Tailoring Nutrition and Training to a Footballer’s Menstrual Cycle – Simone do Carmo

The menstrual cycle can affect an athletes’ dietary patterns and their performance capacity. Sports Nutritionist, exercise physiologist and personal trainer, Simone do Carmo shares her experiences through this case study.

Ultimately, what matters as a practitioner is the person in front of you, and understanding a woman’s unique experiences around her menstrual cycle.”

In a perfect world, we could notice the changes in our symptoms and fluctuations in eating habits, cravings and weight, and relate that to the menstrual cycle. However, more often we feel guilty about eating a chocolate bar or lack of willpower to stick to our usual eating patterns.

The same can happen with training. Fluctuations in energy levels and hormonal changes can strongly affect motivation levels, increase mental and physical fatigue, and impact physical performance.

Recent research has shown that performance can be reduced during the early follicular phase (when oestrogen and progesterone are low) compared to the other phases (1). When working with a client, it is important to consider the literature, and the unique experiences of the person in front of you.

Commonly, athletes use oral contraceptive pills to manipulate their menstrual cycle (i.e., control when to have their withdrawal bleeds), especially around important competitions, and to diminish symptoms that negatively impact their performance. This produces a different hormonal profile. A meta-analysis has shown that oral contraceptive users might experience a slight decline in performance compared to non-users with a natural menstrual cycle (2). However, variability in response to an oral contraceptive was high. This further supports the argument for a personalised approach.

Introducing Anna

Anna, a 22-year-old university student and club-level footballer, trained in the gym twice a week alongside her club twice a week. She usually played one match per week during the university sports season.

Her menstrual cycle was a major concern. Anna didn’t use an oral contraceptive. She experienced debilitating PMS symptoms, specifically bloating, painful cramping and a change in bowel function, with a spike in hunger levels and cravings a few days before her period. She also experienced large fluctuations in energy levels and noted that it affected her performance on the pitch. Her weight also fluctuated between 64kg and 67kg during the month.

After taking an in-depth health history, we agreed that a better understanding of her menstrual cycle, and how this affected her eating habits and training, would be the best thing to focus on. This would be done alongside (i) optimising her current diet, (ii) learning how to fuel properly for training and refuel to support recovery, and (iii) working together in the gym to increase her overall strength levels.

Initial intervention strategies considering the menstrual cycle

We started simply by tracking Anna’s menstrual cycle with an app on her smartphone. This allowed Anna to record her symptoms such as energy levels, sleep, digestive issues, emotional triggers and how heavy her monthly bleed was.

Anna’s existing diet was good, mainly plant-based, with a regular intake of eggs and cheese during the week. However, she didn’t know where to begin with regard to fuelling herself properly for training or how to use nutrition to optimise her recovery. We focused on two metrics: energy levels during training and muscle soreness, which she rated as 5/10 for both during this first session (1 being extremely poor and 10 being excellent).

I looked at Anna’s overall diet and implemented five changes:

1. On average, Anna was close to meeting her overall energy needs, but was very inconsistent on a day-to-day basis, including under-fuelling on training days. We developed a plan to bring more consistency to her eating and make sure she was getting more fuel on training days than non-training days.
2. An increase in her daily protein intake from ~1.2g/kg body weight/day to ~1.6g/kg body weight/day, with an even distribution throughout the day to support recovery, promote a positive protein balance, and support strength-related adaptations (3).
3. Increased omega-3 and iodine intake, which I identified as low in her three-day food diary analysis. Anna was happy to eat fish and seafood – she didn’t eat these foods regularly only because they hadn’t been a staple at home growing up, and her flatmates didn’t cook fish or seafood. We agreed on at least two portions of fish per week (both oily for more omega-3s and white for more iodine) from her local fishmonger, more chia seeds, flaxseeds and walnuts (for omega-3s), and to incorporate seaweed salt (iodine).
4. Although the dietary analysis hadn’t indicated that Anna’s iron intake as low, we optimised it by (i) focusing on specific plant-based foods (such as legumes, nuts, seeds and leafy greens), (ii) reducing her consumption of coffee with or right after her meal, and (iii) increasing her consumption of vitamin C-rich foods (such as citrus fruits, greens, okra and parsley) with iron-rich foods to support absorption (4).
5. Anna’s intake of B vitamins (including B12) was within healthy ranges. Again, we focused on optimising these by tweaking her diet and bringing in more nuts/seeds, leafy greens and grains. She regularly included eggs, cheese, nutritional yeast and fortified plant-based milks in her diet, so I wasn’t overly concerned with her vitamin B12 levels at this point. Adding fish to her diet would also contribute towards more iron and B vitamins, especially B12.
   
   

I recommended that Anna get her vitamin D levels checked before considering supplementation, as living in Scotland and going into winter increased her risk of deficiency.

Sport-specific nutritional strategies

After six weeks of implementing these recommendations, we turned our attention to more sport-specific nutritional strategies: pre-, during and post-exercise strategies.

Pre-exercise (roughly one hour before a training session, usually late afternoon): we focused on good-quality and digestible carbohydrates with a bit of protein to provide amino acids to her system. This helped regulate Anna’s hunger levels especially during her football sessions.

Figure 1 – Examples of pre-exercise snacks agreed with Anna. CHO = carbohydrate; PRO = protein.

During exercise: Anna would drink only water during her football training sessions (which could last up to two hours), so we also introduced a DIY sports drink made with diluted cranberry juice at a six per cent solution with a pinch of sea salt. Gym sessions lasted for 1hr, so water sufficed.

Post-exercise: sometimes Anna would have her main meal about an hour after training. So I wasn’t too concerned if she didn’t eat something after her training session, considering she had a snack before training and could finish any remaining DIY sports drink. But I recommended a few options for when she knew she would only eat her main meal two hours or more after her training session – even if it meant eating less for her main meal if she wasn’t that hungry. Anna could have these as soon as possible after training to provide roughly 20g of protein and carbohydrates to start the recovery process.

Figure 2 – Examples of post-exercise snacks agreed with Anna. CHO = carbohydrate; PRO = protein.

What we learned from tracking Anna’s menstrual cycle

The more time we spent together, the better I became at anticipating how she felt, and I adapted her training accordingly. Had I planned a more intense workout on a particular day, but she felt low in energy, I would modify the workout and kept notes of these modifications to support her profile.

Over five months, we built a personalised profile of Anna’s menstrual cycle. Her vitamin D levels were insufficient, so we agreed to incorporate a vitamin D3 supplement at 1000 IU per day for the rest of the winter and then re-test. Her metrics also improved from 5/10 to 7/10 (energy levels) and 8/10 (muscle soreness).

Anna’s nutrition and training were adjusted accordingly:

1. Anna craved more chocolate and sweetness about a week before her period (the luteal phase when both oestrogen and progesterone are high and then drop as menstruation starts). To support her during these days, we discussed healthier options than a standard chocolate bar, such as:

• Homemade DIY chocolate milk (also a good post-exercise snack) made with plant-based milk, unflavoured plant-based protein blend powder, cacao, and sweetened with good-quality honey. A banana could also be added to thicken the milk and provide more sweetness.
• A few Brazil nuts coated in dark chocolate.
• Homemade 3-ingredient chocolate energy bites made with blended dates, cocoa and walnuts.
• A chocolate mousse – a blend of avocado, banana and cacao.

2. As Anna had elevated hunger levels, we increased her protein to 1.8g/kg body weight/day during this week to increase satiety (5).
3. We realised that Anna was increasing her coffee intake during this week (up to four or five cups a day) to curb cravings and hunger, and give her an energy ‘boost’. We discussed how this reliance on caffeine could disrupt her sleep and exacerbate some of her digestive upsets and bowel-function changes since research shows that caffeine can increase colonic motility (6,7). She agreed to reduce her intake to one cup of coffee in the morning during this phase and to focus more on non-caffeinated teas like rooibos and water infused with lemon and mint or berries, to ensure proper hydration.
4. As Anna’s energy levels and mood were also low a few days before and during her period, we talked about viewing training more as ‘movement’ than ‘planned exercise’. Sometimes, she would understandably have to cancel one or both gym sessions this week because of her symptoms. We agreed that she could choose what she wanted to do in the gym instead: keep the weights light and focus on technique or do something more restorative like a Pilates session as I’m a qualified Pilates teacher. This week would essentially be a de-load week and by giving Anna a choice helped promote adherence and supported her, especially from a mental health perspective. As for her football training, we discussed that it would be best to have a chat with her team captain and coach to see how they could support her and other teammates who experience such debilitating symptoms.
5. After menstruation (early follicular phase characterised by low progesterone levels and slowly increasing oestrogen levels) until ovulation (peak in oestrogen), Anna’s energy levels and mood would improve. She performed well in this phase, and we focused on pushing the intensity of her training sessions. She was already eating enough carbohydrates around her training sessions and throughout the day. Still, we prioritised the DIY sports drink for all the sessions, even if they were only for an hour, to support the intensity.
6. During ovulation (peak in oestrogen), Anna noticed that she was more anxious and aroused than usual, so we agreed to incorporate slow and deep breathing exercises to help modulate these symptoms and promote parasympathetic activity (8).
7. After ovulation, when Anna entered the luteal phase (when progesterone rises), her mood and motivation usually dropped, but there was no noticeable difference in energy levels. We started to gradually decrease the intensity of her gym sessions during this phase, removed the DIY sports drinks from the gym sessions, and included more recovery and restorative strategies, such as a monthly massage or joining her friend at a local pool and sauna. These strategies could also help her prepare mentally for the end of the luteal phase and menstruation when she experiences all the negative symptoms.

Final remarks

I hope this case study highlights the value in profiling an athlete’s menstrual cycle and how individual the experiences are around menstrual symptoms. Working with Anna helped her to realise that she should not feel that she lacks discipline because of her negative symptoms. Instead, she now feels empowered and has the tools and knowledge to cultivate a positive relationship with her menstrual cycle. As for me, I found it incredibly insightful working with Anna as it was the first time I had worked in-depth with a client focusing on their menstrual cycle from both a nutrition and training perspective.