A taboo subject that really needs to be discussed

Sara Chica-Latorre is a PhD candidate and research assistant at the University of Canberra Research Institute for Sport and Exercise, researching menstrual cycle symptoms in sportswomen and how to improve these symptoms through diet.

Since graduating from the Australian National University in 2015 with a Bachelor of Science with Honours where she investigated water/leaf relations in various mangrove species Chica-Latorre has enjoyed a varied career which has included working as a research and technical assistant in plant physiology at the Australian National University, as a personal trainer, cycling instructor, and Certificate III and IV in Fitness teacher at the Canberra Institute of Technology.

She has also completed a Graduate Diploma in Nutritional Science, which led her to pursue a Master in Nutrition and Dietetics, which she completed in 2021. Chica-Latorre’s PhD is combining her three biggest passions: research, exercise, and nutrition, as she strives to make a difference in women in sports research.

Chica-Latorre visited the New South Wales Institute of Sport (NSWIS) and spent time with the Institute’s Manager of Sports Science, Alex Natera, and other experts. She also presented a talk to the Institute’s staff on a subject she insists must be discussed openly – the menstrual cycle of female athletes.

NSWIS: Sara, why did you make the menstrual cycle of professional athletes the focus of you PhD?

Sara Chicha-Latorre (SCL): It wasn’t initially my subject. It was always about female athlete health, but I started my PhD in epigenetics, where we looked at how the body’s immune cells fluctuate through the menstrual cycle, and if there is anything about those immune cells that is changing through lifestyle habits that we need to be aware of in terms of menstrual symptoms. But I changed my direction, leaving the immune cells on the side, and focusing on the diet mediated inflammatory aspect of menstrual symptoms. So, while it wasn’t planned, it shaped into what it is now – a three-way interaction of different factors: (1) menstrual cycle symptoms, (2) inflammation, and (3) diet.

NSWIS: What have you leant so far?

SCL: The one thing that really shocked me is the amount of available information is limited. And what is available is a lot of confounding evidence because the methods we’ve been using throughout the years on these women – female athletes – have been unideal. It all seems to come down to how difficult it is to investigate women and the menstrual cycle. That completely shocked me, but I’ve also found out something quite interesting, that is athletes, and women in general, tend to say they’re comfortable to talk about their menstrual cycle, and the menstrual symptoms they experience, but once they begin talking you can see their micro- expressions [of them feeling uneasy] showing that there’s a sense of it being an uncomfortable topic.

NSWIS: Why is that? It’s tempting to call the menstrual cycle of athletes in sport an ‘issue’ but in reality it’s a fact of life. . . an everyday event.

SCL:  It is an everyday event. I think there are different components to it, culture being quite significant, in my perspective. I come from a different country and talking to my friends and peers about it back at home is completely different to talking about it in Australia, as it is talking to someone in Europe. I’ve had some European participants, and I feel there is a cultural aspect as to how comfortable someone is talking about this subject.

NSWIS: How does it differ?

SCL: In terms of Colombia, it’s a very conservative country and very sexist. So, we don’t discuss ‘women issues’ with men, or even at all. It’s been that way forever, and something you don’t do. Europe is more liberated, I feel. You perceive that they’re a little bit more comfortable [talking] but at the same time, at least in my study, the athletes express there’s not a necessity to discuss anything to do with their cycle with others because it’s ‘just personal stuff’. So, at that level, I thought there was a societal belief that there’s no need [to talk], which makes me think awareness is an important factor. We need to be aware of this, we need to realise it’s important to discuss these things. Australia’s a middle ground, I feel. It’s in between the other two. It’s been interesting to talk to people from different countries and find these patterns. I’ve also found there’s a social aspect of shame and embarrassment that surrounds that topic.

NSWIS: Where do menstrual symptoms originate from?

SCL: We’re not completely sure where they originate from. However, what we do know is that menstrual cycle symptoms are very diverse – there could be more than a hundred, and every woman will experience them differently. It’s so multi-symptomatic it’s difficult to pinpoint where they originate. The prediction is that some of them might originate from an increased inflammation in the body, as most of them tend to happen at the premenstrual phase and the menstrual phase, which are phases of the cycle characterised by increased inflammation. So, inflammation might play a crucial role in the onset and severity of symptoms.

NSWIS: What are the symptoms and how do they affect women?

SCL:  That is precisely one of the questions I ask my interviewees, ‘what are your symptoms and how do these affect you?’ The thing is, they can affect you in different ways because everyone is so different. In a nutshell, symptoms can be psychological, physical, and emotional as well. The most prevalent physical symptoms are menstrual cramps, either mild or severe [dysmenorrhea], and breast tenderness. They’re both on the high level, so a lot of people report experiencing them. Another one is low energy. However, this one can cause confusion because some people might wonder what if it’s not a symptom of the menstrual cycle, and maybe it’s because I didn’t have a good night’s sleep? Or is it because I’m stressed? – which could also be the case. Mood swings are common in the premenstrual phase, and in the menstrual phase you can experience the worry or anxiety of having an accident . . . that you might leak through your pants. It’s something I speak to the athletes about, as I came to realise this from personal experience. When I was in high school, we had to wear these ‘trackies’ that were very light grey in colour. I remember whenever I had to stand up in class I’d always think ‘Please . . . please . . . please . . .  no, no, no . . .  just let it be fine’. But that anxiety, the terrible worry, would make you lose focus and concentration. It can also affect the way you interact with people. Sometimes athletes in team sports won’t interact with their peers because they feel irritated or too anxious, and that impacts the game and interaction with teammates.

NSWIS: Recently, the former Australian women’s cricket captain Alex Blackwell, said it’s a mistake to have females playing in white clothing because there’s the risk that, one day, a player will be embarrassed by leakage, and they’ll have to live with . . . not necessarily ‘shame’ . . . but being remembered forever for her period. Should sporting organisations consider something as basic as the colour of the clothes their female athletes compete in? Would that remove anxiety and nervousness?

SCL: Right now, we’re in an era where women are trying to gain empowerment over their menstruation and menstrual cycle. One could think [changing the colour of women’s playing kit] is the right thing to do so we can avoid all this recurrent stress of possibly having accidents, or we could embrace this thing and empower women so we wouldn’t care if there was an accident. There’s a debate there because while it’d be wonderful to have sport kits that are not white – because it would allow the athletes to feel a little bit more at ease – at the same time [changing it] would be continuing to hide or cover up what has been historically hidden. It’s normalising that embarrassment . . .

NSWIS: But that will come back to it happening to someone – one person – who is not expecting it. Mentally, that could be detrimental for them. I appreciate what you say about normalising the menstrual cycle – it is a natural part of life – but will the person it happens to be strong enough to own it?  And how will the other athletes react? I’m sure many will think ‘I don’t want that to happen to me.’ And social media means there’ll be an element out there who’d see that as an opportunity to ridicule the athlete . . .which says more about them than the athlete.

SCL: You’ve hit the nail in the head, because with this debate what we should really be looking at is to engage more women in sport – which happens in the early teens. When they decide to continue or not is around when their first menstruation occurs, so sporting organisations need to look at the colour of the playing kits – which is something we’re not doing much about.

NSWIS: It’s a barrier. We talk about barriers of poverty stopping youth from playing sport, but something as simple as the colour of a playing kit could be a barrier to someone playing sport . . .

SCL: To participate, yes.

NSWIS: People who don’t suffer migraines can be unsympathetic to those who do, they don’t see it as an issue. Is it the same with menstruation . . . are women who have moderate symptoms similarly harsh on those who suffer terribly?

SCL: Yes. The lack of empathy is not just received from male to female, because, unfortunately, a male will never know what we go through . . . a male will never understand that.

NSWIS: Even so, it’s still possible to empathise  . . .

SCL: There’s always that case the lack of empathy will be there between males and females . . . and that’s the interaction between players and the coaches because most players assume the coach will think one way, and they’ll assume there’s a lack of empathy because they think ‘if I tell the coach he’ll  react one way’, and the coach assumes everything is fine because he isn’t aware there’s a problem because the athlete isn’t raising it. One of the main points of my studies is ‘where do we start?’ and we start with the athlete because the athlete needs to be aware of their menstrual cycle. They need to be aware of what’s happening; ‘am I experiencing this because of my menstrual cycle or is it because of something else?’. Well, if it’s something that’s recurring every single month, they should realise it and then communicate with the coach. Communication is key, but it’s not happening because of embarrassment and shame, the stigma. We don’t talk because there doesn’t appear to be a necessity to discuss what’s seen as ‘my personal stuff’. We are assuming people either understand or they lack empathy. That’s the second point, and the third point will be ‘let me support you’. It is a three step procedure. It’d be so nice to just say ‘let’s talk’ but what is encouraging is both male and female coaches are starting to realise they need to have a positive environment for that communication to take place. And doing that maybe the athletes will open up, maybe they won’t but having a 50-50 chance is better than zero.

NSWIS: And for women who don’t empathise because they have moderate symptoms?

SCL: In terms of a lack of empathy from woman to woman, I would say that although it is a bit surprising and almost disappointing, it is a reality. After all, we go through similar experiences, so a sense of shared understanding and support is almost expected. However, I think it is that same “sense of familiarity” that can lead women to be a bit unempathetic towards other’s experiences of menstrual symptoms. There seems to be a common saying, ‘we all go through it, and is not that bad’. Unfortunately, this is just not correct, because we all experience things in a different way. We perceive, feel, and react to things differently. So, we should not be just assuming that symptoms, for example menstrual cramps, look the same to everyone. In fact, their severity might vary quite drastically, and the ramifications that these symptoms might have could be significantly different from person to person. Some individuals might experience a bit of cramping but still be able to train and go by their day without disruption. While, others might experience severe incapacitating cramping, where even walking becomes a challenge, let alone training, where the pain is so severe there is nausea and vomiting, where the pain is so severe it becomes debilitating. So, how could we just say ‘we all go through it, and is not that bad’, between women? We need to start opening up to being a bit more empathetic.

NSWIS: Have you interviewed any athletes who were dropped from their team because their coach didn’t understand?

SCL: Never, but I’ve interviewed athletes who were afraid that would happen. So, the fear is there, and I’m assuming it has happened?

NSWIS: There were allegations that during the Cold War the USSR stopped women from having their menstrual cycle before a big event, such as the Olympics. Is there any evidence of the ramifications?

SCL: I’m not fluent on that, but I do know athletes will choose on their own to do that, and it’s why  a lot of athletes rely on hormonal contraceptive use, as it allows them to gain greater control over their menstrual cycle. Unfortunately, a lot of women aren’t very regular with their menstrual cycles . . . we’d like a perfect 28 day cycle instead of being all over the place  . . . but the reality is a lot of women – in general – will experience a lot of irregularities. And if you think of irregularities and, for example, water sports, that’s a little bit of a big deal. So, if you have a way where you can take more control, you’ll probably take it. That’s why a lot of athletes use hormonal contraceptives because this is one choice a doctor provides . . , if you want to have a more regular menstrual cycle, here’s the pill or whatever contraceptive they have to offer. The issue is that  hormonal contraceptives, which work by suppressing natural hormones and adding synthetic hormones, can mask sinister things the athlete may be experiencing.  While we may think everything is normal, maybe it’s not. These things could be, for instance, low energy availability [when what you eat is not sufficient to support your energy expenditure], and underlying menstrual and hormonal issues like amenorrhea [when menstruation stops].

NSWIS: It must take its toll.

SCL: What we’re seeing right now is there’s a big shift for women starting to realise there’s no necessity to be on hormonal contraceptives in most cases. From personal experience I can say it’s more liberating to be on a natural cycle, and a lot of women are taking that step and seeing what their natural hormones do for their body. I used hormonal contraceptives since I was 14 because I was irregular and my gynaecologist said, ‘here you go, take these every day’ and I had no idea of what I was doing. Yet, from 14 to 27 years of age I used the pill and other forms of contraception. I tried different hormonal contraceptives, and I thought that feeling not great and even that bleeding every day was normal, and that was how my body works. When I started reading literature about hormonal contraceptive use and that there was so much uncertainty about whether that would have a long-term effect on me, and specifically on the uncertain effects on testosterone levels, I started to worry. I was competing in body building at the time, and I thought there might be a slim chance to be a little bit better at this sport if I withdraw from taking the pill. I tried it – and from my own experience – I experienced a massive change in my metabolism, my retention of muscle mass, and in my performance at the gym when my natural hormones truly kicked in and my cycle became regular. It took for me to experiment on myself to see what happened. I realised it’s better to be my natural self, but  a lot of women in sport may be scared to try because it’ll mean a lot of irregularities in the beginning, and even maybe struggling to regain your cycle, which a lot of athletes’ experience. When is the best time to do it if you’re continuing to train at the elite level? You might not have room for error at that level. It is a tricky situation. Hopefully doctors will realise that in all instances the solution isn’t to say, ‘go with the pill.’ Although, there will be people who medically do need it, for example where the hormonal control is necessary to manage menstrual conditions, or in some cases to manage severe menstrual pain. However, what we’re also seeing is some people might jump into hormonal contraception to reduce or alleviate symptoms and that ends up backfiring because they might increase the number or severity of symptoms they experience – which is cruel. So, although, in reality, there might not be a one size fits all, it would, in my view, be wonderful to start seeing a shift from medical practitioners as well to take one step back from the over-recommendation of hormonal contraceptives and start informing women about other potential alternatives.

Daniel Lane, NSWIS