Journal of Obstetrics and Gynaecology, July 2013; 33: 484488
2013 Informa UK, Ltd.
ISSN 0144-3615 print/ISSN 1364-6893 online
DOI: 10.3109/01443615.2013.790885
GYNAECOLOGY
Menstrual cycle disorders in female volleyball players
M. Wodarska1, J. Witko1, A. Drosdzol-Cop2, J. Dbrowska1, M. Dbrowska-Galas1, M. Hartman1, R. Plinta3 &
V. Skrzypulec-Plinta2
1Department of Physiotherapy, 2Womans Health Institute, and 3Department of Physical Education and Sport, Medical University of Silesia,
Katowice, Poland
The aim of this study was to examine the relation between
increased physical activity and menstrual disorders in
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adolescent female volleyball players. The study was conducted
on 210 Polish female volleyball players, aged 1317 years, the
authorship questionnaire was used. The results of the study
showed that irregular menstruation occurred in 19% of girls,
spotting between menstrual periods in 27% and heavy
menstruation was reported in 33% of girls. Out of all volleyball
female players participating in the study, 94 girls (45%) declared
absence of menstrual periods after regular cycles. Statistical
analysis showed that the more training hours per week, the
bigger probability of the occurrence of irregular menstruation.
It was concluded that the number of hours of volleyball training
For personal use only.
per week affects regularity of menstrual cycles in female
volleyball players. The absence of menstruation might be caused
by the duration of training per week or years of training.
Keywords: Female volleyball players, menstrual disorders,
questionnaire
Introduction
Regular physical activity is a key component of a balanced, healthy
lifestyle. It helps to maintain optimal physical fitness and prevents
a number of lifestyle diseases, such as obesity or atherosclerosis,
contributing to good general health. However, physical exercise
will only bring positive results if its level corresponds with our
bodily needs, particularly in the case of professional athletes.
Young females who take up sport professionally often undertake
physical activity, which does not meet their bodily needs, which
may result in severe health problems (Kishali et al. 2006).
A girls body matures during puberty, physically and sexually.
Many biological, psychological and social changes appear and
girls attain reproductive maturity. The frequency of menstrual
cycle disorders in girls participating in vigorous physical activity
depends on: sports discipline, intensity and duration of physical
activity, low body mass, young age, improper diet and professional
sports-related emotional stress. High intensity training can cause
hormonal changes, which in turn can lead to menstrual cycle
disorders or even secondary amenorrhoea. Vigorous training can
lead to a problem called female athlete triad a combination
of three conditions: disordered eating, menstrual cycle disorders
and reduced bone mineral density (Loucks 2005; Nichols et al.
2006; Carlson et al. 2007).
Correspondence: A. Drosdzol-Cop, Womans Health Institute, the Medical University of Silesia, ul. Medykw 12; 40-752 Katowice, Poland. E-mail: cor111@
poczta.onet.pl
During puberty, increased production of gonadotropin-
releasing hormone (GnRH) by the hypothalamus initiates the
higher activation of the hypothalamicpituitarygonadal axis.
Consequently, the level of luteinising hormone (LH) and follicle-
stimulating hormone (FSH) produced by pituitary and steroid
hormones produced by gonads, increases (Bumbuliene 2003).
A problem called luteal phase defect can be caused by a too high
training intensity in sportswomen and the symptoms are low
level FSH between luteal and follicular stages; decreased level of
oestradiol and progesterone in both luteal and follicular stages,
with a high probability of abnormally short or even no luteal
phase and long follicular phase. Hormone profile abnormalities
observed in female athletes originate in hypothalamic amenor-
rhoea, which is associated with strenuous exercise. It results in
low levels of gonadotropin-releasing hormone (GnRH), gonado-
tropins and oestrogens. Due to excessive exercise, decreased
hypothalamic function may occur and the pulse frequency
and secretion of LH also decreases, even if it does not lead to
menstrual disorders (Zabielska and Ziemba 2009).
The aim of the study was to examine the relation between
increased physical activity and menstrual disorders in adolescent
female volleyball players.
Material and methods
Patient enrollment
The study was conducted on 239 female volleyball players, 210
of whom, aged 1317 years (15.15 1.29), were found suitable
for the final analysis. The inclusion criteria were: full completion
of a questionnaire with no errors, and non-application of oral
contraceptives (OCs). The exclusion criterion included: lack of
menarche, and use of oral contraceptives. Thus, 26 (10.9%) and
three (1.3%) girls, respectively, were eliminated from the study.
A questionnaire created specifically for this study contained
questions about the menarche; menstrual cycle regularity and
lack of menstruation after regular cycles; pain during menstrua-
tion and spotting between menstrual periods. Respondents also
answered questions about training duration during each session
and years of volleyball training. General characterisation of the
examined group of girls is presented in Table I.
Statistical analysis
Data from the questionnaires were transferred into Excel 2007.
The results obtained underwent a statistical analysis based on
 Menstrual cycle disorders in volleyball players 485
Table I. General characterisation of the examined girls.
Without absence of
Mean SD Minimum Maximum period
Absence <3 months
Age (years) 15.15 1.29 13.00 17.00 38%
55% 45%
BMI 20.74 2.33 15.12 31.11
Absence 36 months
Body fat tissue (% body mass) 22.99 4.73 10.00 39.00
Years of training 3.98 1.50 1.00 7.00 4%
3% Absence >6 months
Training hours per week 4.61 2.12 2.00 10.00
Menarche (years) 12.55 1.08 10.00 16.00
Average duration of menstrual 29.71 5.44 19.00 60.00 Figure 2. Percentage of girls reporting dierent length of time without
cycle (days) menstrual period.
Average duration of menstrual 5.08 1.38 2.00 11.00
bleeding (days)

No pain

the Statistica 9.0 programme. Multiple logistic regression and 58% Pain at the beginning
34% 66%
multiple analysis were used for the data analysis. The value of of period
statistical significance was p 0.05. Pain throughout the
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8% whole period

Results
Figure 3. Percentage of girls reporting pain at the beginning and during
The results of the study showed that irregular menstruation the whole menstrual bleeding.
occurred in 39 girls (19%); spotting between menstrual periods
in 56 girls (27%) and heavy menstruation was reported in 70 girls
Regression analysis showed that the occurrence of irregular
(33%) (Figure 1).
menstrual cycles decreased with age, while such factors as later
Out of all volleyball female players participating in the study,
occurrence of menarche; longer menstrual cycle; and more
94 girls (45%) declared absence of menstrual periods after regular
training hours per week influenced an increased probability of
cycles (Figure 2).
irregular menstruations (Table II, Figures 5 and 6). Heavy men-
Absence of menstruation periods for 3 months was reported
For personal use only.

strual bleeding was more likely to occur together with prolonged

in 79 girls (38%); the absence of periods from 3 to 6 months in
menstrual bleeding and years of training (Table II, Figures 5 and
nine female players (4%); and 6 months in six respondents
7). Absence of a menstrual period, spotting between menstrual
(3%). About 30% (n 63) of girls did not know about menstrua-
periods and painful menstruations did not depend on such fac-
tion disorders; different reasons for the absence of menstruation
tors as age, BMI, body fat tissue percentage, menarche, average
reported by girls included: stress in 7% (n 15); decreased body
duration of menstrual cycle and menstrual bleeding or training
mass in 4% (n 9); hormonal disorders in 2% (n 5); and other
hours per week and years of training (Table II).
in 1% (n 2).
Answers to the question concerning pain at the beginning or
during the whole menstruation cycle showed that 71 girls (34%) Discussion
declared no pain during their menstrual cycle; 123 players (58%)
Menstrual cycle is a complex physiological process, which may be
experienced pain at the beginning of the menstrual bleed; and 16
severely disturbed in females undertaking very intense physical
girls (8%) felt pain during the whole menstrual bleed (Figure 3).
activity at too early an age. Menstrual disorders in sportswomen
The intensity of pain varied (ranging in an analogue scale from 0
may be divided into primary and secondary. Primary amenor-
as no pain to 10 as a severe pain). A total of 26 girls (12%) assessed
rhoea (amenorrhoea primaria) is the absence of first natural men-
their pain as 3; another 23 players (11%) as 4; while 5 and 8 was
struation in a girl by the age of 16, while secondary amenorrhoea
pain intensity declared by 19 respondents (9%), in each group.
(amenorrhoea secundaria) occurs when menstruation has ceased
Different remaining answers are illustrated in Figure 4.
for a period exceeding 6 months in a woman of reproductive age
(Bumbuliene 2003).
35
35
30
30
Percentage of respondents
Percentage of girls

25
33 25
20
20
15 27 34
15
10 19
10
5
5 12 11
0 9 9
6 7
2 4 3 2
Irregular menstrual Spotting between Heavy menstrual 0
cycle periods bleeding 0 1 2 3 4 5 6 7 8 9 10
Pain intensity
Figure 1. Percentage of girls with irregular menstruations, spotting between
menstrual periods and heavy menstruation. Figure 4. Percentage of girls reporting dierent intensity of pain.
 486 M. Wodarska et al.

Table II. Odds ratios (OR), 95% condence intervals (95 CI), and the results of the Wald test based on the multivariate logistic regression analyses evaluating the relationship between menstrual disorders and dierent

p value

0.63
0.48
0.28
0.35
0.24
0.20
0.48
0.24
Research conducted for the purpose of this study showed

Painful menstruations
menstrual disorders in 19% of female volleyball players. Absence
of a period for 3 months after regular bleeding was observed in

5%; 95%CI
38% of the girls. Statistical analysis showed that the more training

0.63; 1.33
0.68; 1.20
0.94; 1.24
0.62; 1.18
0.97; 1.11
0.93; 1.45
0.80; 1.11
0.88; 1.68
hours per week, the bigger the probability of irregular menstrua-
tions. This shows that menstrual disorders are common in girls
participating in regular volleyball training and result from too
intense, too strenuous and too long physical exercise sessions.

0.91
0.90
1.08
0.86
1.04
1.16
0.94
1.21
OR However, the correlation between the absence of menstruation
and both training hours per week and years of training was not
5%; 95%CI p value

0.32
0.97
0.45
0.85
0.97

0.91
0.011

0.011
found in our study.
Heavy menstrual bleeding

The incidence of menstrual disorders in sportswomen varies

and may be as high as 44%. There are several disciplines, however,
in which girls are particularly exposed to for such disorders, e.g.
0.55; 1.21
0.75; 1.32
0.92; 1.22
0.71; 1.33
0.95; 1.06
1.07; 1.69
0.84; 1.17
1.10; 2.20
dancing menstrual disorders occur in 7579% of female danc-
ers (Bale et al. 1996). Cobb and colleagues (2003) indicate that
in other disciplines, this percentage is between 3.4% and 66%, as
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opposed to 25% in women who do not do sports profession-

0.82
0.99
1.06
0.97
1.00
1.35
0.99
1.56
OR

ally. Studies conducted by other authors (Warren and Chua 2008)

have shown that menstrual disorders occur in 69% of ballet danc-
5%; 95%CI p value

0.066
0.084
0.43
0.48
0.44
0.15
0.56

0.54

ers and 65% of professional runners. It was also observed that the
Spotting between periods

younger the female runners, the more frequently they suffered

from menstrual disorders. Furthermore, the research has shown
that secondary amenorrhoea was much more common in female
0.56; 1.28
0.66; 1.21
0.91; 1.23
0.91; 1.83
0.92; 1.05
0.62; 1.02
0.70; 1.02
0.78; 1.59

runners aged 15 or younger (67%, as opposed to 9% in older

runners) (Warren and Chua 2008). It was observed that 24% of
secondary-school-aged athletes had irregular periods and that
they were most common in young girls with low body weight.
0.85
0.90
1.06
1.29
0.98
0.79
0.84
1.12
OR
For personal use only.

Some people believe that young girls should not be allowed to

take up sports that pose increased risk of menstrual disorders
5%; 95%CI p value

0.84
0.42
0.98
0.72
0.26
0.19
0.34
0.34

(Kishali et al. 2006).

Many researchers show that menarche in girls who do strenu-
Absence of period

ous physical exercise at a young age is often delayed, since intense

physical activity undertaken by females who have not yet reached
0.73; 1.48
0.68; 1.18
0.88; 1.14
0.78; 1.42
0.98; 1.09
0.93; 1.41
0.79; 1.09
0.85; 1.58

sexual maturity, may alter the functions of the hypothalamic-

pituitary-gonadal axis (Bale et al. 1996; Bumbuliene 2003; Cobb
et al. 2003; Loucks 2005; Kishali et al. 2006; Nichols et al. 2006;
Carlson et al. 2007; Warren and Chua 2008; Zabielska and Ziemba
1.04
0.89
1.00
1.06
1.03

0.93
1.15

1.16
OR

2009). In such cases, absence of menstruation may result from

a disturbed communication between the hypothalamus and the
0.00001
5%; 95%CI p value

0.061

0.087
0.0068

pituitary gland. If the reproductive system functions correctly,

0.32
0.67

0.019
0.037
Irregular menstrual cycle

GnRH is released from the neurons within the hypothalamus and

LH from the pituitary gland in a pulsatile manner. Irregular and
infrequent secretion of LH in young girls may therefore disturb
1.05; 1.79
0.86; 1.27
0.52; 1.24

1.03; 2.80
1.42; 2.53

0.93; 2.92
0.22; 0.79

0.48; 1.02

the function of the ovaries, including formation of ovarian fol-

licles, ovulation and the function of the corpus luteum (Warren
and Chua 2008). Studies conducted by Klentrou and Plyley (2003)
on a group of gymnasts, have shown that the average age of first
1.37
1.04

1.90

1.64
0.80

1.70

0.70
0.42
OR

menstrual bleed was 13.8, as opposed to 12.5 in the control group,

and the difference was considered statistically significant. Men-
Average duration of menstrual bleeding (days)

strual cycle abnormalities were reported by as many as 78% of

Average duration of menstrual cycle (days)

the respondents, while none of the respondents from the control

group reported such problems. Oligomenorrhea was observed
in 61% of the gymnasts and secondary amenorrhoea in 17%.
Torstveit and Sundgot-Borgen (2005), having conducted research
on famous Norwegian sportswomen, reported that there was no
factors characterising girls.

significant difference between the age of the first menstrual cycle in

Training hours per week

such females and the women from the control group (13.4 vs 13).
Body fat tissue (%)

Primary amenorrhoea was observed in 7.3% of the respondents,

Menarche (years)

Years of training

compared with 2.0% in the control group. Noteworthy was the

Not signicant.

comparable percentage of girls with menstrual disorders in both

Age (years)

groups: 16.5% in sportswomen and 15.2% in the control group. It

was also observed that women who took up sports at a young age
BMI

had their first period later than their peers who did not undertake
 Menstrual cycle disorders in volleyball players 487

Irregular menstrual cycles Heavy menstrual

3.0 bleeding
2.8
2.5
2.3
2.0

Odds ratio
1.8
1.5
1.3 0.42
1.0
0.8 1.70 1.90 1.37 1.35 1.56
0.5
0.3
0.0
Age
(years)

Menarche
(years)

Average duration
of menstrual cycle
(days)

Average duration
of menstrual bleeding
(days)
Training hours
per week

Years of
training
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Figure 5. Odds ratios (OR), and 95% condence intervals (95%CI) of irregular and heavy menstruation in relation to dierent factors characterising
examined girls.

physical activity, and more frequently suffered from menstrual
disorders (Kishali et al. 2006). Claessens and colleagues (1992)
indicates that the average age of menarche in Belgian gymnasts
is 15.6 2.1, compared with 13.2 1.2 in other females. Loucks
research (2005) shows that primary amenorrhoea absence of
menarche by the age of 15 occurs in approximately 1% of all
For personal use only.
fractures, which may have a dramatic impact on many aspects of
training (Zabielska and Ziemba 2009).
Absence of menstruation concurrent with a low level of
gonadotrophins and oestrogen deficiency is most frequently
an acquired disorder, resulting from stress, chronic diseases,
strenuous physical activity or exhausting training and inad-

girls, while in 22% of gymnasts, the first menstrual bleed appeared
when they were over 16. Secondary amenorrhoea occurred in
25% of the female population, compared with 65% in female
runners.
To sum up, it should be noted that the actual incidence and
types of menstrual disorders are difficult to estimate, since a num-
ber of girls would not report any problems, sometimes treating
the absence of menstruation as a perfect opportunity for constant
intense training (De Souza 2003). Unfortunately, young girls are
often unaware of the fact that amenorrhoea leads to prolonged
oestrogen deficiency, which results in the decrease of the peak
bone mass.
A disturbance of hormonal mechanisms regulating bone mass
may lead to osteopenia, and eventually even to osteoporosis and
equate nutrition (including bad eating habits and anorexia
nervosa) (Bale et al. 1996; Bumbuliene 2003). Such inadequate
nutrition may often lead to hypometabolism, a state of dispro-
portion between energy level and its expenditure (Skrzypulec
et al. 2005).
Menstrual disorders in female athletes are also related to their
body weight there is a strong correlation between body fat levels
and menstrual cycle disturbances (Cobb et al. 2003). Correlation
between the intensity of physical exercise and between menstrual
disorders and eating disorders in female volleyball of our study
has been subjects of separate studies.
On the other hand, many researchers prove that about 68
93% of young healthy girls experience painful menstrual cycles
(Agarwal and Venkat 2009; Chan et al. 2009; Zegeye et al. 2009;

100% 100%
11
90% 16
90%
33 80 training 29
80% hours per week 80%
67 years of
70% 70% training
32
Percentage of girls

47
Percentage of girls

60% 60%
46 training
50% hours per week 50% 40 45 years of
38
training
40% 40%
30% 30%
23 training 52 13 years of
42 hours per week
20% 20% training
28 31
10% 10%

0% 0%
Regular menstrual Menstrual cycles Normal menstrual Heavy menstrual
cycles disorders bleeding bleeding

Figure 6. The relationship between menstrual regularity, menstrual cycle Figure 7. The relationship between menstrual bleeding and degree of
disorders and degree of physical activity (training hours per week). physical activity (years of training).
 488 M. Wodarska et al.
Parker et al. 2010). Our results confirm other studies and show
that this problem concerns 66% of young sportswomen.
Parker et al. (2010) in a cross-sectional study conducted
on a group of 1,051 Australian girls, aged between 15 and 19
years, reported that menstrual disorders included pain (93%);
cramping (71%); premenstrual symptoms (96%); and mood
disturbances (73%). However, the absence of menstruation was
not reported. Agarwal and Venkat (2009) showed that 83.2%
out of 5,561 girls in Singapore reported painful menstruation in
various degrees. Irregular menstrual cycles concerned 23.1% of
their respondents. The risk of the prevalence of oligomenorrhea
increased with higher BMI and affected 15.3% of girls, while
polymenorrhea more often appeared in participants with lower
BMI and concerned 2% of the girls. Chan et al. (2009) con-
ducted a study on a group of 5,609 girls aged 15.1 2.0 in Hong
Kong, and have shown that 76.4% of girls had a normal cycle
length; 8.6% had short ( 21 days); and 15% long menstrual
cycles ( 35 days). Participants also reported dizziness (30.2%);
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headache (27.5%); backache (24.2%); and fatigue (24.2%). The
prevalence of these symptoms and painful menstruation signifi-
cantly increased with the menstrual age. Zegeye et al. (2009) in
their study, concluded that about 30% of girls experienced abnor-
mal menstrual cycle length ( 21 or 35 days) in the first 2 years
after menarche and 42.8% had irregular menstrual cycles. The
authors also pointed out the need for further research to verify
whether such factors as vigorous exercise, cigarette smoking or
stress could influence menstrual irregularity (Zegeye et al. 2009).
There are several potential limitations of our study that could
influence the interpretation. The first limitation is the relatively
For personal use only.
small sample size, especially in a group of girls with the high-
est intensity of training. Therefore, it is difficult to generalise
the results from this sample to the whole population of girls
playing volleyball in Poland. The number of girls in this group
were the advanced level of girls compared with two other
groups. They were the best female volleyball players at this age,
selected from the whole Silesia region in Poland. Second, we
have not compared the prevalence of menstrual disorders in
adolescent volleyball players to a control female group. The
next limitation is the fact that this was a retrospective study
with subjective responses by the players about menstrual disor-
ders. Despite the limitations of the study concerning menstrual
disorders, the results lead us to believe that girls practicing
sport with high intensity are subjected to a serious problem
called female athlete triad. Thus, the results of this innovative
study should be highlighted. Further research is warranted
to examine these associations longitudinally, implementing
prospective methods, randomisation and comparison with a
control female group.
The number of hours of volleyball training per week affects
regularity of menstrual cycles in female volleyball players. The
occurrence of heavy menstrual bleeding was associated with the
number of years of training. The absence of menstruation might
have been caused by the duration of training per week or the years
of training.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the paper.
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