It is hard enough to talk about menstruation as it is. Add sports to this, and we have more questions than answers. Have you ever wondered why an ace sportswoman suddenly loses to a newcomer on a big match? Or how sportswomen manage during their period, when so many regular women suffer from menstrual cramps and pain? And how should sports authorities ensure a fair match, if menstruating women indeed have a disadvantage over their non-menstruating opponents?

Too many questions. Too few answers.

No wonder then, we all act as if sportswomen never bleed.

What the latest research indicate

A blog in the New York Times titled How Periods Might Affect Athletic Performance by Gretchen Reynolds (dated Aug 17, 2016) quotes Dr Lynn Rogers, the director of the Neuralplasticity Laboratory at the Rehabilitation Institute of Chicago, stating two contradictory findings:

First, she says that some women may have a higher risk of tissue injuries at certain points of the menstrual cycle; and that researchers found that women tend to be more likely to experience injury in the first half of the menstrual cycle, especially as they approach ovulation.

The same article quotes Dr Rogers again to say “The available research, such as there is suggests that progesterone can alter the body’s fuel metabolism and its ability to handle heat”, meaning that women will probably feel hotter and more fatigued during prolonged exercise in the second half of the menstrual cycle, when progesterone levels rise, than before menses, when progesterone is low”.

The concluding lines of the blog, quote Dr Rogers again saying “The available research at the moment related to athletes and menstruation is woefully inadequate”.

This pretty much sums up the extent to which the confusion and information exists in modern science.

Knowledge of Menstruation in Modern Science

The deepest level at which the Modern Science explains menstruation is through an understanding of hormones. Here is a simplified explanation of how the hormones estrogen, progesterone and testosterone influence the menstrual cycle (assuming that most readers may not be medically trained).

• The Menstrual Cycle is counted from the first day of a woman’s period to the first day of her very next period; typically it is around 28 days.
• Day 1 – 4: On Day 1 of the menstrual cycle, i.e. when a period starts, estrogen and progesterone levels are low. The low estrogen levels result in women feeling a little down/depressed and low on energy during her period.
• Days 5 – 14: Once the period ends, estrogen levels begin to rise. Estrogen is responsible for thickening the lining of uterus for pregnancy; it influences how the body uses calcium and maintains healthy cholesterol levels in the body. This rise in estrogen results in women feeling a lot more energetic and strong, physically as well as emotionally just after menses. The rise of estrogen continues until Ovulation, which happens around the 14th day of the menstrual cycle. At Ovulation, there is also a rise in Testosterone. Testosterone in females increases the sex drive, metabolic and muscular function.
• Days 15 – 28: After ovulation, progesterone levels begin to rise. Progesterone causes thickening of the endometrium in preparation for pregnancy. If pregnancy occurs, progesterone levels remain high. The high levels of progesterone just before menses are considered responsible for Pre-Menstrual Syndrome (PMS), such as breast tenderness, bloating, mood swings, etc. If pregnancy does not occur, estrogen and progesterone levels drop and, around Day 28, the menses begin. The drop in progesterone causes the endometrium to shed its thickened lining, which becomes the period we experience.

Modern Medicine has not yet been able to pinpoint what causes the hormones to be released at certain points, what causes hormonal imbalance and how sports or excessive exercising might impact the normal course of hormones. The causes for menstrual disorders such as Dysmennorhea (period pain), Mennorhagia (heavy bleeding), Amenorrhea (missed periods) and PCOD are still being researched. So, that leaves us with hardly an option, but to turn to other forms of science, which can offer explanations and a deeper understanding. Perhaps, it can even aid research.

Ayurveda as a language to understand the body

While Ayurvedic doctors themselves maintain that Modern Medicine has made great advances, when it comes to handling emergency situations, where it greatly lags is in explaining causes and effects.

Just as menstruation has been reduced to use of sanitary products, in recent times Ayurveda too has been reduced to herbal medicines and belief systems. Whether one chooses Ayurveda as a line of treatment or not is a personal choice, and outside the purpose of this write-up. This write-up looks to draw from Ayurveda’s holistic knowledge of the human body to explain how sports and excessive physical exercise can impact the menstrual cycle and a woman’s health. In other words, we look at how Ayurveda can be used as a language to explain, express and understand how menstruation affects sportswomen, and why performance in sports might be altered if a sportswoman is menstruating. This is especially needed, when Modern Medicine is falling short of explaining seemingly contradictory things, as earlier quoted by Dr Rogers.

To arrive at the content of this write-up, women from diverse sports backgrounds, such as athletics, long jump, power lifting, gymnastics, sports bike racing, kabbadi and traditional martial arts, such as Capoeira, Kalaripayattu and Silambam, have been interviewed. To understand the Ayurvedic perspective, Dr Ramya Bhat, an Ayurvedic Physician based in Bengaluru, has been consulted.

Do Menstrual experiences vary?

An article in Telegraph quotes former British number one tennis player Annabel Croft saying:

“Every woman is different, but any woman, who has bad or heavy periods will know you feel overwhelmingly tired…. I’d get really achey legs and quite headachey. Your mood changes as well. You get more emotional and tearful. I would have had all of those symptoms, when I was playing.”

Another article in BBC mentions the opposite example of Paula Radcliffe, who set the marathon world record in 2002, while she was menstruating!

Back home in India too, we find that experiences of menstruation among sportswomen greatly vary. This is what former top athletes Ashwini Nachappa and Reeth Abraham had to say in an email interview:

Ashwini Nachappa, an Arjuna Awardee, who represented India in three South Asian Federation Games and two World Championships, said in an email interview to me:

“I was lucky, when compared to some of my fellow athletes, who suffered from dizziness, nausea, low energy levels and spells of feeling light-headed and the physical pain they went through.”

Whereas, Reeth Abraham, a former athlete and South Asian Games Champion in Long Jump, had quite an opposite experience during her period. When I interviewed her via email, she wrote:

“Couple of times during the Asian championships, I was expecting to win a Gold, but due to my periods, I could not Jump as well as I had expected and could only win Bronze ….. My body gets heavy, exhausted sooner than normal days. During training, it wasn’t much of an issue, but during competition, it is totally demotivating.”

Often coaches and sportswomen themselves tend to think that it is just a matter of mind over body. Sure, mind does play an important role. But to say that it is all about the mind and nothing else, makes it difficult for those whose physical problems during menstruation are very real. The silence on this subject is proof enough that they would rather suffer than be looked at as making excuses for underperformance. So, how do we explain why different women, sometimes involved in the same activity, experience menstruation and its impact on their performance, differently?

Body type and menstrual experience

According to Ayurveda, each individual has a specific body constitution or Prakriti, based on which our health, personality and menstrual experiences vary. This is called the Tri-Dosha system, wherein the three doshas of Vata, Pitta and Kapha in different combinations occur in individuals. Being disease free means having an equilibrium of Vata, Pitta and Kapha. Disease and imbalance can cause doshas to increase or decrease temporarily. Therefore, treatment in Ayurveda is centred around bringing the doshas back in balance, rather than suppressing symptoms.

A brief explanation of each dosha and its function is presented below.

(Note: The explanations are largely restricted to the purpose of this study and further information can be found by referring to the books mentioned in the reference section at the end of the article.)

Vata – Vata Dosha comprises the elements of air and ether. It is the primary mover of all things within the body. It is responsible for blood circulation, movement of wastes out of the body, movement of menstrual blood and even the downward movement of a child during birthing. It is considered as the life breath of living beings.

With respect to sportswomen, Vata performs several important functions – it manages the movement of hormones; it maintains the equilibrium of tissues and strength of joints; and, it is responsible for coordination of the senses. While Vata plays an important role throughout the menstrual cycle, it naturally increases during the process of the menstrual/blood flow.

Those with an aggravated Vata dosha will be restless, moody, have dry skin, cannot tolerate cold, are more prone to have gastric problems and constipation.

Pitta – Pitta Dosha comprises the elements of fire and air. It is responsible for digestion, all the transformative processes and metabolism within the body. During the menstrual cycle, Pitta increases during ovulation and the week after that when women experience more heat (or Pittam). It is the Pitta, which causes skin eruptions just before the period.

Those with an aggravated Pitta dosha will be more prone to skin diseases, have excessive body heat, short-temper, aggressive personality, intolerance to hot environments and improper digestion causing frequent loose bowel movements.

Kapha – Kapha Dosha comprises the elements of earth and water. It is responsible for maintaining structure and stability. Kapha dosha increases in the first week of the menstrual cycle, soon after menstruation, when women feel the most energetic and healthy.

Those with an aggravated Kapha dosha, will feel lethargic, heavy, dull, depressed, need for excessive sleep, are more prone to problems of the upper respiratory tract (cold, congestion, cough, etc.), have difficulty breathing and obesity.

Of the three doshas, Vata is the most important as any disturbance in Vata can affect the other two doshas as well. It is said that all gynaecological disorders have their root in Vata imbalance, and that needs to be treated first before fixing the other doshas.

Causes of Menstrual difficulties among sportswomen

As per Ayurveda, Vata dosha is responsible for sending signals to initiate movement of hormones that cause ovulation and menstruation. However, if Vata is aggravated and not functioning normally, this sending and receiving of signals to trigger hormones could be affected, resulting in various menstrual disorders. Let’s take a look at the different menstrual disorders and how it might be caused among sportswomen.

Dysmenorrhea (Menstrual Cramps/Pain/Discomfort)

Vata Dosha has five sub-types which govern movements in different parts of the body. The sub-type, which is responsible for downward movement of urination, excretion, menstrual blood and child birth is called Apana Vata. It is located in the lower part of the body near the genitals. During menstruation, Apana Vata moves downwards to facilitate the flowing out of menstrual blood. Dysmenorrhea can result from any of the below causes:

• Improper diet just before or during menses – Among most women suffering from menstrual pain and cramps, Dysmenorrhea occurs due to consumption of unwholesome food just before or during menses and incomplete digestion, which causes gastric problems. When Apana is acting downward during menstruation, it pushes out the toxins and excessive gas accumulated in the body. If the toxins are more due to unhealthy food habits, we experience greater pain and cramps. In this sense, menstruation is viewed as a detoxification process in Ayurveda since it forcibly ejects accumulated toxins.

• Excessive physical exercise – Among sportswomen, the Vata aggravation happens mainly due to excessive physical exercise just before or during menstruation. Since Vata is associated with movement, excessive movement disturbs the natural balance of Vata. Menstruation is a process where Vata naturally increases; therefore, putting the body through excessive physical exercise during menstruation aggravates the Vata, causing menstrual discomfort.

• Stopping or upward movement of Apana – During menstruation, if women undertake activities which change the direction of Apana or temporarily stop its downward flow, then they are quite likely to experience menstrual cramps due to the Apana being pulled in opposite directions. For example, swimming or being under water for long will temporarily stop menstrual flow (we can observe this temporary stopping of menses even when we take a long shower); inverted postures during Yoga or Gymnastics could reverse Apana; activities such as long jump which temporarily lifts the body against gravity, might also cause Apana to act against gravity, causing menstrual pain.

Amenorrhea (missed period for 6 months or more)

During week 1 & 2 of the menstrual cycle, the hormone estrogen increases, i.e. the week after a period and leading to ovulation. During this time, an aggravated Vata can affect the menstrual cycle in the following ways:

• If Vata is already disrupted at the beginning of the first week, then estrogen levels do not rise as expected, resulting in anovulation (no ovulation).
• If Vata is disturbed during the second week, it prevents signals from being sent to reduce estrogen. Therefore, estrogen levels keep rising and there will be no menstruation. This stopping of periods is called Amenorrhea.

It is mainly a deficiency disease due to Vata. Lack of body fat and too much exercise can bring it about, which is why athletic women often fail to get their period.

Menorrhagia (Heavy Menstrual Bleeding) and Anemia

In 2015, universities in UK undertook a research “The Prevalence and Impact of Heavy Menstrual Bleeding (Menorrhagia) among Elite and Non-Elite Athletes”. They studied 789 participants via an online survey and 1073 via face-to-face interviews at the 2015 London Marathon.  The results revealed that 54% of those surveyed online reported Heavy Menstrual Bleeding and 37% of Elite athletes also reported Heavy Menstrual Bleeding. Overall, 32% of exercising females reported a history of Anemia. Only a minority (22%) had sought medical advice.

According to Ayurveda, Mennorhagia and Anemia are conditions that occur due to vitiated Pitta dosha. Pitta can get vitiated due to over-eating of hot, spicy, sour or salty food, resulting in improper digestion. Any vitiation in Vata can also cause Pitta to increase. Thus, excessive exercising, especially on the days just before and during menstruation, could result in Heavy Menstrual Bleeding. It is more common among women with a dominant Pitta dosha.

Heavy Menstrual Bleeding could also result in Anemia, i.e. a haemoglobin count of less than 12mg/dL. Anemia can cause weakness, exhaustion and lack of concentration.

Polycystic Ovarian Disorder (PCOD)

In an article titled “Role of Testosterone for the Female Athlete”, coach and author Amber Larsen looks at research done to study the effect of exercise on female testosterone. She writes:

“A main effect occurred for exercise with the post-testosterone concentration being greater than pre-exercise, although pre-exercise versus thirty minutes after was not different. All testosterone hormonal concentrations immediately post-exercise greatly exceeded the baseline levels………. So basically, when you work out, your body is either making more testosterone or destroying less of it. Either way, you end up with a higher total level right after you exercise.”

According to Dr. Ramya Bhat, an increase in Testosterone could happen, when women are involved in male-dominated sports, such as wrestling or weight lifting. In such cases, the increased Testosterone could result in Polycystic Ovarian Disorder (PCOD), which is characterized by excessive facial hair and infertility.

Injuries while menstruating

A BBC article by Aimee Lewis (dated 22-Jan-2015) titled “Curse or Myth – do periods affect performance?” quotes several sportswomen sharing their experience of how menstruation has affected their performance. The article writes:

In 2009, Anne Keothavong became the first British woman in 16 years to be ranked inside the world’s top 50 but hers was a career troubled by knee injuries sustained when she was menstruating.

“It does affect you, there’s no doubt about it. I had ACL injuries on both knees and both times when I fell over it was that time of the month,” says the 31-year-old.

Traditionally, in most cultures, menstruating women were told not to engage in excessive physical exercise. Somehow being modern has meant that we dismiss everything that was ancient without investigating the reasons enough. So, it has been the trend that in the race to be equal to men, women have been trained to act like their bodies are no different from that of men. And naturally, there have been consequences.

All women are more easily susceptible to injuries, if they engage in excessive physical exercise just prior to or during menstruation. This is because exercise aggravates the already high Vata in a menstruating woman. In healthy women, Vata maintains the equilibrium of tissues and strength of joints. So, when it is aggravated like in the case of menstruation, the chances of injuries become higher. Dr Ramya Bhat says that girls, who are introduced early into sports, such as at the age of 6 or 7 and are not guided on measures to prevent Vata aggravation, become highly susceptible to weak joints and injuries by the time they are 18 or 20 years old.

Disorientation during menstruation

Vata also controls our sensory perceptions and coordination of our sense organs. During menstruation, even simple activities like driving a car would seem a little daunting as our ability to assess distances become clouded, thanks to the increased Vata. So, expecting a sportswoman to perform during menses is like expecting us to do the same, when we experience a jet lag.

When I interviewed Aishwarya Mannivannan, a National & International Silambam* Champion, and asked if she faced any difficulty in hand-eye coordination during menstruation, this is what she had to say in response:

“I have not faced any specific issues so far. During menstruation, I feel that the fatigue and body pain sometimes leads to lack of concentration. In Silambam, even a momentary lapse in focus can lead to injury and one hitting themselves. So, during my period, I have faced situations occasionally, where I have lost concentration due to tiredness and failed to keep up my regular rhythm in movement.”

(*Note: Silambam is a weapon-based traditional martial art from Tamil Nadu.)

Like Aishwarya, other sportswomen, who were interviewed too did not make much of poor concentration or lack of coordination during menstruation, although they might have experienced it. Their sheer mental effort and determination to overcome this temporary disorientation is indeed laudable.

Most women do not distinguish between overall fatigue during menstruation, and specific problems like sensory disorientation. Further, in the absence of any evidence, which supports it in modern science, it is not surprising that disorientation during menstruation is largely unnoticed. But, think of how much it could impact a sport, where hand-eye coordination or assessing distances can make all the difference in winning and losing.

Long term impact

Frequent use of period-postponing pills and excessive exercise during menstruation can have long term health impacts, even if it doesn’t show in obvious ways immediately.

A continuous aggravation of Vata can result in early Osteoporosis, as the bone density lowers with continuous Vata aggravation. A woman whose Vata has been aggravated and has become pregnant, might face difficulties during childbirth and labour. Since Apana Vata’s downward movement is the force that pushes the child out, any disturbance in it or change in its direction can make labour very difficult.

Summarising body types and menstrual impact

The seemingly contradictory observations made by Dr Rogers and team can actually be explained through Ayurveda and its understanding of different body types, as summarized below:

Vata type sportswomen – Women whose body type is dominated by Vata, tend to have more menstrual problems and injuries, especially if they engage in physical activity during or just prior to their period. Vata women are thus more likely to have Amenorrhea, Dysmenorrhoea and injuries. By sheer will of their mind, they might even overcome the cramps, pain and disorientation. But, the long term effect of the continuous aggravated Vata could be difficulty during childbirth and early osteoporosis.

Pitta type sportswomen – Any aggravation in Vata can also result in a disturbance in Pitta. Pitta type women tend to feel too much body heat just before their period and excessive physical exercise can worsen it. Usually, heavy menstrual bleeding is characteristic of a Pitta type. So is Anemia. When it comes to sports, Pitta women are highly competitive, focused and determined.

Kapha type sportswomen – Kapha type women actually benefit from sports as it increases the Vata and balances out the heavy feeling of Kapha. Such women might even feel that they perform better when they have their period! Kapha types have greater endurance and can experiment pushing their limits. Kapha types make great marathoners, sprinters and wrestlers. I found that most of the sportswomen I interviewed have a dominant Kapha dosha. Perhaps it is the reason why they stick to it and do well in sports.

Most women, are a combination of two Doshas with one dominant Dosha. So a combination of Kapha-Pitta might be very well suited for sports and intensive physical exercises, as it combines Kapha’s endurance and strength with Pitta’s focus and competitiveness.

Your individual body constitution should ideally be determined via a Nadi Pariksha (pulse reading) done on an empty stomach by an Ayurvedic Physician. However, just to get an idea you can try taking this online self-test to know your dominant Dosha Type – http://www.mapi.com/doshas/dosha-test/index.html#gsc.tab=0

As Paula Radcliffe said “Sport has not learned how to deal with elite athletes’ periods”

When women go out there and play for their nation, they do put their health at risk. The solution does not obviously lie in asking a woman not to participate in sports, but rather in acknowledging that menstruation does have an impact, and taking measures to prevent health risks for sportswomen based on their dosha imbalances. Perhaps, Ayurveda’s knowledge of menstruation can play an important role in helping sportswomen perform better.

In the next part of this series, we will cover the measures that can be taken to prevent injuries and menstrual disorders due to aggravated doshas.

References:

1. Charaka Samhita Vol 1 & 2. Charaka Chikitsa Sthana 30th Chapter – Yoni Vyapat
2. Sushrutha Samhita Vol 1 & 2
3. Frawley David, Ayurvedic Healing, a comprehensive guide
4. Bruinvels G, Burden R, Brown N, Richards T, Pedlar C (2016) The Prevalence and Impact of Heavy Menstrual Bleeding (Menorrhagia) in Elite and Non-Elite Athletes.
5. BBC, Paula Radcliffe: Sports has not learned about periods http://www.bbc.com/sport/athletics/30927245
6. Telegraph. Radhika Sanghani, Periods in sport: Half of athletes don’t perform as well when menstruating. http://www.telegraph.co.uk/women/womens-life/11794088/Periods-in-sport-Half-of-athletes-dont-perform-as-well-when-menstruating.html
7. New York Times Blog, Gretchen Reynolds. How periods might affect women’s athletic performance. http://well.blogs.nytimes.com/2016/08/17/how-periods-might-affect-womens-athletic-performance/?_r=0
8. California College of Ayurveda. Asthi Dhatu: A Closer Look at the Bones from the Ayurvedic Perspective – http://www.ayurvedacollege.com/articles/drhalpern/Ashti%20Dhatu
9. Amber Larsen. Role of Testosterone for the female athlete – https://breakingmuscle.com/womens-fitness/the-role-of-testosterone-for-the-female-athlete
10. Simon Peach. Independent. World Championships 2013: Jessica Judd admits 800m performance was ‘a disaster’ after exit in Moscow – http://www.independent.co.uk/sport/general/athletics/world-championships-2013-jessica-judd-admits-800m-performance-was-a-disaster-after-exit-in-moscow-8762949.html
11. Scroll.in. Aarefa Johari. As UK tennis player breaks silence on menstruation, Indian sportswomen speak out on taboo subject – http://scroll.in/article/703877/as-uk-tennis-player-breaks-silence-on-menstruation-indian-sportswomen-speak-out-on-taboo-subject

Sinu Joseph

Sinu Joseph is the Managing Trustee of Mythri Speaks Trust and works on issues pertaining to women and children