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      The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis

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          Abstract

          Background

          Concentrations of endogenous sex hormones fluctuate across the menstrual cycle (MC), which could have implications for exercise performance in women. At present, data are conflicting, with no consensus on whether exercise performance is affected by MC phase.

          Objective

          To determine the effects of the MC on exercise performance and provide evidence-based, practical, performance recommendations to eumenorrheic women.

          Methods

          This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four databases were searched for published experimental studies that investigated the effects of the MC on exercise performance, which included at least one outcome measure taken in two or more defined MC phases. All data were meta-analysed using multilevel models grounded in Bayesian principles. The initial meta-analysis pooled pairwise effect sizes comparing exercise performance during the early follicular phase with all other phases (late follicular, ovulation, early luteal, mid-luteal and late luteal) amalgamated. A more comprehensive analysis was then conducted, comparing exercise performance between all phases with direct and indirect pairwise effect sizes through a network meta-analysis. Results from the network meta-analysis were summarised by calculating the Surface Under the Cumulative Ranking curve (SUCRA). Study quality was assessed using a modified Downs and Black checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group.

          Results

          Of the 78 included studies, data from 51 studies were eligible for inclusion in the initial pairwise meta-analysis. The three-level hierarchical model indicated a trivial effect for both endurance- and strength-based outcomes, with reduced exercise performance observed in the early follicular phase of the MC, based on the median pooled effect size (ES 0.5 = − 0.06 [95% credible interval (CrI): − 0.16 to 0.04]). Seventy-three studies had enough data to be included in the network meta-analysis. The largest effect was identified between the early follicular and the late follicular phases of the MC (ES 0.5 = − 0.14 [95% CrI: − 0.26 to − 0.03]). The lowest SUCRA value, which represents the likelihood that exercise performance is poor, or among the poorest, relative to other MC phases, was obtained for the early follicular phase (30%), with values for all other phases ranging between 53 and 55%. The quality of evidence for this review was classified as “low” (42%).

          Conclusion

          The results from this systematic review and meta-analysis indicate that exercise performance might be trivially reduced during the early follicular phase of the MC, compared to all other phases. Due to the trivial effect size, the large between-study variation and the number of poor-quality studies included in this review, general guidelines on exercise performance across the MC cannot be formed; rather, it is recommended that a personalised approach should be taken based on each individual's response to exercise performance across the MC.

          Electronic supplementary material

          The online version of this article (10.1007/s40279-020-01319-3) contains supplementary material, which is available to authorized users.

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          Most cited references111

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          The Bayesian New Statistics: Hypothesis testing, estimation, meta-analysis, and power analysis from a Bayesian perspective.

          In the practice of data analysis, there is a conceptual distinction between hypothesis testing, on the one hand, and estimation with quantified uncertainty on the other. Among frequentists in psychology, a shift of emphasis from hypothesis testing to estimation has been dubbed "the New Statistics" (Cumming 2014). A second conceptual distinction is between frequentist methods and Bayesian methods. Our main goal in this article is to explain how Bayesian methods achieve the goals of the New Statistics better than frequentist methods. The article reviews frequentist and Bayesian approaches to hypothesis testing and to estimation with confidence or credible intervals. The article also describes Bayesian approaches to meta-analysis, randomized controlled trials, and power analysis.
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            Where are all the female participants in Sports and Exercise Medicine research?

            The aim of this study is to estimate the ratio of male and female participants in Sports and Exercise Medicine research. Original research articles published in three major Sports and Exercise Medicine journals (Medicine and Science in Sports and Exercise, British Journal of Sports Medicine and American Journal of Sports Medicine) over a three-year period were examined. Each article was screened to determine the following: total number of participants, the number of female participants and the number of male participants. The percentage of females and males per article in each of the journals was also calculated. Cross tabulations and Chi-square analysis were used to compare the gender representation of participants within each of the journals. Data were extracted from 1382 articles involving a total of 6,076,580 participants. A total of 2,366,968 (39%) participants were female and 3,709,612 (61%) were male. The average percentage of female participants per article across the journals ranged from 35% to 37%. Females were significantly under-represented across all of the journals (χ(2) = 23,566, df = 2, p < 0.00001). In conclusion, Sports and Exercise Medicine practitioners should be cognisant of sexual dimorphism and gender disparity in the current literature.
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              Changes in muscle strength, relaxation rate and fatiguability during the human menstrual cycle.

              1. The effect of the different phases of the menstrual cycle on skeletal muscle strength, contractile properties and fatiguability was investigated in ten young, healthy females. Results were compared with a similar group on the combined (non-phasic) oral contraceptive pill (OC). Cycle phases were divided into the early and mid-follicular, mid-cycle (ovulatory) and mid- and late luteal. Cycle phases were estimated from the first day of the menstrual bleed. 2. Subjects were studied weekly through two complete cycles. Measurements included quadriceps and handgrip maximum voluntary isometric force and the relaxation times, force-frequency relationship and fatigue index of the quadriceps during percutaneous stimulation at a range of frequencies from 1 to 100 Hz. 3. In the women not taking the OC there was a significant increase of about 11% in quadriceps and handgrip strength at mid-cycle compared with both the follicular and luteal phases. Accompanying the increases in strength there was a significant slowing of relaxation and increase in fatiguability at mid-cycle. No changes in any parameter were found in the women taking the OC. 4. The changes in muscle function at mid-cycle may be due to the increase in oestrogen that occurs prior to ovulation.
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                Author and article information

                Contributors
                kirsty.elliottsale@ntu.ac.uk
                Journal
                Sports Med
                Sports Med
                Sports Medicine (Auckland, N.z.)
                Springer International Publishing (Cham )
                0112-1642
                1179-2035
                13 July 2020
                13 July 2020
                2020
                : 50
                : 10
                : 1813-1827
                Affiliations
                [1 ]GRID grid.42629.3b, ISNI 0000000121965555, Department of Sport, Exercise and Rehabilitation, Faculty of Health and Life Sciences, , Northumbria University, ; Newcastle-upon-Tyne, UK
                [2 ]GRID grid.12361.37, ISNI 0000 0001 0727 0669, Department of Sport Science, Sport, Health and Performance Enhancement (SHAPE) Research Centre, , Nottingham Trent University, ; Nottingham, UK
                [3 ]GRID grid.11899.38, ISNI 0000 0004 1937 0722, Applied Physiology and Nutrition Research Group, Escola de Educação Física e Esporte, Faculdade de Medicina FMUSP, , Universidade de São Paulo, ; São Paulo, Brazil
                [4 ]GRID grid.59490.31, ISNI 0000000123241681, School of Health Sciences, , Robert Gordon University, ; Aberdeen, Scotland, UK
                Author information
                http://orcid.org/0000-0001-6176-7983
                http://orcid.org/0000-0003-1122-5099
                http://orcid.org/0000-0002-1018-7601
                http://orcid.org/0000-0001-9663-0696
                http://orcid.org/0000-0001-7542-1107
                http://orcid.org/0000-0001-9029-2171
                http://orcid.org/0000-0003-2973-5337
                http://orcid.org/0000-0002-5057-9191
                Article
                1319
                10.1007/s40279-020-01319-3
                7497427
                32661839
                fdd308c6-b442-4edb-b163-35f1758d9d13
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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