“Impact without infrastructure”: Why elite sport is still failing female physiology

As a new global study exposes systemic gaps in how elite sport manages menstrual health, those behind it explain how current systems are failing women and why it’s time for a fundamental redesign of high-performance care. 

While menstrual health is almost universally recognised as a critical factor in women’s performance, few professional sports organisations have the systems or structures in place to address it, according to new research. 

Drawing on data from international practitioners and athletes across various sports, including football, rugby, basketball, and hockey, in Europe and North America, the research quantifies what many in women’s sport have long suspected. 

While the menstrual cycle is perceived to influence performance, recovery, and availability, a systematic approach to understanding, measuring, and managing it still lags far behind. 

A global blind spot 

The study, conducted by sports science and performance intelligence company, Kitman Labs.

found that 88 per cent of support staff working in professional settings are aware of the potential effects of the menstrual cycle on performance, but 86 per cent of elite female athletes report receiving no menstrual-specific support.

Researchers describe the pattern as “impact without infrastructure,” a situation in which awareness of menstrual health’s importance far outpaces the systems, technology, and education required to support it. 

“This study puts numbers behind what practitioners have been telling us for years,” said Anne Makinen, lead author and performance strategist at Kitman Labs. 

“Even though many seem to understand that menstrual health has an impact on athlete performance and injury risk, most organisations still can’t see it, measure it, or manage it.

The result is a blind spot in athlete care and competitive performance.”

Among professionals who responded to the study, only 49 per cent reported that their organisations systematically track menstrual cycle data, and fewer than one in five organisations have any formal policy or workflow addressing menstrual health.

The majority (71 per cent) of support staff view menstrual cycle-related communication as very important, yet less than half of the athletes report conversations taking place. 

And only 26 per cent of practitioners work with systems that they deemed suitable for assessing the effect of the menstrual cycle on health and performance.

Built for men

Cultural discomfort, stigma, or lack of confidence were all cited as barriers to action.

However, the study also highlights the imbalance in what it calls the ‘gendered sporting context’ – a legacy of male-defined systems, research, and coaching models that were never redesigned for female physiology.

Women differ significantly from men in anatomy, body composition, cardiovascular and respiratory responses, thermoregulation and beyond, all of which influence tolerance to internal and external load, explains Makinen.

Yet elite sport continues to be underpinned by male physiological models.

“This manifests in training load prescriptions, testing protocols, and injury management practices,” Makinen tells Femtech World.

“Most existing frameworks have been developed from research conducted on men and are routinely applied to female athletes without accounting for sex-specific physiological differences.”

Hormonal fluctuations across the menstrual cycle also modulate exercise responses and adaptations, yet these factors are largely absent from male-derived models.

Makinen says this can lead to inaccurate estimations of recovery time and adaptation windows, increasing the risk of non-functional overreaching or stagnation, and neglecting phases where symptoms or heightened injury susceptibility may temporarily affect optimal loading.

Testing protocols widely regarded as gold standards, such as VO₂ max assessments, repeated sprint tests, and strength evaluations, have also been validated primarily in male populations and adopted for women without sex-specific normative ranges or consideration of menstrual cycle phase. 

“This introduces biological variability that can obscure true performance changes or misrepresent an athlete’s capacity,” Makinen says. 

“Even pre-participation health screenings often fail to incorporate female-specific considerations, prompting calls for revised protocols that address this gap.”

Injury management further illustrates this, she says.

Female athletes exhibit distinct injury epidemiology influenced by anatomical, biomechanical, and hormonal factors, including pelvic structure, ligament laxity, and neuromuscular control. 

But rehabilitation guidelines and return-to-play criteria frequently overlook hormonal milieu, bone health, and symptom burden, increasing the risk of premature return or prolonged recovery.

Conditions such as low energy availability, menstrual dysfunction, and compromised bone health remain insufficiently addressed within current frameworks, and practitioners are often forced to make critical decisions without vital physiological data.

“Ultimately, reliance on male physiological models represents a missed opportunity to optimise female athlete performance and safety,” Makinen says.

“Reviews of female athlete physiology advocate for sex-specific resistance and neuromuscular training, tailored loading strategies, and hormonal management approaches.

“Without these adjustments, elite sport perpetuates practices that are not only suboptimal but potentially harmful for female athletes.”

The data gap

Increasing numbers of female athletes are turning to apps for menstrual cycle tracking, but elite practice also requires the ability to link menstrual cycle data to training loads, testing, wellness, and return-to-play decisions. 

Many respondents described an urgent need for standardised data systems, practical education resources, and technological integration that embed menstrual variables into everyday workflows. 

“Few systems offer interoperable, athlete-centric dashboards combining medical, biometric, and performance data, which reduces actionable use by support staff,” says Makinen. 

“There is no technical barrier to collecting this data”, Makinen says.

“The only thing missing is a clear decision from governing bodies and federations to prioritize it and mandate the capture of the requisite information.”

The FASE framework 

The findings call for a fundamental redesign of high-performance systems through a female physiological lens. 

“To enable a cultural shift, organisations need a systematic approach to female athlete support, otherwise their impact is limited,” Makinen continues. 

“The study also points to a cultural transition moment in women’s sport: to dismantle the gendered sporting context with a lingering stigma around the menstrual cycle, a collective effort is called for to create supportive environments and systems to operate in it.”

The study identified seven support considerations for a Female Athlete Supportive Environment (FASE), namely education, communication, training & performance, medical, wellness, resources, and research.

This underlines the need for an individual approach to athletes’ training and performance, including safe and secure tracking and monitoring of the menstrual cycle, proper screening tools for cycle function and dysfunction, and integrated wellness tracking, such as recovery, sleep, and nutrition, to be tailored to each phase of the cycle. 

The model also calls for educational interventions that address the physiology of the menstrual cycle and its impact on the athlete, for regular, staff-initiated conversations to help women feel more comfortable discussing their cycle with their team, and for access to menstrual products, specialist medical practitioners, and appropriate gear.

Beyond this, Makinen also highlights the need for more longitudinal data monitoring and collection, and future research to understand the impact of hormonal phases and fluctuations on health and performance.

“The FASE framework gives clubs a structure to begin, from basic education modules to staff conversations and screening protocols.

“This doesn’t require advanced tech, just commitment,” Makinen explains.

“Awareness and education are powerful first steps, and staff-initiated, normalised conversations mark the beginning of a genuine, taboo-breaking culture shift.”

High stakes for women’s sport 

In many senses, the menstrual health blind spot in elite sport mirrors the broader state of women’s healthcare, with innovation outpacing implementation, and evidence struggling to penetrate systems designed without female physiology in mind.

As investment and professionalism in women’s sport accelerates globally, the researchers warn that if menstrual health remains unmanaged, teams and governing bodies risk falling behind, competitively, ethically, and medically.  

“This isn’t about placing blame,” said Stephen Smith, founder & CEO of Kitman Labs. 

“It’s about performance risk and organizational evolution. Women’s sport has been forced to rely on male-dominated physiological models and research.

If women’s sport is going to advance, its frameworks must be rebuilt through a female lens — grounded in evidence, not assumption.”

As the study notes, overcoming the inertia of the gendered sporting context – and rebuilding sport systems around female data and physiology – will define the next frontier of competitive advantage in women’s sport.

“The stakes are clear,” added Smith. 

“You can’t claim to optimize performance if you’re ignoring the data that defines half your athletes.

“This is about redefining what world-class looks like and we’re committed to collaborating with our partners to help establish that.”