs globally (Igbokwe & John-Akinola, 2021 ). Female athletes in sports such as running, ballet, swimming, and gymnastics, exhibit notably higher rates of MDs, including oligomenorrhea (infrequent menstrual periods), primary amenorrhoea (failure to menstruate by age 15), secondary amenorrhoea (previously menstruating but not having a period for three months or more), and delayed menarche (Redman & Loucks, 2005 ). The prevalence rates range from 6–79%, significantly exceeding the 2–5% observed in the general population (Gimunová et al., 2022 ). This higher prevalence of MDs among athletes can be attributed to intense training regimens, inadequate recovery periods, energy imbalances, and suppression of endocrine function, restrictive dietary practices, weight loss, and insufficient nutritional intake during periods of heightened physical activity (Berz & McCambridge, 2016 ; Gimunová et al., 2022 ). Evidence indicates that 21.9% of all athletes engaged in aesthetic sports like ballet, running, and swimming an 10.6% in endurance sports, live and compete with MDs, although the number is likely to be underreported (Torstveit & Sundgot-Borgen, 2005 ). Another study by Amoruso et al. ( 2024 ) indicates irregular menstrual cycles, potentially indicative of menstrual dysfunction, were observed in 33.0% of athletes, with 41.1% participating in lean sports. Additionally, an overestimation of body image was associated with a higher likelihood of experiencing menstrual irregularities. At a socioecological level, MD rates in athletes are culturally influenced. Indian athletes had a greater prevalence (63.5%) than Western athletes (50%), which might be due to challenges in tracking cycles, inadequate awareness, stigmatised communication, reluctance to medicate and inadequate management (Majumder et al., 2022 ). However, across countries, multiple factors impede an accurate diagnosis (Verhoef et al., 2021 ) and overall MDs have received little attention in the sports environment (Adam et al., 2022 ). Impact of MDs among Athletes The incidence of MDs, particularly primary amenorrhoea, is more prominent among athletes in sports that prioritize leanness (Sundgot-Borgen & Larsen, 2007 ). This is often associated with self-imposed dietary restrictions, weight concerns, lower BMI, increased psychological stress, decreased self-esteem, heightened perfectionism, and rigorous physical training, all of which can contribute to delays or disruptions in menstrual cycles (Senatore et al., 2019 ). Other causal factors such as influence of medications, genetic predisposition, psychological stressors, and alterations in lifestyle, such as changes in dietary patterns, obesity, smoking, and drinking also negatively affect athletes (Redman & Loucks, 2005 ; Ansong et al., 2019 , Latif et al., 2022 ). Among athletes, MDs can result in various psychological consequences such as eating disorders, diminished cognitive functioning, reduced concentration, heightened levels of anxiety and depression, insomnia, feelings of worthlessness, and increased irritability (Strine et al., 2005). Athletes experiencing MDs may report physical symptoms such as heightened pelvic pain, increased fatigue, lower back discomfort, nausea, gastrointestinal disturbances, and reduced energy levels. These physical symptoms often negatively affect their athletic performance (Senatore et al., 2019 ; Heather et al., 2021 ) and presented challenges which lead to withdrawal from sport, unforseen disruption in training and prevent achievement of peak performance or maintenance of well-being (Adam et al., 2022 ). In serious cases, some athletes with MDs may even consider ending their sporting careers (Czajkowska et al., 2019 ). Due to the multilevel impact athletes with MDs often utilise medication such as combined oral contraceptive pill (COCP), hormonal contraceptives, and birth control pills for the menstrual cycles, enhancement of cycle regularity, alleviation of associated symptoms, and management of acne concerns which lead to side-effects such mood disturbances, weight management issues, training load difficulties and other issues (Heather et al., 2021 ). However, despite there, to our knowledge, there is no study outlining the lived experiences of athlete’s living with MDs. The Current Study With the increased participation in and professionalisation of women’s sport, there is an urgent need to better understand and support the holistic mental and physical health of female athletes (Bowes et al., 2021 ). MDs and how athletes cope with them have received limited scientific attention (Adam et al., 2022 ) and it is crucial for medical professionals, sport management, coaches, parents and athletes better to understand the lived experience of athletes with an MD, to help improve adjustment and quality of life (Senatore et al., 2019 ; Czajkowska et al., 2020). While there are a few studies on the physiological impacts on MDs, these studies do not explore the diverse range of psychological experiences that can exist along a continuum among athletes (Adam et al., 2022 ). This highlights a clear gap and urgent need to explore the lived experiences of MDs among female athletes. As such, the present study seeks to bridge this research gap by understanding the psychosocial experiences of female athletes with menstrual disorders, with a specific focus on their lived experiences, challenges in daily life and how MDs affect their performance as athletes. Most studies tend to focus primarily on prevalence data with very few exploring the experiential aspects of MDs among athletes. We focus on the experiential lives experience of athletes which has little to no research (Bruinvels et al., 2016 ). To our knowledge, this is the second study of its kind incorporating MDs in training, competition, and daily life (Adam et al., 2022 ). The current study aims to provide a lived-experience perspective of female athletes with MDs to understand risk factors, stressors, adversities, challenges, support systems and resilience factors experienced by athletes with an MD. It aims to contribute to the literature by identifying effective areas of support and education, including organizational support provisions, one-on-one assistance and staff working with female athletes. Research Question What are the lived psychosocial experiences of athletes with menstrual disorders (MDs) in the context of their overall well-being and sporting life? Methods Research Philosophy & Study Design This study adopts a qualitative design embracing a constructivist approach undertaken through a subjective ontology and relativist epistemology (Guba & Lincoln, 1994 ), aiming to delve into the unique experiences of female athletes living with MDs within the complex interplay of sport and everyday life. This approach recognised the inherent subjectivity in how individuals construct meaning from their experiences (Creswell, 2013 ) and a qualitative, interview study design was chosen. An experiential, semi-structured, one-on-one interview guide was used to capture the rich and nuanced insights of participants. This allowed a balance between structured questions and the flexibility needed to explore the diverse perspectives and narratives of participants. Participants Ten female athletes (Mean age = 24.5, SD = 5.20) ranging from various individual and team sports both active and recently retired, were recruited for the study. Athletes who had engaged in competitive sport and lived with a menstrual dysfunction (medically diagnosed including endometriosis, adenomyosis, polycystic ovary syndrome, primary dysmenorrhea, and premenstrual dysphoric disorder) for a minimum duration of one year was included in this study (see Table 1 for demographic details). Table 1 Demographic data for participating individuals Participant Code Age Sports Participated Level attained MDs (Menstrual Dysfunctions) Active or Retired Nationality P01 23 Archery World Championship Endometriosis Active British P02 36 Riffle Shooting Nationals PCOS Retired Indian P03 21 Cricket County Cricket and Coach Endometriosis Active British P04 19 Table Tennis National Level PCOS Active Indian P05 27 Track Athlete National and regional level. Primary Dysmenorrhea & PMDD Retired Indian P06 27 Football National & Asian Endometrial Cysts Active Indian P07 24 CrossFit, Weightlifting Nationals and International PCOS Active British P08 22 Volleyball National PCOS Active Indian P09 20 Weightlifting Nationals PCOS Retired Dubai P10 23 Volleyball National PCOS Active British *N = 10 **All athletes identified as she/her Procedure Following institutional ethical approval (Loughborough University Ethics Committee Ref: 14047) potential participants were recruited through purposive sampling aligned to sampling criteria. Recruitment was conducted through professional networks, referrals and social media. Potential participants were informed of the study and informed consent was obtained (British Psychological Society, 2021 ). Participants were explicitly informed about confidentiality, data management and their right to withdraw. Participants were invited to provide their demographic details which included the nature of their menstrual disorder diagnosis, sport, and duration, following which they were invited for the interview. During the interview, participants were encouraged to reflect on and discuss their past experiences with MDs and how they impacted their lives and sports careers through life experiences. Prior to interview, participants were provided with an overview of the interview topics (though not limited to), ensuring that they were comfortable with the discussion and consent to answer. Any questions or concerns were addressed to promote a comfortable and voluntary participatory environment. To reduce any initial apprehension, the interviewer introduced themselves and the project (cf. DiCicco-Bloom & Crabtree, 2006 ). The interviews were conducted online via MS Teams. All data, including consent forms, interview recordings, and transcripts, were stored in an encrypted folder to ensure data security and participant confidentiality. Interview Guide & Process The research questions informed the development of the semi-structured interview guide. The semi-structured nature of the interview was chosen since it allows a record of questions to be asked and allows the opportunity to be flexible and follow the flow of experience (Guest et al., 2012 ). After introductory questions were asked to initiate conversation and establish rapport, the interview question began with a set of questions on their background, sporting journey and their experienced with the menstrual disorder that they had. Following on, the interview consisted of questions around lifestyle, sport, adjustment at living and competing with a menstrual disorder, barriers and facilitators that they experienced. A subsequent part of the questions involved asking about the specific changes in their psychosocial, physical and performance elements as a consequence of their menstrual disorder. A total of 14 hours of interviews with an average interview time of 77.5 minutes (SD = 15.68) were transcribed and analysed. Data Analysis Interview audio recordings verbatim transcribed for subsequent data analysis, and research purposes. Transcripts were carefully reviewed to immerse the researchers in the data. The data collected was then subjected to two-way analysis using Braun and Clarke's (2019) established six-phase guide for reflexive thematic analysis. The six steps included- data familiarization, initial code generation, theme exploration, review phase, definition of codes, and lastly report production. This analysis incorporated a three-step coding process (Moghaddam, 2006 ). The transcripts open coded independently by the first and second author by, assigning sections of texts to individual codes aligning with the research questions of before they were converged to ensure rigour. These codes were used as a guide to identify patterns and descriptive labels and both authors re-reviewed labels to identify initial trends. Codes underwent relevant revisions and updates to enhance clarity by merging or deleting codes that had redundancy or overlap. Both authors agreed on distinct categories of codes and labels collaboratively to engage in selective coding that yielding central overarching categories. Trustworthiness & Rigour Several steps consistently adhered to ensure methodological rigour while maintaining a coherent qualitative focus on comprehending the subjective and diverse perspectives of the study participants (Smith & McGannon, 2018 ). Acknowledging potential biases, the research team scrutinized the interview questions to ensure no leading questions, and any bias/personal experiences were communicated clearly to the participants. Regular bi-weekly meetings were conducted in the researcher team to ensure consistent approach to interviewing (e.g., awareness of researcher bias in probing questions) and transcribing. The thematic analysis process underwent refinement through extensive discussion and peer-reviewing to ensure that the inductively derived themes were intricately linked to the data rather than being driven solely by the researcher's theoretical interests. This was essential in maintaining rigour due to the exploratory nature of the study and to ensure alignment with the philosophical underpinnings that prioritise data-driven exploration as seen in prior research (Brown et al., 2016; Smith et al., 2018). Authors also kept a diary during the itnerview and coding process to monitor self-bias. Results Results of this study were analysed at two levels aligned to the research questions. The first thematic analysis focused on the “psychosocial experiences of living with MD” resulted in (1) Health Impact on Life (2) Medical Experiences with MDs (3) Psychological Impact (4) Sociocultural Impact (5) Social Support. The second thematic analysis focused on the “barriers and facilitators of living from an athlete’s lived experience” included the three themes of: (1) Barriers (2) Facilitators (3) Management and Recommendation. Health Impact on Life Athletes dealing with menstrual dysfunctions (MDs) frequently experience a range of symptoms and underlying causes, with severe cramps being the most common and debilitating. These cramps and the high degree of pain experience significantly impeded their ability to attend engage in daily life, train, or compete in sports. As athlete P06 noted, "If it occurred on a competition day, I wouldn't know how to cope with it. I might have to withdraw because I wouldn't be able to stand for the entire day." Additional symptoms include hair growth and acne appearing right before the period, which can lead to emotional sensitivity and irritability during the menstrual cycle. These emotional fluctuations can result in crying spells and affect their interactions with coaches, teammates, and others outside of their sport. Another common concern among athletes is weight gain, which impacts their body image and self-esteem. These weight changes can also have repercussions on their athletic performance, as highlighted by P07 who participates in weightlifting. There's more risk if you gain weight in weightlifting than in any other sport because it's so bodyweight focused because we compete in body weight categories. So the lighter you are, the less bodyweight you put. So that put me over the edge and honestly, I don't think I'll be competing for the next couple months. Figure 1 : Thematic analysis on psychosocial experiences living with MDs Upon investigation, these menstrual disorders (MDs) were found to have various potential causes, including genetic factors, lifestyle changes, "excessive sports," or unknown causes. Surprisingly, many retired athletes expressed that their menstrual disorders had worsened after concluding their sports careers. P05 shared, There is no secondary cause as to why I am experiencing period pain of such intensity. So they (doctors) did not find any reason and called it primary dysmenorrhea. Some athletes not only strive to manage their sports and menstrual disorders (MDs), but they also report coping with additional comorbidities, such as anxiety, depression, eating disorders, and PTSD to name a few. These comorbidities often present overlapping symptoms with MDs, including fatigue, irregular periods body aches, nausea and more. As P07 recalls dealing with an eating disorder she mentions, “I didn't have my period for like 2 years, like two or three years, which is obviously not OK.” P05 even disclosed experiencing suicidal thoughts. Dealing with premenstrual dysphoric disorder (PMDD) she recalls: So in my luteal phase, I experience a lot of, I used to experience a lot of, how do I say it suicidal ideation. I used to have, really terrible mental health, but because it was undiagnosed, untreated, but now that I'm diagnosed, I'm treated. I don't have such you know extensive mental health symptoms, but I do feel like down. I wouldn't say depressed. I can see the difference in my mood. Like it's low. I feel fatigue faster. I have sleep paralysis on my PMDD night. So like my sleep is not good which then affects everything else. Then I also have a lot of joint pains, ankle pain. I get a lot of breast tenderness, of course. So it becomes almost impossible to like, do a high intensity workout. Due to heavy bleeding, athletes with endometriosis often struggle with anemia. This complex constellation of symptoms from MDs and comorbidities frequently leaves them bewildered, as P07 mentions "It's a very hard thing for me because I don't know which symptoms were coming from what". The management of these symptoms further impacts their performance in sports Medical Experiences & treatment of MDs Every participating athletes reported encountering significant healthcare challenges. They often received generic advice that left them feeling dismissed or as if their concerns were being dismissed. As described by P05: They'll be like, “OK, you have this period pain. So she is just too sensitive to pain. You're just too sensitive. You're just too...” I don't know. “It's all in your head.” And like “eat healthy”. Like what more do you want me to eat healthy? I'm like a damn athlete who's being monitored everything I eat. What do you want? what else do you want? I used to do exercise, right? They'll be like, “exercise more”. Literally the genetic advice that was given to me when I went. Some athletes even experienced misdiagnoses or delayed attention to their concerns as “it took a very long time to get the diagnosis because of the waiting times and the NHS,” explained P03. Others struggled with limited information or conflicting advice, where they had to experiment with “3 to 4 gynacs and every time, every gynec had a different view”, as mentioned by P02. This lead to a loss of trust in healthcare providers. Additionally, P10 also mentions having to “take a flight back” to her homecountry for treatments as “NHS was unreliable”, adding to the frustration. These interactions left athletes feeling stuck, unsatisfied, confused, and sometimes even blamed for their symptoms. Consequently, they expressed a strong desire for more informed, compassionate, and effective care. P03 articulated her experience, I had a very good idea of what was wrong, but how could a medical professional not confirm it? Mentally, it was horrendous because every symptom made me worry about serious conditions like cancer or other diseases. Like many athletes, P03 also found relief once she received a confirmed diagnosis. Some athletes report similar challenges with medications. In addition to managing their existing comorbidities, these medications often come with a range of added side effects such as, “feeling groggy”, “added weight” “mood swings”, and “hormonal fluctuations”, adding an extra layer of complexity to their situation. Many athletes describe undergoing a trial-and-error process to find the right medication for them making them feel “bit all over the place really” as they “weren’t able to settle on any kind of routine.”, P02 explains. The hit and miss nature of these prescribed medicines made them question, “did I make the wrong choice, like, what's happening?” They also have to monitor their medication intake carefully in relation to their competition schedules, adding another task to their already busy routines. Some athletes also express the need to double-check certain medications to ensure they are not prohibited in sports, as they could lead to positive results in drug tests. This limitation on prescribed drug intake resulted in participant P01’s avoidance or reluctance to take necessary medication as she explains: So it is banned and if we have that and if a the drug test happens after a medal in nationals and if you are caught with that you will be under, like, the report would be that you have taken some drugs or steroids. So that's why I never had a medicine like cyclopam in my life. While some athletes have expressed disappointment with medications and healthcare, there is a small subset who have reported satisfaction with their experiences. These athletes highlight their doctors' proactive, patient, and persistent approach to their treatment. Their treatments were personalized to accommodate their bodies, routines, and sports commitments. Doctors and medical staff took the time to educate athletes about their conditions and how to manage them effectively. This comprehensive support made athletes feel “not abnormal," comforted, and trusted in the treatment process. Reflecting on her experience, P05 shared: When she diagnosed me, first was like, “OK, she knows something, so it's gonna be fine”. She somewhat finally listened to me. She validated me, believed me. So that felt really great. I was like, my problems are all going to stop right now and it's all going to be because of her. While many doctors primarily prescribed allopathic medications, some also suggested alternative approaches such as homeopathic and Ayurvedic medications, particularly for Asian athletes which they found beneficial. Additionally, many doctors recommended incorporating yoga and mindfulness-based practices into their management of menstrual disorders (MDs). With appropriate guidance and consistent medication adherence, coupled with personalized lifestyle adjustments, athletes have reported stabilization of their symptoms and improvement in their overall condition. Having gotten such support earlier athletes mentioned they could have better managed their MDs better and advised other athletes to communicate with their coaches and get timely help. Social Support The challenges for healthcare was also made worse because athletes often found themselves lacking adequate support from their coaches. Despite the physical and emotional toll that menstrual disorders (MDs) can take, some coaches exhibit dismissive attitudes, saying ”so?” whenever athletes explain absence from training because they had “really bad cramps”, being unaware of the impact of these conditions on their athletes' performance and well-being. Due to lack of awareness P02 also mentions her coach saying “no, there's no solution to it. Why don't you sit out?”; benching her and further instigating her to quit her sport. Particularly, male coaches were sometimes less open to discussing issues related to menstruation, viewing them as outside the scope of their expertise or discomfort in addressing them. Moreover, like many athletes, reflecting on her sporting journey, P02 mentions “we never were really open about talking about periods with them (male coaches).” This was because “it wasn't even the pain and having it. It was the fact like trying to explain it to somebody and them not understanding.” These athletes faced excessive pressure to perform despite their symptoms, wherein their coaches say to them “”get on with it and it'll be fine”. Additionally, some athletes like P07 experienced body shaming from coaches wherein without being aware of the conditions they made statements such as ”you're too skinny. You have to eat more, ”you're too big. You have to eat less. Maybe you can give her (teammates) some of your food”, further exacerbating feelings of discomfort and inadequacy. These factors collectively contribute to a lack of support and understanding within the coach-athlete dynamic, hindering athletes' ability to effectively manage their MDs while pursuing their athletic goals. Expressing the pressure of not letting her coaches down, P05 mentioned: "He literally used to say 'Champions don't cry.' I still remember my coaching left in 2012 and even after that, sometimes I used to not cry because I tell myself, 'Champions don't cry.' So it affected me on such a deep emotional level that I'm just like crying and champions don't get to cry. You know he had that attitude. So crying was absolutely not allowed on the ground. He is like, 'Cry on your own time, not here.' This approach further isolates athletes and reinforces feelings of frustration and invisibility regarding their struggles with MDs. Athletes also reported similar experience with other males (teammates, partners and/or family members) who lacked awareness or empathy regarding the challenges associated with MDs. This led to repetitive cycles of similar dismissive attitudes or discomfort to discuss MDs and their impact openly- making them feel stigmatised. Athletes also felt they were treated as "mini-men" and that training regimens were primarily designed with male physiology in mind, making them question, “Is sport not meant for women?”. Consequently, coaches could not create a supportive environment which caused frustration of having to explain everytime, lack of awareness among others making it difficult to confide in coaches. They were often compared to other female athletes without MDs which led to them feeling uncomfortable and disregarded with the “unhealthy environment which was not supportive”. It is important to note that the gender of the coach was not a automatic supportive factor. Several athletes reported that female coaches disregarded their concerns by comparing their pain tolerance to others. Despite some negative experiences, some athletes mentioned coaches and medical professionals also assisted them. Coaches who had open communication, provided helpful information, were understanding and empathetic, and informed themselves about MDs their athletes dealt with were characterized as coaches who were understanding, supportive, and proactive in addressing their needs. Another supportive behavior reported was when coaches asked to be informed prior to competitions or training sessions about any potential issues related to MDs and were accommodating. Additionally, they were described as motivating and empowering, helping athletes navigate their challenges with confidence. Athletes felt heard and supported by their coaches, fostering a positive and conducive environment as P03 mentions: ”We obviously don't know what it's like, but if we can help you in any way, we want to help you. Don't feel like you're obliged to come to this or that, or do this or things like that”... I just remember telling them and they had no clue and as a Cricket Club then we were thinking, “right, I think we might need to try and get a female in so at least you've got someone to talk. Not just you, but so the girls have got someone to talk to”. In challenging situations, coaches demonstrated remarkable support by providing interpersonal support to athletes by taking care of their wellbeing, such as "don't push yourself. If the body is saying no, just take it", or reassuring sentiments like "It's just one match. S**t happens. You go again later, OK? It's OK". They also foster a sense of self-awareness and empowerment by asking questions like "Are you able to pick up this much weight? What does your body tell you?". This made athletes feel feel "supported", "heard", and reassured that they are not at fault. Athletes also mention seeking support from their family members, friends, partners and teammates. As recounted by P01, having a supportive circle of fellow athletes fosters a sense of camaraderie and belonging: So it is nice to have a bubble of ladies around you post you having a rubbish day and cramps. As you mention the owrd they ask “Do you want paracetamol? do you want hot water bottle? Do you want this? Do you?”. You know it's a very wholesome atmosphere where everybody like wanting to pitch in and help, which is nice…and makes you want to be out on the competition field because you know you're not there on your own. Where I was just quite easy to be like, ”Hello! I feel rubbish. Can I please have a hug?” and then they'll be like okay (giggles). Furthermore, communication within the team is crucial in ensuring that athletes feel supported and in control of challenging situations. By giving a heads-up to teammates and captains about their menstrual cycles, athletes have the opportunity to collaborate on alternative strategies for games, as exemplified by P05's experience: “OK, we're gonna change the strategy. You're (P05) gonna run half court and then you're gonna, like switch off.” So we have this 3 − 1 thing. So in that way they can't recognize the pattern that I'm always going to be there so. So we switched up. We stopped doing man to man defense and we started doing zone defense only so that I don't have to run that much. So it was overall great. Some athletes have also extended their support network to include professionals such as “nutritionists”, “psychologists”, “coaches”, and “fitness trainers”, recognizing the importance of holistic support in managing menstrual health and performance. This comprehensive approach underscores the athletes' commitment to their well-being and success in their sport. These experiences left the athletes feeling that their team and sport were indeed "the best place to be," as aptly expressed by P04. Furthermore, the support received from family members, particularly fathers, has been instrumental in creating a supportive environment for athletes to openly discuss menstrual health. As described by P03, the comfort of being able to confide in her father without hesitation highlights the importance of breaking down societal taboos surrounding menstruation and promoting open communication within families “I'll be like, ‘Oh my God, Dad, can you get me some tampons?’ and it's not weird for me to ask that. Wheras a lot of girls would never really speak to males and their families about that.” (P03) Some athletes had parents who were doctors, and they expressed trust in their parents, feeling reassured that "they're doing the right thing for me," as mentioned by P04. Fortunately, P05 also highlighted being raised in an environment where menstrual health education was provided in school. All these factors acted differently as facilitators and barriers for the athletes and are outlined in Fig. 2 below. Socio-Cultural Impact Most athletes mention that these unpredictable bursts of symptoms have a major impact on daily life and routines. This varied across cultural background in terms of social perception and mitigation interventions chosen. A majority of these cultural differences are seen in the types of treatments preferred. Figure 2 Facilitators and barriers within lived experienced of athletes with MD Most Asian cultures prefer a more traditional route to treating MDs. These include naturopathy, ayurvedic medicines and seed cycling. Several athletes reported that culturally, in their family systems having birth control pills for MDs are considered a taboo. Having a similar experience one athletes mentions: My mom was like ”no, we come from a very like conservative kind of culture. You shouldn't be taking birth control so early on when you're 15–16 like that's not good” and stuff. ”You shouldn't be taking any medicines. It's not our culture, it's not good. Later on, when you have kids and like, you know, fertility issues”. It was very much like, "girls like in our culture don't take birth control“. It was a major taboo-taboo Due to this, the athlete were provided alternative medications for different symptoms, with each medication focused on one symptom. This made led to multiple side effects since athletes were not allowed to have one medication that would address most major issue caused by the MD. There was also a very real financial strain of the MD. This include medical costs, menstrual hygiene and nutrition. For several affected athletes, excessive bleeding necessitates purchasing menstrual products in bulk quantities which far exceeded typical needs. Due to heavy bleeding P03 living with endometriosis expresses adding 10 packs of tampons costing her £25 compared to someone who can manage with as little as £2.5 for the same period product for a month, making it expensive for them. With clothing choices athletes express a reluctance to wear white due to past experiences or fears of staining, getting rashes from pads and discomfort from tight bras which don't provide adequate support for tender breasts. The issue of traveling for competitions while dealing with these symptoms adds to the challenges. These concerns have been cited to make them feel conscious and distracted affecting their play as an athlete mentions ,“I shouldn't be worried about that. I should realistically just be worried about me dealing with it (game) for myself.” Hence, athletes express their MD symptoms and not getting periods to have been normalized in their daily conversations to which they rebel saying “no, this is not normal!” and potentially having negative long-term health consequences Such situations make it hard for them to explain to people the struggles they go through as it has been normalized or dismissed making them feel helpless as P03 explains: “We used to get a lot of girls who I play cricket with, being almost like ”Ohh, it's just a period”. I'm thinking, ”Yeah, it's just a period to you, but to me, it's not just a period, it's basically probably five of your periods in one”. Psychological impact The unpredictability of unexpected periods or the fear of onset of period-related symptoms during a game heightens their anxiety, increases disappointment and significant distraction and leads to performance setbacks. P05 mentions: “So I literally got it (periods) like on the day we reached there and I used to just feel like a lot of mental block. It gave me a lot of anxiety… My top worries were like getting like one of that pain attack or pain episode during the game. The second thing was that not being able to control my anger because I was very irritable.” Living with MDs while actively participating in sports led to a range of thoughts and feelings among athletes. Athletes reported frequent self-doubt and engage in self-deprecating thoughts, labeling themselves as "lazy," "arrogant," or "overdramatic" and in turn not a good athlete. They frequently wonder, "why is it me that has to deal with that pain?". These athletes often find themselves comparing their bodies, performance, and MD symptoms to those of their teammates who experience regular periods. The competitive environment intensifies these comparisons as P01 with endometriosis feels “defeated” as she explains: everybody's competing at once, you can see other people's scores. You know, it's quite a tough mental battle anyway, but when you're already fighting yourself, that's not great start. Despite these difficulties, these athletes display remarkable resilience and emphasize the importance of self-love, patience, and compassion towards their past selves, acknowledging the hardships they have endured while competing as athletes with MDs. They also explain their desires if they were not living with MDs and how “life would be good” and they would be “happier” without it. P08, a retired athletes reflects on such desires mentioning: I do think that honestly, the insecurities or the self-consciousness I've kind of developed with the weight gain and like not being able to perform because of it, like the social comparison and stuff. It would be a lot less if I didn't have PCOS. I think the PCOS was kind of like a trigger for a lot of things that I've have stayed with me even up until now. Management and Recommendations Lifestyle changes, such as regular exercise, mindful dieting, home-cooked meals, abstaining from alcohol and smoking, prioritizing sleep, and practicing meditation, have been commonly adopted by athletes. However, not all athletes have found success with these strategies and often turn to medications. A cultural difference had been witnessed where some athletes are suggested “seed cycling”, “ayurvedic” and “naturopathy” treatment, other athletes is not allowed to have contraceptives to help treat their symptoms because "girls in our culture don't take birth control.”, she says. Receiving a diagnosis helped athletes plan their game schedules, manage symptoms with the right medications, and prepare essential resources like hot water bags, puke bags, spare clothing, and period products to prevent staining and some quick fix for discomfort during competitions. Mental affirmations play a role too, as athletes encourage themselves with thoughts like "any arrow I get to shoot is a good arrow." They also prioritize rest before, during, and after their games. In some cases, athletes have resorted to surgery as a means to better manage their MDs. Most athletes mention receiving adequate emotional support, getting the right information and acts of help from family and friends which further helped them cope well with the MDs. Athletes further recommend the sporting fraternity to raise awareness about menstrual health, educate and inform coaches and other sporting fraternity so as to communicate empathetically, have open conversations about the topic and health needs of athlete, recruited informed and licensed medical teams or guide athletes to the right source of information, understand what is ‘not normal’ and not dismissing their concerns. Discussion The findings of this study highlight the daily real-life experiences of athletes living with menstrual dysfunctions (MDs) in and out of sport with further experiential outcomes of athletes' thought processes concerning the impact of MDs on their sports participation and personal well-being. The different dimensions our findings are discussed in context of wider literature and applied recommendations below. Living with MDs is a Multifaceted Experiences, not a singular reality Existing evidence notes that athletes with MDs deal with varied physical symptoms such as headache, fatigue, nausea, body pain and more (Redman & Loucks, 2005 ) with the commonly expressed symptoms such as menstrual cramps and energy deficiency having a substantial impact on their attendance in various domains, including school, work, sports training, and competitions. Our findings support this from a lived experience perspective, extending Adam et al., ( 2022 ) findings that athletes perceive menstrual cramps and fatigue as direct contributors to reduced athletic performance, hindering their ability to excel in their respective sports. Our findings also highlighted that the intense pain, and other medical treatment requirements have forced participants to alter daily patterns and force non-adherence in sport. We echo the previous findings in non-sport literature (cf. Poureslami & Farzaneh Osati-Ashtiani, 2002) which showcased pain related to menstrual cramps as a prominent cause of absenteeism. Emotional impacts such as unmanaged anxiety triggered by hormonal fluctuations, irritability, arousal dysregulation are also an additional challenge of living with MDs. Our findings support the current research outlining how significant emotional challenges impact performance and skill execution (Adam et al., 2022 ; Findlay et al., 2020 ). While prior research has examined similar symptoms in sport, it is limited on normal menstrual-cycle symptoms (Burinvels et al., 2016). Our study provides a unique experiential insight into how the emotional toll is severe leading to mental health risks through anxiety and depression since seeking treatment is often futile, and the lack of knowledge as well as stigma surrounding MDs may amplify isolation and helplessness in those living with MDs (Sheinfield et al., 2007). More research is needed specific to MDs within this area. Our findings repetitively indicate that living with MDs includes the whole self. This includes experiencing negative thoughts and feelings about themselves, often attaching labels, and engaging in comparisons with other athletes, particularly concerning their performance and body image. This aligns with research indicating that women with MDs tend to experience negative thinking due to their symptoms, which further diminishes their self-esteem and self-confidence (Moradi et al., 2014 ). The present study contributes to this body of knowledge by shedding light on how these negative self-labels and comparisons can detrimentally affect athletes' performance and found that indicators similar to Heather et al., ( 2021 ) in how athletes engage in these body image and performance considerations which manifest as self-doubt, demotivation, and an increased risk of disordered eating. Therefore, it is critical to consider living with MDs as a multifaceted impact on the individual, not just ‘one thing’ the athlete has to focus on. On this note, person-centred sport psychology support may be a useful approach in such cases (Gupta & Duncan, 2023 ). Social Support as a Barrier & Facilitator A majority of the athletes perceived their coaches, and doctors to be unsupportive, ineffective and generally lacking an understanding of their MDs which align with research findings indicating that healthcare professionals often dismiss the needs of women with MDs, lack accurate communication skills, and provide poor-quality support, ultimately compromising athletes' health (Moradi et al., 2014 ; O’Loughlin et al., 2022 ). Our findings echo the findings of Laske et al., ( 2022 ) where male coaches have been observed to exhibit discomfort and under-confidence discussing menstrual health or downplaying its impact on performance which leads to athletes feeling stuck and unheard all linked to a lack of awareness, knowledge. There is also the tendency to normalize MD symptoms as something ‘every female athlete has to go through (von Rosen et al., 2022 ). Participants in our study also echoed Pitchers & Elliot-Sale, 2019) who noted that all research and practices are focused on male physiology leading to training and periodisation plans viewing MDs as a hindrance to inclusion. A few athletes also noted positive interactions with coaches and doctors, but only who were updated in their knowledge base and were open and respectful in their communication of MDs. Marais (2012) linked such behaviours to the longevity of female swimmers in sport, and our findings indicate would benefit athletes with MDs. Additionally, our findings support McGawley et al., ( 2023 ) who reported that athleted with MD build trust with medical professionals built upon accurate diagnosis, timely referral and well long-term supported treatment that has positive repercussions of sporting performance Management and recommendations As highlighted above, there is a lack of applied focused literature in this area. To this end, we discuss certain proposed best practice recommendations in line with findings of the study and the wider literature. First, we support the assertions of (Paice, 2021 ) that menstrual health literature and awareness is notably low among female athletes, coaches, and practitioners due to the taboo surrounding the topic and the relatively recent but limited research in the field with a lack of guidance or organizations dedications to supporting individuals with MDs. We support the findings of Carmichael et al., ( 2024 ) to outline the need for athletes to be educated about basic female physiology in easily digestible ways. We recommend National Governing Body (NGBs) or other sources to provide effective psychoeducational and literacy resources for athletes living with MDs to refer to. Second, clear referral pathways i.e., first point of contact in female sport for menstrual health related concerns as advocated by Findlay et al., ( 2020 ). Within this, there should be an education of support staff and literacy which has been highlighted to be needed and beneficial since female reproductive health expertise in the multidisciplinary management of performance pathway and elite athletes are required (Jones et al., 2024 ; McGawley et al., 2023 ). Third, our findings and previous findings showcase the importance of not dismissing or denying athlete concerns, suggesting promotion of empathetic regard and medical advice (see Verhoef et al., 2021 ; Klingenberg, 2022 ). This is especially important for coaches. We recommend incorporation of MD experience education in coach education and CPD for coaches who are trained to work with female athletes. Having trained female coaches in performance pathways with the right knowledge and communication skills is likely to promote help-seeking behaviour. Fourth, expanding on Klingenberg ( 2022 ) there is a critical need to address treatment delays. We recommend encouraging regular health screening and support for menstrual health assessment with this being a component of athlete monitoring for health by the medical team. Fifth, in line with findings of Kolić et al. ( 2021 ) and Adam et al., ( 2022 ), clothing options with dark colours, sizes, styles and comfortable fits and providing them with menstrual hygiene products as part of sport kit would be beneficial. Finally, it is essential to priortise physiological and emotional recovery as a priority not just performance-based recovery (Verhoef et al., 2021 ). This can be incorporated with self-care strategies, more scheduled recovery time or seeking support from sport psychologists who are trained in female athlete care due to the unique experience of living with MDs. Declarations Human Ethics & Consent to Participation statement Written ethical consent was secured from all participants aligned with the Helsinki Declaration (which included consent for publication post anonymisation). The study was approved by Loughborough University Institutional Ethics Committee (Ref: 14047). Research was conducted in line with ethical parameters of human participant research in the Declaration of Helsinki. Data availability statement Data (i.e., anonymised transcripts and coding) can be made available on request, but cannot be made full open access. Conflict of Interest Statement The authors declare no competing interests or conflicts of interests. Funding Statement Funding for this study was provided by Talented Athlete Scholarship Scheme (TASS) Early Career Research Grant. Acknowledgements We would like to support TASS and Emily Cartigny for their support and all particpants for their time and contributions. References Abdelmoty, H. I., Youssef, M., abdallah, S., Abdel-Malak, K., Hashish, N. M., Samir, D., Abdelbar, M., Hosni, A. N., Ghafar, M. A.-E., Khamis, Y., & Seleem, M. (2015). Menstrual patterns and disorders among secondary school adolescents in Egypt. A cross-sectional survey. BMC Women’s Health , 15 (1). https://doi.org/10.1186/s12905-015-0228-8 Adam, M. E. K., Bristow, A., Neely, K. C., & Erlandson, M. C. (2022). 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BMC Sports Science, Medicine and Rehabilitation , 13 (1). https://doi.org/10.1186/s13102-021-00372-3 von Rosen, P., Ekenros, L., Solli, G. S., Sandbakk, Ø., Holmberg, H.-C., Hirschberg, A. L., & Fridén, C. (2022). Offered support and knowledge about the menstrual cycle in the athletic community: A cross-sectional study of 1086 female athletes. International Journal of Environmental Research and Public Health , 19 (19), 11932. https://doi.org/10.3390/ijerph191911932 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 25 Jul, 2024 Editor assigned by journal 24 Jul, 2024 Submission checks completed at journal 24 Jul, 2024 First submitted to journal 22 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4782294","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331534775,"identity":"98227aad-278d-4578-b25b-92e9cb960aac","order_by":0,"name":"Ritu Verma","email":"","orcid":"","institution":"Loughborough University","correspondingAuthor":false,"prefix":"","firstName":"Ritu","middleName":"","lastName":"Verma","suffix":""},{"id":331534777,"identity":"09e6117b-6582-4054-99d4-71fda63e0a7e","order_by":1,"name":"Sahen Gupta","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8klEQVRIiWNgGAWjYFACHjiL8QFC9AAxWtgYmA2AlARJWtgkiNIi33724OMChtrE7fLNz6oLKu7VMbAffsDMcwa3FoMzecnGMxiOJ+5sYzO7PeNMsQQDT5oBM88NPFoYcsykeRiOJW44xmB2m7ctAeiwHAZmng94HNb/xvw3RAv7t2KwFv43+LUw3MgxY+ZhqAFq4TFjBmuRANmCz2E33hhL8xgcMN7ZllMsPeNMgmSbxDODg3PweF++P8fwM09Fnex25uMbPxdUJPDz8yc/fPDmGB6HQew6zACKRmYQm42BQERCQR1CyygYBaNgFIwCdAAAfJ5Ktf+KByoAAAAASUVORK5CYII=","orcid":"","institution":"University of Portsmouth","correspondingAuthor":true,"prefix":"","firstName":"Sahen","middleName":"","lastName":"Gupta","suffix":""}],"badges":[],"createdAt":"2024-07-22 13:39:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4782294/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4782294/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62854293,"identity":"1574e47f-bd77-4365-9e48-c6c0185e0c3a","added_by":"auto","created_at":"2024-08-20 09:10:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":119692,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eThematic analysis on psychosocial experiences living with MDs\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4782294/v1/bfe5b5afb249e2415fd0b0d6.png"},{"id":62854294,"identity":"5393db97-d94b-4b9a-aaeb-949b7d570745","added_by":"auto","created_at":"2024-08-20 09:10:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":126371,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eFacilitators and barriers within lived experienced of athletes with MD\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4782294/v1/b16828f7d1f9d8d20200969d.png"},{"id":62855002,"identity":"505878ef-360f-4436-b3ea-656e17deaa13","added_by":"auto","created_at":"2024-08-20 09:18:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":960983,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4782294/v1/53ab9707-b7c9-4b31-af52-554572ac257c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“No, that is not normal”: Psychosocial lived experiences of Elite Athletes living and performing with Menstrual Dysfunctions","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMenstrual dysfunctions (MDs) are a prevalent concern among women of reproductive\u003c/p\u003e\n\u003cp\u003eage and is a prominent cause for gynecological consultations worldwide\u003c/p\u003e\n\u003cp\u003e(Bahamondes \u0026amp; Ali, 2015). Dovom et al., (2016) define regular menstrual cycles, or eumenorrhea, as those lasting fewer than 35 days but no longer than 23 days, with an ideal\u003c/p\u003e\n\u003cp\u003eduration of three to seven days for normal bleeding. MDs deviate from the regular\u003c/p\u003e\n\u003cp\u003emenstrual cycle and typically become apparent one to two years after the initiation of the first\u003c/p\u003e\n\u003cp\u003emenstrual period (Rani et al., 2016). MDs can serve as indicative symptoms of conditions, such as polycystic ovarian syndrome (PCOS) and endometriosis (Abdelmoty et al., 2015). If left\u003c/p\u003e\n\u003cp\u003eundiagnosed or untreated can lead to substantial long-term consequences, including reduced\u003c/p\u003e\n\u003cp\u003equality of life due to worsening symptoms, the potential for infertility, negative self-perceptions\u003c/p\u003e\n\u003cp\u003eof body image, an increased susceptibility to comorbidities like depression and anxiety, and\u003c/p\u003e\n\u003cp\u003esignificant financial burden caused by increased healthcare expenses (Agarwal et al., 2019;\u003c/p\u003e\n\u003cp\u003eFernandez et al., 2021).\u003c/p\u003e\n\u003ch3\u003ePrevalence of Menstrual Dysfunctions (MDs) in Female Sport\u003c/h3\u003e\n\u003cp\u003eStatistics indicate 30\u0026ndash;70% women, experience MDs globally (Igbokwe \u0026amp; John-Akinola, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFemale athletes in sports such as running, ballet, swimming, and gymnastics, exhibit notably higher rates of MDs, including oligomenorrhea (infrequent menstrual periods), primary amenorrhoea (failure to menstruate by age 15), secondary amenorrhoea (previously menstruating but not having a period for three months or more), and delayed menarche (Redman \u0026amp; Loucks, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). The prevalence rates range from 6\u0026ndash;79%, significantly exceeding the 2\u0026ndash;5% observed in the general population (Gimunov\u0026aacute; et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This higher prevalence of MDs among athletes can be attributed to intense training regimens, inadequate recovery periods, energy imbalances, and suppression of endocrine function, restrictive dietary practices, weight loss, and insufficient nutritional intake during periods of heightened physical activity (Berz \u0026amp; McCambridge, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Gimunov\u0026aacute; et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEvidence indicates that 21.9% of all athletes engaged in aesthetic sports like ballet, running, and swimming an 10.6% in endurance sports, live and compete with MDs, although the number is likely to be underreported (Torstveit \u0026amp; Sundgot-Borgen, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Another study by Amoruso et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) indicates irregular menstrual cycles, potentially indicative of menstrual dysfunction, were observed in 33.0% of athletes, with 41.1% participating in lean sports. Additionally, an overestimation of body image was associated with a higher likelihood of experiencing menstrual irregularities. At a socioecological level, MD rates in athletes are culturally influenced. Indian athletes had a greater prevalence (63.5%) than Western athletes (50%), which might be due to challenges in tracking cycles, inadequate awareness, stigmatised communication, reluctance to medicate and inadequate management (Majumder et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, across countries, multiple factors impede an accurate diagnosis (Verhoef et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and overall MDs have received little attention in the sports environment (Adam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eImpact of MDs among Athletes\u003c/h2\u003e \u003cp\u003eThe incidence of MDs, particularly primary amenorrhoea, is more prominent among athletes in sports that prioritize leanness (Sundgot-Borgen \u0026amp; Larsen, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). This is often associated with self-imposed dietary restrictions, weight concerns, lower BMI, increased psychological stress, decreased self-esteem, heightened perfectionism, and rigorous physical training, all of which can contribute to delays or disruptions in menstrual cycles (Senatore et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Other causal factors such as influence of medications, genetic predisposition, psychological stressors, and alterations in lifestyle, such as changes in dietary patterns, obesity, smoking, and drinking also negatively affect athletes (Redman \u0026amp; Loucks, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Ansong et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e, Latif et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong athletes, MDs can result in various psychological consequences such as eating\u003c/p\u003e \u003cp\u003edisorders, diminished cognitive functioning, reduced concentration, heightened levels of anxiety\u003c/p\u003e \u003cp\u003eand depression, insomnia, feelings of worthlessness, and increased irritability (Strine et al.,\u003c/p\u003e \u003cp\u003e2005). Athletes experiencing MDs may report physical symptoms such as\u003c/p\u003e \u003cp\u003eheightened pelvic pain, increased fatigue, lower back discomfort, nausea, gastrointestinal\u003c/p\u003e \u003cp\u003edisturbances, and reduced energy levels. These physical symptoms often\u003c/p\u003e \u003cp\u003enegatively affect their athletic performance (Senatore et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Heather et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and presented challenges which lead to withdrawal from sport, unforseen disruption in training and prevent achievement of peak performance or maintenance of well-being (Adam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In serious cases, some athletes with MDs may even consider ending their sporting careers (Czajkowska et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDue to the multilevel impact athletes with MDs often utilise medication such as combined oral contraceptive pill (COCP), hormonal contraceptives, and birth control pills for the menstrual cycles, enhancement of cycle regularity, alleviation of associated symptoms, and management of acne concerns which lead to side-effects such mood disturbances, weight management issues, training load difficulties and other issues (Heather et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, despite there, to our knowledge, there is no study outlining the lived experiences of athlete\u0026rsquo;s living with MDs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe Current Study\u003c/h2\u003e \u003cp\u003eWith the increased participation in and professionalisation of women\u0026rsquo;s sport, there is an urgent need to better understand and support the holistic mental and physical health of female athletes (Bowes et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). MDs and how athletes cope with them have received limited scientific attention (Adam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) and it is crucial for medical professionals, sport management, coaches, parents and athletes better to understand the lived experience of athletes with an MD, to help improve adjustment and quality of life (Senatore et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Czajkowska et al., 2020). While there are a few studies on the physiological impacts on MDs, these studies do not explore the diverse range of psychological experiences that can exist along a continuum among athletes (Adam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This highlights a clear gap and urgent need to explore the lived experiences of MDs among female athletes.\u003c/p\u003e \u003cp\u003eAs such, the present study seeks to bridge this research gap by understanding the\u003c/p\u003e \u003cp\u003epsychosocial experiences of female athletes with menstrual disorders, with a specific focus on\u003c/p\u003e \u003cp\u003etheir lived experiences, challenges in daily life and how MDs affect their performance as athletes. Most studies tend to focus primarily on prevalence data with very few exploring the experiential aspects of MDs among athletes. We focus on the experiential lives experience of athletes which has little to no research (Bruinvels et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). To our knowledge, this is the second study of its kind incorporating MDs in training, competition, and daily life (Adam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The current study aims to provide a lived-experience perspective of female athletes with MDs to understand risk factors, stressors, adversities, challenges, support systems and resilience factors experienced by athletes with an MD. It aims to contribute to the literature by identifying effective areas of support and education, including organizational support provisions, one-on-one assistance and staff working with female athletes.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eResearch Question\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eWhat are the lived psychosocial experiences of athletes with menstrual disorders (MDs) in the context of their overall well-being and sporting life?\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eResearch Philosophy \u0026amp; Study Design\u003c/h2\u003e \u003cp\u003eThis study adopts a qualitative design embracing a constructivist approach undertaken through a subjective ontology and relativist epistemology (Guba \u0026amp; Lincoln, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1994\u003c/span\u003e), aiming to delve into the unique experiences of female athletes living with MDs within the complex interplay of sport and everyday life. This approach recognised the inherent subjectivity in how individuals construct meaning from their experiences (Creswell, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) and a qualitative, interview study design was chosen. An experiential, semi-structured, one-on-one interview guide was used to capture the rich and nuanced insights of participants. This allowed a balance between structured questions and the flexibility needed to explore the diverse perspectives and narratives of participants.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eTen female athletes (Mean age\u0026thinsp;=\u0026thinsp;24.5, SD\u0026thinsp;=\u0026thinsp;5.20) ranging from various individual and team\u003c/p\u003e \u003cp\u003esports both active and recently retired, were recruited for the study. Athletes who had engaged in competitive sport and lived with a menstrual dysfunction (medically diagnosed including endometriosis, adenomyosis, polycystic ovary syndrome, primary dysmenorrhea, and premenstrual dysphoric disorder) for a minimum duration of one year was included in this study (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for demographic details).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDemographic data for participating individuals\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant Code\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSports Participated\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLevel attained\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMDs (Menstrual Dysfunctions)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive or Retired\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNationality\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eArchery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWorld\u003c/p\u003e \u003cp\u003eChampionship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEndometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBritish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRiffle\u003c/p\u003e \u003cp\u003eShooting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNationals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePCOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCricket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCounty Cricket\u003c/p\u003e \u003cp\u003eand Coach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEndometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBritish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTable Tennis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNational Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePCOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTrack\u003c/p\u003e \u003cp\u003eAthlete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNational and\u003c/p\u003e \u003cp\u003eregional level.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003cp\u003eDysmenorrhea \u0026amp; PMDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFootball\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNational \u0026amp; Asian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEndometrial\u003c/p\u003e \u003cp\u003eCysts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrossFit,\u003c/p\u003e \u003cp\u003eWeightlifting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNationals and\u003c/p\u003e \u003cp\u003eInternational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePCOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBritish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVolleyball\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePCOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeightlifting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNationals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePCOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDubai\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVolleyball\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNational\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePCOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eActive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBritish\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e*N\u0026thinsp;=\u0026thinsp;10\u003c/h2\u003e \u003cp\u003e**All athletes identified as she/her\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003e Following institutional ethical approval (Loughborough University Ethics Committee Ref: 14047) potential participants were recruited through purposive sampling aligned to sampling criteria. Recruitment was conducted through professional networks, referrals and social media. Potential participants were informed of the study and informed consent was obtained (British Psychological Society, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Participants were explicitly informed about confidentiality, data management and their right to withdraw. Participants were invited to provide their demographic details which included the nature of their menstrual disorder diagnosis, sport, and duration, following which they were invited for the interview. During the interview, participants were encouraged to reflect on and discuss their past experiences with MDs and how they impacted their lives and sports careers through life experiences. Prior to interview, participants were provided with an overview of the interview topics (though not limited to), ensuring that they were comfortable with the discussion and consent to answer. Any questions or concerns were addressed to promote a comfortable and voluntary participatory environment. To reduce any initial apprehension, the interviewer introduced themselves and the project (cf. DiCicco-Bloom \u0026amp; Crabtree, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). The interviews were conducted online via MS Teams. All data, including consent forms, interview recordings, and transcripts, were stored in an encrypted folder to ensure data security and participant confidentiality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eInterview Guide \u0026amp; Process\u003c/h2\u003e \u003cp\u003eThe research questions informed the development of the semi-structured interview guide. The semi-structured nature of the interview was chosen since it allows a record of questions to be asked and allows the opportunity to be flexible and follow the flow of experience (Guest et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). After introductory questions were asked to initiate conversation and establish rapport, the interview question began with a set of questions on their background, sporting journey and their experienced with the menstrual disorder that they had. Following on, the interview consisted of questions around lifestyle, sport, adjustment at living and competing with a menstrual disorder, barriers and facilitators that they experienced. A subsequent part of the questions involved asking about the specific changes in their psychosocial, physical and performance elements as a consequence of their menstrual disorder. A total of 14 hours of interviews with an average interview time of 77.5 minutes (SD\u0026thinsp;=\u0026thinsp;15.68) were transcribed and analysed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eInterview audio recordings verbatim transcribed for subsequent data analysis, and research purposes. Transcripts were carefully reviewed to immerse the researchers in the data. The data collected was then subjected to two-way analysis using Braun and Clarke's (2019) established six-phase guide for reflexive thematic analysis. The six steps included- data familiarization, initial code generation, theme exploration, review phase, definition of codes, and lastly report production. This analysis incorporated a three-step coding process (Moghaddam, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). The transcripts open coded independently by the first and second author by, assigning sections of texts to individual codes aligning with the research questions of before they were converged to ensure rigour. These codes were used as a guide to identify patterns and descriptive labels and both authors re-reviewed labels to identify initial trends. Codes underwent relevant revisions and updates to enhance clarity by merging or deleting codes that had redundancy or overlap. Both authors agreed on distinct categories of codes and labels collaboratively to engage in selective coding that yielding central overarching categories.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTrustworthiness \u0026amp; Rigour\u003c/h2\u003e \u003cp\u003eSeveral steps consistently adhered to ensure methodological rigour while maintaining a coherent qualitative focus on comprehending the subjective and diverse perspectives of the study participants (Smith \u0026amp; McGannon, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Acknowledging potential biases, the research team scrutinized the interview questions to ensure no leading questions, and any bias/personal experiences were communicated clearly to the participants. Regular bi-weekly meetings were conducted in the researcher team to ensure consistent approach to interviewing (e.g., awareness of researcher bias in probing questions) and transcribing. The thematic analysis process underwent refinement through extensive discussion and peer-reviewing to ensure that the inductively derived themes were intricately linked to the data rather than being driven solely by the researcher's theoretical interests. This was essential in maintaining rigour due to the exploratory nature of the study and to ensure alignment with the philosophical underpinnings that prioritise data-driven exploration as seen in prior research (Brown et al., 2016; Smith et al., 2018). Authors also kept a diary during the itnerview and coding process to monitor self-bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eResults of this study were analysed at two levels aligned to the research questions. The first thematic analysis focused on the \u0026ldquo;psychosocial experiences of living with MD\u0026rdquo; resulted in (1) Health Impact on Life (2) Medical Experiences with MDs (3) Psychological Impact (4) Sociocultural Impact (5) Social Support. The second thematic analysis focused on the \u0026ldquo;barriers and facilitators of living from an athlete\u0026rsquo;s lived experience\u0026rdquo; included the three themes of: (1) Barriers (2) Facilitators (3) Management and Recommendation.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHealth Impact on Life\u003c/h2\u003e \u003cp\u003eAthletes dealing with menstrual dysfunctions (MDs) frequently experience a range of symptoms and underlying causes, with severe cramps being the most common and debilitating. These cramps and the high degree of pain experience significantly impeded their ability to attend engage in daily life, train, or compete in sports. As athlete P06 noted, \"If it occurred on a competition day, I wouldn't know how to cope with it. I might have to withdraw because I wouldn't be able to stand for the entire day.\"\u003c/p\u003e \u003cp\u003eAdditional symptoms include hair growth and acne appearing right before the period, which can lead to emotional sensitivity and irritability during the menstrual cycle. These emotional fluctuations can result in crying spells and affect their interactions with coaches, teammates, and others outside of their sport. Another common concern among athletes is weight gain, which impacts their body image and self-esteem. These weight changes can also have repercussions on their athletic performance, as highlighted by P07 who participates in weightlifting.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere's more risk if you gain weight in weightlifting than in any other sport because it's so bodyweight focused because we compete in body weight categories. So the lighter you are, the less bodyweight you put. So that put me over the edge and honestly, I don't think I'll be competing for the next couple months.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1\u003c/b\u003e:\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThematic analysis on psychosocial experiences living with MDs\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUpon investigation, these menstrual disorders (MDs) were found to have various potential causes, including genetic factors, lifestyle changes, \"excessive sports,\" or unknown causes. Surprisingly, many retired athletes expressed that their menstrual disorders had worsened after concluding their sports careers. P05 shared,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere is no secondary cause as to why I am experiencing period pain of such intensity. So they (doctors) did not find any reason and called it primary dysmenorrhea.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome athletes not only strive to manage their sports and menstrual disorders (MDs), but they also report coping with additional comorbidities, such as anxiety, depression, eating disorders, and PTSD to name a few. These comorbidities often present overlapping symptoms with MDs, including fatigue, irregular periods body aches, nausea and more. As P07 recalls dealing with an eating disorder she mentions, \u0026ldquo;I didn't have my period for like 2 years, like two or three years, which is obviously not OK.\u0026rdquo;\u003c/p\u003e \u003cp\u003eP05 even disclosed experiencing suicidal thoughts. Dealing with premenstrual dysphoric disorder (PMDD) she recalls:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo in my luteal phase, I experience a lot of, I used to experience a lot of, how do I say it suicidal ideation. I used to have, really terrible mental health, but because it was undiagnosed, untreated, but now that I'm diagnosed, I'm treated. I don't have such you know extensive mental health symptoms, but I do feel like down. I wouldn't say depressed. I can see the difference in my mood. Like it's low. I feel fatigue faster. I have sleep paralysis on my PMDD night. So like my sleep is not good which then affects everything else. Then I also have a lot of joint pains, ankle pain. I get a lot of breast tenderness, of course. So it becomes almost impossible to like, do a high intensity workout.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDue to heavy bleeding, athletes with endometriosis often struggle with anemia. This complex constellation of symptoms from MDs and comorbidities frequently leaves them bewildered, as P07 mentions \"It's a very hard thing for me because I don't know which symptoms were coming from what\". The management of these symptoms further impacts their performance in sports\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eMedical Experiences \u0026amp; treatment of MDs\u003c/h2\u003e \u003cp\u003eEvery participating athletes reported encountering significant healthcare challenges. They often received generic advice that left them feeling dismissed or as if their concerns were being dismissed. As described by P05:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey'll be like, \u0026ldquo;OK, you have this period pain. So she is just too sensitive to pain. You're just too sensitive. You're just too...\u0026rdquo; I don't know. \u0026ldquo;It's all in your head.\u0026rdquo; And like \u0026ldquo;eat healthy\u0026rdquo;. Like what more do you want me to eat healthy? I'm like a damn athlete who's being monitored everything I eat. What do you want? what else do you want? I used to do exercise, right? They'll be like, \u0026ldquo;exercise more\u0026rdquo;. Literally the genetic advice that was given to me when I went.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome athletes even experienced misdiagnoses or delayed attention to their concerns as \u0026ldquo;it took a very long time to get the diagnosis because of the waiting times and the NHS,\u0026rdquo; explained P03. Others struggled with limited information or conflicting advice, where they had to experiment with \u0026ldquo;3 to 4 gynacs and every time, every gynec had a different view\u0026rdquo;, as mentioned by P02. This lead to a loss of trust in healthcare providers. Additionally, P10 also mentions having to \u0026ldquo;take a flight back\u0026rdquo; to her homecountry for treatments as \u0026ldquo;NHS was unreliable\u0026rdquo;, adding to the frustration.\u003c/p\u003e \u003cp\u003eThese interactions left athletes feeling stuck, unsatisfied, confused, and sometimes even blamed for their symptoms. Consequently, they expressed a strong desire for more informed, compassionate, and effective care. P03 articulated her experience,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI had a very good idea of what was wrong, but how could a medical professional not confirm it? Mentally, it was horrendous because every symptom made me worry about serious conditions like cancer or other diseases.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLike many athletes, P03 also found relief once she received a confirmed diagnosis. Some athletes report similar challenges with medications. In addition to managing their existing comorbidities, these medications often come with a range of added side effects such as, \u0026ldquo;feeling groggy\u0026rdquo;, \u0026ldquo;added weight\u0026rdquo; \u0026ldquo;mood swings\u0026rdquo;, and \u0026ldquo;hormonal fluctuations\u0026rdquo;, adding an extra layer of complexity to their situation. Many athletes describe undergoing a trial-and-error process to find the right medication for them making them feel \u0026ldquo;bit all over the place really\u0026rdquo; as they \u0026ldquo;weren\u0026rsquo;t able to settle on any kind of routine.\u0026rdquo;, P02 explains. The hit and miss nature of these prescribed medicines made them question, \u0026ldquo;did I make the wrong choice, like, what's happening?\u0026rdquo;\u003c/p\u003e \u003cp\u003eThey also have to monitor their medication intake carefully in relation to their competition schedules, adding another task to their already busy routines. Some athletes also express the need to double-check certain medications to ensure they are not prohibited in sports, as they could lead to positive results in drug tests. This limitation on prescribed drug intake resulted in participant P01\u0026rsquo;s avoidance or reluctance to take necessary medication as she explains:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo it is banned and if we have that and if a the drug test happens after a medal in nationals and if you are caught with that you will be under, like, the report would be that you have taken some drugs or steroids. So that's why I never had a medicine like cyclopam in my life.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile some athletes have expressed disappointment with medications and healthcare, there is a small subset who have reported satisfaction with their experiences. These athletes highlight their doctors' proactive, patient, and persistent approach to their treatment. Their treatments were personalized to accommodate their bodies, routines, and sports commitments. Doctors and medical staff took the time to educate athletes about their conditions and how to manage them effectively. This comprehensive support made athletes feel \u0026ldquo;not abnormal,\" comforted, and trusted in the treatment process. Reflecting on her experience, P05 shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen she diagnosed me, first was like, \u0026ldquo;OK, she knows something, so it's gonna be fine\u0026rdquo;. She somewhat finally listened to me. She validated me, believed me. So that felt really great. I was like, my problems are all going to stop right now and it's all going to be because of her.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile many doctors primarily prescribed allopathic medications, some also suggested alternative approaches such as homeopathic and Ayurvedic medications, particularly for Asian athletes which they found beneficial. Additionally, many doctors recommended incorporating yoga and mindfulness-based practices into their management of menstrual disorders (MDs). With appropriate guidance and consistent medication adherence, coupled with personalized lifestyle adjustments, athletes have reported stabilization of their symptoms and improvement in their overall condition. Having gotten such support earlier athletes mentioned they could have better managed their MDs better and advised other athletes to communicate with their coaches and get timely help.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSocial Support\u003c/h2\u003e \u003cp\u003eThe challenges for healthcare was also made worse because athletes often found themselves lacking adequate support from their coaches. Despite the physical and emotional toll that menstrual disorders (MDs) can take, some coaches exhibit dismissive attitudes, saying \u0026rdquo;so?\u0026rdquo; whenever athletes explain absence from training because they had \u0026ldquo;really bad cramps\u0026rdquo;, being unaware of the impact of these conditions on their athletes' performance and well-being. Due to lack of awareness P02 also mentions her coach saying \u0026ldquo;no, there's no solution to it. Why don't you sit out?\u0026rdquo;; benching her and further instigating her to quit her sport. Particularly, male coaches were sometimes less open to discussing issues related to menstruation, viewing them as outside the scope of their expertise or discomfort in addressing them. Moreover, like many athletes, reflecting on her sporting journey, P02 mentions \u0026ldquo;we never were really open about talking about periods with them (male coaches).\u0026rdquo; This was because \u0026ldquo;it wasn't even the pain and having it. It was the fact like trying to explain it to somebody and them not understanding.\u0026rdquo; These athletes faced excessive pressure to perform despite their symptoms, wherein their coaches say to them \u0026ldquo;\u0026rdquo;get on with it and it'll be fine\u0026rdquo;. Additionally, some athletes like P07 experienced body shaming from coaches wherein without being aware of the conditions they made statements such as \u0026rdquo;you're too skinny. You have to eat more, \u0026rdquo;you're too big. You have to eat less. Maybe you can give her (teammates) some of your food\u0026rdquo;, further exacerbating feelings of discomfort and inadequacy. These factors collectively contribute to a lack of support and understanding within the coach-athlete dynamic, hindering athletes' ability to effectively manage their MDs while pursuing their athletic goals. Expressing the pressure of not letting her coaches down, P05 mentioned:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"He literally used to say 'Champions don't cry.' I still remember my coaching left in 2012 and even after that, sometimes I used to not cry because I tell myself, 'Champions don't cry.' So it affected me on such a deep emotional level that I'm just like crying and champions don't get to cry. You know he had that attitude. So crying was absolutely not allowed on the ground. He is like, 'Cry on your own time, not here.'\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis approach further isolates athletes and reinforces feelings of frustration and invisibility regarding their struggles with MDs. Athletes also reported similar experience with other males (teammates, partners and/or family members) who lacked awareness or empathy regarding the challenges associated with MDs. This led to repetitive cycles of similar dismissive attitudes or discomfort to discuss MDs and their impact openly- making them feel stigmatised. Athletes also felt they were treated as \"mini-men\" and that training regimens were primarily designed with male physiology in mind, making them question, \u0026ldquo;Is sport not meant for women?\u0026rdquo;.\u003c/p\u003e \u003cp\u003eConsequently, coaches could not create a supportive environment which caused frustration of having to explain everytime, lack of awareness among others making it difficult to confide in coaches. They were often compared to other female athletes without MDs which led to them feeling uncomfortable and disregarded with the \u0026ldquo;unhealthy environment which was not supportive\u0026rdquo;. It is important to note that the gender of the coach was not a automatic supportive factor. Several athletes reported that female coaches disregarded their concerns by comparing their pain tolerance to others.\u003c/p\u003e \u003cp\u003eDespite some negative experiences, some athletes mentioned coaches and medical professionals also assisted them. Coaches who had open communication, provided helpful information, were understanding and empathetic, and informed themselves about MDs their athletes dealt with were characterized as coaches who were understanding, supportive, and proactive in addressing their needs. Another supportive behavior reported was when coaches asked to be informed prior to competitions or training sessions about any potential issues related to MDs and were accommodating. Additionally, they were described as motivating and empowering, helping athletes navigate their challenges with confidence. Athletes felt heard and supported by their coaches, fostering a positive and conducive environment as P03 mentions:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026rdquo;We obviously don't know what it's like, but if we can help you in any way, we want to help you. Don't feel like you're obliged to come to this or that, or do this or things like that\u0026rdquo;... I just remember telling them and they had no clue and as a Cricket Club then we were thinking, \u0026ldquo;right, I think we might need to try and get a female in so at least you've got someone to talk. Not just you, but so the girls have got someone to talk to\u0026rdquo;.\u003c/p\u003e\u003cp\u003eIn challenging situations, coaches demonstrated remarkable support by providing interpersonal support to athletes by taking care of their wellbeing, such as \"don't push yourself. If the body is saying no, just take it\", or reassuring sentiments like \"It's just one match. S**t happens. You go again later, OK? It's OK\". They also foster a sense of self-awareness and empowerment by asking questions like \"Are you able to pick up this much weight? What does your body tell you?\". This made athletes feel feel \"supported\", \"heard\", and reassured that they are not at fault.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAthletes also mention seeking support from their family members, friends, partners and teammates. As recounted by P01, having a supportive circle of fellow athletes fosters a sense of camaraderie and belonging:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo it is nice to have a bubble of ladies around you post you having a rubbish day and cramps. As you mention the owrd they ask \u0026ldquo;Do you want paracetamol? do you want hot water bottle? Do you want this? Do you?\u0026rdquo;. You know it's a very wholesome atmosphere where everybody like wanting to pitch in and help, which is nice\u0026hellip;and makes you want to be out on the competition field because you know you're not there on your own. Where I was just quite easy to be like, \u0026rdquo;Hello! I feel rubbish. Can I please have a hug?\u0026rdquo; and then they'll be like okay (giggles).\u003c/p\u003e\u003cp\u003eFurthermore, communication within the team is crucial in ensuring that athletes feel supported and in control of challenging situations. By giving a heads-up to teammates and captains about their menstrual cycles, athletes have the opportunity to collaborate on alternative strategies for games, as exemplified by P05's experience:\u003c/p\u003e\u003cp\u003e\u0026ldquo;OK, we're gonna change the strategy. You're (P05) gonna run half court and then you're gonna, like switch off.\u0026rdquo; So we have this 3\u0026thinsp;\u0026minus;\u0026thinsp;1 thing. So in that way they can't recognize the pattern that I'm always going to be there so. So we switched up. We stopped doing man to man defense and we started doing zone defense only so that I don't have to run that much. So it was overall great.\u003c/p\u003e\u003cp\u003eSome athletes have also extended their support network to include professionals such as \u0026ldquo;nutritionists\u0026rdquo;, \u0026ldquo;psychologists\u0026rdquo;, \u0026ldquo;coaches\u0026rdquo;, and \u0026ldquo;fitness trainers\u0026rdquo;, recognizing the importance of holistic support in managing menstrual health and performance. This comprehensive approach underscores the athletes' commitment to their well-being and success in their sport. These experiences left the athletes feeling that their team and sport were indeed \"the best place to be,\" as aptly expressed by P04. Furthermore, the support received from family members, particularly fathers, has been instrumental in creating a supportive environment for athletes to openly discuss menstrual health. As described by P03, the comfort of being able to confide in her father without hesitation highlights the importance of breaking down societal taboos surrounding menstruation and promoting open communication within families \u0026ldquo;I'll be like, \u0026lsquo;Oh my God, Dad, can you get me some tampons?\u0026rsquo; and it's not weird for me to ask that. Wheras a lot of girls would never really speak to males and their families about that.\u0026rdquo; (P03)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome athletes had parents who were doctors, and they expressed trust in their parents, feeling reassured that \"they're doing the right thing for me,\" as mentioned by P04. Fortunately, P05 also highlighted being raised in an environment where menstrual health education was provided in school. All these factors acted differently as facilitators and barriers for the athletes and are outlined in Fig.\u0026nbsp;2 below.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSocio-Cultural Impact\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMost athletes mention that these unpredictable bursts of symptoms have a major impact on daily life and routines. This varied across cultural background in terms of social perception and mitigation interventions chosen. A majority of these cultural differences are seen in the types of treatments preferred.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eFacilitators and barriers within lived experienced of athletes with MD\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMost Asian cultures prefer a more traditional route to treating MDs. These include naturopathy, ayurvedic medicines and seed cycling. Several athletes reported that culturally, in their family systems having birth control pills for MDs are considered a taboo. Having a similar experience one athletes mentions:\u003c/p\u003e \u003cp\u003eMy mom was like \u0026rdquo;no, we come from a very like conservative kind of culture. You shouldn't be taking birth control so early on when you're 15\u0026ndash;16 like that's not good\u0026rdquo; and stuff. \u0026rdquo;You shouldn't be taking any medicines. It's not our culture, it's not good. Later on, when you have kids and like, you know, fertility issues\u0026rdquo;. It was very much like, \"girls like in our culture don't take birth control\u0026ldquo;. It was a major taboo-taboo\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eDue to this, the athlete were provided alternative medications for different symptoms, with each medication focused on one symptom. This made led to multiple side effects since athletes were not allowed to have one medication that would address most major issue caused by the MD. There was also a very real financial strain of the MD. This include medical costs, menstrual hygiene and nutrition. For several affected athletes, excessive bleeding necessitates purchasing menstrual products in bulk quantities which far exceeded typical needs. Due to heavy bleeding P03 living with endometriosis expresses adding 10 packs of tampons costing her \u0026pound;25 compared to someone who can manage with as little as \u0026pound;2.5 for the same period product for a month, making it expensive for them.\u003c/p\u003e \u003cp\u003eWith clothing choices athletes express a reluctance to wear white due to past experiences or fears of staining, getting rashes from pads and discomfort from tight bras which don't provide adequate support for tender breasts. The issue of traveling for competitions while dealing with these symptoms adds to the challenges. These concerns have been cited to make them feel conscious and distracted affecting their play as an athlete mentions ,\u0026ldquo;I shouldn't be worried about that. I should realistically just be worried about me dealing with it (game) for myself.\u0026rdquo;\u003c/p\u003e \u003cp\u003eHence, athletes express their MD symptoms and not getting periods to have been normalized in their daily conversations to which they rebel saying \u0026ldquo;no, this is not normal!\u0026rdquo; and potentially having negative long-term health consequences Such situations make it hard for them to explain to people the struggles they go through as it has been normalized or dismissed making them feel helpless as P03 explains:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;We used to get a lot of girls who I play cricket with, being almost like \u0026rdquo;Ohh, it's just a period\u0026rdquo;. I'm thinking, \u0026rdquo;Yeah, it's just a period to you, but to me, it's not just a period, it's basically probably five of your periods in one\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003ePsychological impact\u003c/h2\u003e \u003cp\u003eThe unpredictability of unexpected periods or the fear of onset of period-related symptoms during a game heightens their anxiety, increases disappointment and significant distraction and leads to performance setbacks. P05 mentions:\u003c/p\u003e \u003cp\u003e\u0026ldquo;So I literally got it (periods) like on the day we reached there and I used to just feel like a lot of mental block. It gave me a lot of anxiety\u0026hellip; My top worries were like getting like one of that pain attack or pain episode during the game. The second thing was that not being able to control my anger because I was very irritable.\u0026rdquo;\u003c/p\u003e \u003cp\u003eLiving with MDs while actively participating in sports led to a range of thoughts and feelings among athletes. Athletes reported frequent self-doubt and engage in self-deprecating thoughts, labeling themselves as \"lazy,\" \"arrogant,\" or \"overdramatic\" and in turn not a good athlete. They frequently wonder, \"why is it me that has to deal with that pain?\". These athletes often find themselves comparing their bodies, performance, and MD symptoms to those of their teammates who experience regular periods. The competitive environment intensifies these comparisons as P01 with endometriosis feels \u0026ldquo;defeated\u0026rdquo; as she explains:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eeverybody's competing at once, you can see other people's scores. You know, it's quite a tough mental battle anyway, but when you're already fighting yourself, that's not great start.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite these difficulties, these athletes display remarkable resilience and emphasize the importance of self-love, patience, and compassion towards their past selves, acknowledging the hardships they have endured while competing as athletes with MDs. They also explain their desires if they were not living with MDs and how \u0026ldquo;life would be good\u0026rdquo; and they would be \u0026ldquo;happier\u0026rdquo; without it. P08, a retired athletes reflects on such desires mentioning:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI do think that honestly, the insecurities or the self-consciousness I've kind of developed with the weight gain and like not being able to perform because of it, like the social comparison and stuff. It would be a lot less if I didn't have PCOS. I think the PCOS was kind of like a trigger for a lot of things that I've have stayed with me even up until now.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eManagement and Recommendations\u003c/h2\u003e \u003cp\u003eLifestyle changes, such as regular exercise, mindful dieting, home-cooked meals, abstaining from alcohol and smoking, prioritizing sleep, and practicing meditation, have been commonly adopted by athletes. However, not all athletes have found success with these strategies and often turn to medications. A cultural difference had been witnessed where some athletes are suggested \u0026ldquo;seed cycling\u0026rdquo;, \u0026ldquo;ayurvedic\u0026rdquo; and \u0026ldquo;naturopathy\u0026rdquo; treatment, other athletes is not allowed to have contraceptives to help treat their symptoms because \"girls in our culture don't take birth control.\u0026rdquo;, she says.\u003c/p\u003e \u003cp\u003eReceiving a diagnosis helped athletes plan their game schedules, manage symptoms with the right medications, and prepare essential resources like hot water bags, puke bags, spare clothing, and period products to prevent staining and some quick fix for discomfort during competitions. Mental affirmations play a role too, as athletes encourage themselves with thoughts like \"any arrow I get to shoot is a good arrow.\" They also prioritize rest before, during, and after their games. In some cases, athletes have resorted to surgery as a means to better manage their MDs. Most athletes mention receiving adequate emotional support, getting the right information and acts of help from family and friends which further helped them cope well with the MDs.\u003c/p\u003e \u003cp\u003e Athletes further recommend the sporting fraternity to raise awareness about menstrual health, educate and inform coaches and other sporting fraternity so as to communicate empathetically, have open conversations about the topic and health needs of athlete, recruited informed and licensed medical teams or guide athletes to the right source of information, understand what is \u0026lsquo;not normal\u0026rsquo; and not dismissing their concerns.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study highlight the daily real-life experiences of athletes living with menstrual dysfunctions (MDs) in and out of sport with further experiential outcomes of athletes' thought processes concerning the impact of MDs on their sports participation and personal well-being. The different dimensions our findings are discussed in context of wider literature and applied recommendations below.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eLiving with MDs is a Multifaceted Experiences, not a singular reality\u003c/h2\u003e \u003cp\u003eExisting evidence notes that athletes with MDs deal with varied physical symptoms such as headache, fatigue, nausea, body pain and more (Redman \u0026amp; Loucks, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) with the commonly expressed symptoms such as menstrual cramps and energy deficiency having a substantial impact on their attendance in various domains, including school, work, sports training, and competitions. Our findings support this from a lived experience perspective, extending Adam et al., (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) findings that athletes perceive menstrual cramps and fatigue as direct contributors to reduced athletic performance, hindering their ability to excel in their respective sports. Our findings also highlighted that the intense pain, and other medical treatment requirements have forced participants to alter daily patterns and force non-adherence in sport. We echo the previous findings in non-sport literature (cf. Poureslami \u0026amp; Farzaneh Osati-Ashtiani, 2002) which showcased pain related to menstrual cramps as a prominent cause of absenteeism.\u003c/p\u003e \u003cp\u003eEmotional impacts such as unmanaged anxiety triggered by hormonal fluctuations, irritability, arousal dysregulation are also an additional challenge of living with MDs. Our findings support the current research outlining how significant emotional challenges impact performance and skill execution (Adam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Findlay et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). While prior research has examined similar symptoms in sport, it is limited on normal menstrual-cycle symptoms (Burinvels et al., 2016). Our study provides a unique experiential insight into how the emotional toll is severe leading to mental health risks through anxiety and depression since seeking treatment is often futile, and the lack of knowledge as well as stigma surrounding MDs may amplify isolation and helplessness in those living with MDs (Sheinfield et al., 2007). More research is needed specific to MDs within this area.\u003c/p\u003e \u003cp\u003eOur findings repetitively indicate that living with MDs includes the whole self. This includes experiencing negative thoughts and feelings about themselves, often attaching labels, and engaging in comparisons with other athletes, particularly concerning their performance and body image. This aligns with research indicating that women with MDs tend to experience negative thinking due to their symptoms, which further diminishes their self-esteem and self-confidence (Moradi et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The present study contributes to this body of knowledge by shedding light on how these negative self-labels and comparisons can detrimentally affect athletes' performance and found that indicators similar to Heather et al., (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) in how athletes engage in these body image and performance considerations which manifest as self-doubt, demotivation, and an increased risk of disordered eating. Therefore, it is critical to consider living with MDs as a multifaceted impact on the individual, not just \u0026lsquo;one thing\u0026rsquo; the athlete has to focus on. On this note, person-centred sport psychology support may be a useful approach in such cases (Gupta \u0026amp; Duncan, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003eSocial Support as a Barrier \u0026amp; Facilitator\u003c/h2\u003e \u003cp\u003eA majority of the athletes perceived their coaches, and doctors to be unsupportive, ineffective and generally lacking an understanding of their MDs which align with research findings indicating that healthcare professionals often dismiss the needs of women with MDs, lack accurate communication skills, and provide poor-quality support, ultimately compromising athletes' health (Moradi et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; O\u0026rsquo;Loughlin et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Our findings echo the findings of Laske et al., (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) where male coaches have been observed to exhibit discomfort and under-confidence discussing menstrual health or downplaying its impact on performance which leads to athletes feeling stuck and unheard all linked to a lack of awareness, knowledge. There is also the tendency to normalize MD symptoms as something \u0026lsquo;every female athlete has to go through (von Rosen et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Participants in our study also echoed Pitchers \u0026amp; Elliot-Sale, 2019) who noted that all research and practices are focused on male physiology leading to training and periodisation plans viewing MDs as a hindrance to inclusion.\u003c/p\u003e \u003cp\u003eA few athletes also noted positive interactions with coaches and doctors, but only who were updated in their knowledge base and were open and respectful in their communication of MDs. Marais (2012) linked such behaviours to the longevity of female swimmers in sport, and our findings indicate would benefit athletes with MDs. Additionally, our findings support McGawley et al., (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) who reported that athleted with MD build trust with medical professionals built upon accurate diagnosis, timely referral and well long-term supported treatment that has positive repercussions of sporting performance\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eManagement and recommendations\u003c/h2\u003e \u003cp\u003eAs highlighted above, there is a lack of applied focused literature in this area. To this end, we discuss certain proposed best practice recommendations in line with findings of the study and the wider literature.\u003c/p\u003e \u003cp\u003eFirst, we support the assertions of (Paice, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) that menstrual health literature and awareness is notably low among female athletes, coaches, and practitioners due to the taboo surrounding the topic and the relatively recent but limited research in the field with a lack of guidance or organizations dedications to supporting individuals with MDs. We support the findings of Carmichael et al., (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) to outline the need for athletes to be educated about basic female physiology in easily digestible ways. We recommend National Governing Body (NGBs) or other sources to provide effective psychoeducational and literacy resources for athletes living with MDs to refer to.\u003c/p\u003e \u003cp\u003eSecond, clear referral pathways i.e., first point of contact in female sport for menstrual health related concerns as advocated by Findlay et al., (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Within this, there should be an education of support staff and literacy which has been highlighted to be needed and beneficial since female reproductive health expertise in the multidisciplinary management of performance pathway and elite athletes are required (Jones et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; McGawley et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThird, our findings and previous findings showcase the importance of not dismissing or denying athlete concerns, suggesting promotion of empathetic regard and medical advice (see Verhoef et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Klingenberg, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This is especially important for coaches. We recommend incorporation of MD experience education in coach education and CPD for coaches who are trained to work with female athletes. Having trained female coaches in performance pathways with the right knowledge and communication skills is likely to promote help-seeking behaviour.\u003c/p\u003e \u003cp\u003eFourth, expanding on Klingenberg (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) there is a critical need to address treatment delays. We recommend encouraging regular health screening and support for menstrual health assessment with this being a component of athlete monitoring for health by the medical team.\u003c/p\u003e \u003cp\u003eFifth, in line with findings of Kolić et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and Adam et al., (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), clothing options with dark colours, sizes, styles and comfortable fits and providing them with menstrual hygiene products as part of sport kit would be beneficial.\u003c/p\u003e \u003cp\u003eFinally, it is essential to priortise physiological and emotional recovery as a priority not just performance-based recovery (Verhoef et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This can be incorporated with self-care strategies, more scheduled recovery time or seeking support from sport psychologists who are trained in female athlete care due to the unique experience of living with MDs.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics \u0026amp; Consent to Participation statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten ethical consent was secured from all participants aligned with the Helsinki Declaration (which included consent for publication post anonymisation). The study was approved by\u0026nbsp;Loughborough University Institutional Ethics Committee (Ref: 14047). Research was conducted in line with ethical parameters of human participant research in the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData (i.e., anonymised transcripts and coding) can be made available on request, but cannot be made full open access.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests or conflicts of interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided by Talented Athlete Scholarship Scheme (TASS) Early Career Research Grant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;We would like to support TASS and Emily Cartigny for their support and all particpants for their time and contributions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbdelmoty, H. 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J., Wielink, M. C., Achterberg, E. A., Bongers, M. Y., \u0026amp; Goossens, S. M. T. A. (2021). Absence of menstruation in female athletes: why they do not seek help. \u003cem\u003eBMC Sports Science, Medicine and Rehabilitation\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(1). https://doi.org/10.1186/s13102-021-00372-3\u003c/li\u003e\n\u003cli\u003evon Rosen, P., Ekenros, L., Solli, G. S., Sandbakk, \u0026Oslash;., Holmberg, H.-C., Hirschberg, A. L., \u0026amp; Frid\u0026eacute;n, C. (2022). Offered support and knowledge about the menstrual cycle in the athletic community: A cross-sectional study of 1086 female athletes. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(19), 11932. https://doi.org/10.3390/ijerph191911932\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"MDs, menstrual cycle, coaches, medical professionals, self-perception, Female athlete","lastPublishedDoi":"10.21203/rs.3.rs-4782294/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4782294/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWith the increasing representation of women in sports, addressing menstrual health issues, specifically menstrual dysfunctions (MDs), has gained significance. This study aimed to gain a comprehensive understanding of the experiences of athletes living with MDs and how they manifest in their sports performance and psychological well-being\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTen female athletes (mean age\u0026thinsp;=\u0026thinsp;24.5, SD\u0026thinsp;=\u0026thinsp;5.20), active and retired, living with MDs, including endometriosis, polycystic ovary syndrome (PCOS), primary dysmenorrhea, and premenstrual dysphoric disorder (PMDD), for a minimum of one year, were engaged in semi-structured interviews. Data analyses utilized Braun and Clarke's (2019) six-phase guide for reflexive thematic analysis, which incorporated a three-step coding process (Moghaddam, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) for an in-depth exploration.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA two-phase thematic analysis highlighted six key themes: medical impact, health impact, psychological impact, socio-cultural impact, social support, and suggestions. These themes illuminate how their physical symptoms led to psychological challenges and underscore the inadequate support received from sporting and medical professionals. In the second phase we identified several barriers and facilitators as illustrated from the lived experience with MDs. These are then synthesised into reccomendations that the athletes suggest themselves which offer insights that can benefit other athletes with MDs and guide coaches and medical practitioners in providing effective support.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eStudy findings highlight athletes' daily experiences living with menstrual dysfunctions (MDs) both in and out of sport, including their thoughts on how MDs affect their sports participation, sense of self and personal well-being. Future studies can adopt a more longitudinal approach, delving into various MDs individually for a deeper understanding and conduct focus groups with medical personnel, support staff and athletes for improved support provisions. We recommend an education programme for athletes and coaches in an asynchronous format for access to information and CPD for holistic support for pathway athletes.\u003c/p\u003e","manuscriptTitle":"“No, that is not normal”: Psychosocial lived experiences of Elite Athletes living and performing with Menstrual Dysfunctions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-20 09:10:16","doi":"10.21203/rs.3.rs-4782294/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-25T06:22:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-24T11:49:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-24T11:48:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Sports Science, Medicine and Rehabilitation","date":"2024-07-22T13:38:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-sports-science-medicine-and-rehabilitation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssmr","sideBox":"Learn more about [BMC Sports Science, Medicine and Rehabilitation](http://bmcsportsscimedrehabil.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ssmr/default.aspx","title":"BMC Sports Science, Medicine and Rehabilitation","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5aeb21ce-c823-47cb-8a0f-ad8d4ff6238e","owner":[],"postedDate":"August 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-03T12:08:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-20 09:10:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4782294","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4782294","identity":"rs-4782294","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}