Adolescent Female Athletes With Menstrual Dysfunction Report Worse Sleep and Stress Than Those Without Menstrual Dysfunction

Key Points

• Adolescent female athletes participating in flag football reported significantly worse sleep and significantly more stress in-season than those without menstrual dysfunction.

• Weekly ratings of energy and mood were not significantly different between adolescents with and without menstrual dysfunction participating in flag football.

• These findings contribute to the importance of monitoring and addressing menstrual dysfunction and its association with quality-of-life factors in female adolescent athletes.

There are numerous health benefits to sport participation for female adolescents.^1–3 Participating in sports helps promote female adolescents’ confidence, self-esteem, resilience, and academic performance and improves emotional health by fostering social interactions.^1–4 However, up to 70% of female adolescents may drop out of sports by the age of 13.⁵ One of the reasons for premature dropout in sports participation is female athletes have a greater tendency to be more self-conscious of their bodies, be more self-critical, and compare themselves with others more than their male athlete peers.^4,6,7 These concerns become more apparent with the many physical and psychological changes that occur with puberty during adolescence.^4,6,7 Therefore, it is imperative to understand ways in which individuals can encourage female adolescents to participate in sports. One growing avenue for female sports participation is flag football. Flag football is a noncontact version of American football that can include both boys and girls, representing an emerging and understudied sport.

Although sports participation is associated with a myriad of health benefits, it may also lead to detrimental effects such as sport-related injuries or relative energy deficiency in sport.^1–3,8,9 Relative energy deficiency in sport was introduced in 2014, with the intention to expand the previous diagnosis of the female athlete triad.⁸ Relative energy deficiency in sport refers to a condition in which energy imbalance leads to impaired physiological function of multiple organ systems.^8,9 One of the components of relative energy deficiency is menstrual function, and when there is a disruption to this component, it is referred to as menstrual dysfunction.⁸ Menstrual dysfunction is often defined as menarche ≥15 years of age, 3 consecutive months without a menstrual period in the past year, and/or ≤9 menstrual periods in the last 12 months in those who are not taking hormonal contraceptives.^9,10 As such, female athletes who participate in lean sports (such as gymnastics, wrestling, and running; 35.6%, P = .01) and who are younger (ages 15–24; 35%, P = .033) are at highest risk for menstrual dysfunction.^11,12 Furthermore, menstrual dysfunction is also associated with more missed participation days in sport (odds ratio = 1.79; 95% CI = 1.05–3.07).¹² As flag football typically represents a younger age group of female adolescent athletes, it is important to better understand the prevalence of menstrual dysfunction in flag football, which is currently unknown.

Previous work has suggested associations between poor quality of life, poor psychological health (eg, stress and mood), poor perceived sleep quality, and menstrual dysfunction among adolescent females and adolescent female athletes.^13–15 Elite female athletes with menstrual dysfunction had worse quality-of-life ratings, such as mood and energy, and higher levels of stress.¹⁶ Additionally, out of 235 female adolescents with menstrual dysfunction and 60 adolescents with a regular menstrual cycle, the group with menstrual dysfunction had significantly lower quality-of-life scores in the domains of general health and social functioning than the controls.¹⁷ Menstrual dysfunction was also associated with shorter perceived sleep duration and poor perceived sleep quality in adolescent females.^18–20 Thus, menstrual health, mental health, and sleep health may interact among adolescent female athletes. It is reasonable to anticipate that menstrual dysfunction among adolescent athletes may be associated with poor perceived sleep quality or reduced quality of life during a season of athletic participation.

The purpose of this study was to examine if female adolescent athletes participating in flag football with menstrual dysfunction report different levels of energy, mood, sleep, and stress during the season than those without menstrual dysfunction. We hypothesized that adolescent athletes participating in flag football with menstrual dysfunction would report worse levels of energy, mood, perceived sleep quality, and stress during the season than those without menstrual dysfunction.

METHODS

RESULTS

We enrolled 83 participants into the study and excluded 14 participants who reported active hormonal contraceptive use and 9 who completed none of the surveys (Table 1). Therefore, we monitored 60 adolescent female flag football athletes over the course of a season, 15 (25%) of which reported menstrual dysfunction at the start of the season. Those who did and did not report menstrual dysfunction demonstrated similar baseline characteristics and in-season survey adherence, including age (mean = 16.3 ± 1.1 years of age), number of weekly surveys completed (7.0 ± 1.6), BMI (21.7 ± 2.7 kg/m²), and hours/week of time playing flag football during the season (8.0 ± 4.9 hours/week). Following univariable examination, the groups were not significantly different in weekly ratings of energy (Figure A, no effect) or mood (Figure B, small effect). However, the menstrual dysfunction group reported significantly worse weekly perceived sleep quality (Figure C, moderate effect) and significantly more stress (Figure D, large effect) during the season than the no menstrual dysfunction group. After adjusting for school year, BMI, and injuries sustained during the season, menstrual dysfunction was significantly associated with worse perceived sleep quality and worse stress (Table 2).

Table 1.Participant Characteristic Comparisons Between Female Flag Football Participants Who Did and Did Not Report Menstrual Dysfunction

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Table 2.Multivariable Linear Regression Model Results Evaluating the Association Between Reported Average Weekly Mental Health Ratings (Outcome in Each Model) and Menstrual Dysfunction (Predictor Variable), Adjusting for the Independent Effect of School Year, BMI, and Whether They Reported an Injury During the Season (Covariates)

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DISCUSSION

We examined if female adolescent athletes participating in flag football with menstrual dysfunction report different levels of energy, mood, perceived sleep quality, and stress during the season than those without menstrual dysfunction. We found no significant differences in weekly ratings of energy or mood between groups. However, the menstrual dysfunction group reported significantly worse perceived sleep quality and significantly more stress in-season than those without menstrual dysfunction. When adjusting for school year, BMI, and injuries sustained during the season, menstrual dysfunction was significantly associated with worse perceived sleep quality and more stress. These findings partially support our initial hypothesis, as adolescent athletes participating in flag football with menstrual dysfunction reported worse levels of perceived sleep quality and stress during the season than those without menstrual dysfunction. However, we identified that adolescent athletes with menstrual dysfunction did not report different mood and energy levels than adolescent athletes without menstrual dysfunction.

Of the 60 adolescent female flag football athletes we monitored over the course of a season, a quarter (25%) reported menstrual dysfunction at the start of the season. The prevalence of menstrual dysfunction in our study was higher than other studies that report a prevalence between 15% and 18% in adolescent female athletes.^22,23 The higher prevalence of menstrual dysfunction in our study may reflect the high prevalence of menstrual dysfunction specifically in flag football rather than across a variety of different sports. Although menstrual dysfunction is most common in endurance, aesthetic, and weight-based sports, it is imperative to also monitor for menstrual dysfunction in team sports, such as flag football.¹¹ Additionally, the higher prevalence may also reflect a rise of menstrual dysfunction among youth athletes over the years with the rise of female adolescents participating in sports.²⁴ Our findings emphasize the importance of monitoring for menstrual dysfunction among adolescent athletes of all sport types, including flag football.

Adolescent female athletes with menstrual dysfunction reported significantly worse weekly perceived sleep quality during the season than the no menstrual dysfunction group. Our findings are consistent with previous work that suggest that menstrual dysfunction is associated with poor perceived sleep quality among adults, adolescent females, and adolescent female athletes.^{18–20,25,26} A systematic review including adult women found that worse sleep quality is associated with menstrual dysfunction, and each sleep characteristic, including perceived sleep quality, efficiency, and duration, is independently associated with menstrual disturbances.²⁵ Specifically, in adolescent females between the ages of 15 and 18, 194 participants reported poor sleep quality. Of those 194 participants, 19% had menstrual dysfunction, indicating that there was a significant relationship between perceived poor sleep quality and menstrual dysfunction in adolescent females.²⁰ Menstrual dysfunction may be characterized by hormonal fluctuations (ie, increased or decreased) of estrogen and/or progesterone, which may in turn affect sleep.²⁷ For example, elevated progesterone levels can impact sleep-regulating neurotransmitters such as gamma-aminobutyric acid and serotonin.²⁷ Changes in these neurotransmitters can influence sleep quality, ultimately leading to negative changes in sleep efficiency and subjective sleep quality.²⁷ Additionally, mental health factors, such as heightened anxiety or stress, can cause sleep disturbances, such as falling and staying asleep.²⁸ In female college students, going to bed later as well as irregular sleep/wake times (ie, 1 or more hours of deviation from regular sleep/wake times) was associated with greater depressive symptoms and more severe menstrual symptoms, regardless of sleep duration.²⁸ This suggests that going to bed earlier and maintaining a consistent sleep schedule may be beneficial for those with menstrual irregularities.

We also found that athletes with menstrual dysfunction reported more stress during the season than those without menstrual dysfunction. Previous studies suggest that female adolescents are more likely to experience more stress than male adolescents and that stress is associated with menstrual dysfunction.^{13–15,29,30} High stress levels, depressive mood, and participation in psychological counseling have previously been linked to greater risks of menstrual cycle irregularity in Korean female adolescents.³¹ Another study found that 235 female adolescents with menstrual dysfunction reported significantly lower quality-of-life scores in the domains of general health and social functioning than adolescents without menstrual dysfunction.¹⁷ Although the association between stress and menstrual dysfunction has been less researched among adolescent athletes specifically, menstrual dysfunction is associated with higher levels of stress among adult, elite athletes.¹⁶ Thus, our finding is in line with other work that suggests that menstrual dysfunction is associated with more stress in female adolescents, and further research should examine this association specifically in adolescent female athletes.

We found no significant differences in weekly ratings of energy or mood between those with and without menstrual dysfunction. Research is scarce on the associations between menstrual dysfunction and energy and mood, particularly among adolescent athletes, compared with perceived sleep quality and stress. To the best of our knowledge, no studies have compared ratings of energy and mood in adolescent athletes with and without menstrual dysfunction. However, 1 study found that menstrual dysfunction was associated with higher levels of anxiety, fatigue, and pain interference among adolescent female athletes.¹³ Other studies demonstrate an association between menstrual dysfunction and depression, but we did not find a significant difference in self-reported history of depression or anxiety between groups.^31–33 Our findings may suggest a protective effect of sport participation on mood and energy despite the presence of menstrual dysfunction. Research shows that participating in sports or physical activity for at least 60 minutes daily improves mood.^34–36 All athletes in our study participated in weekly physical activity that exceeded the recommended amount (9.6 ± 4.7 hours/week) in an organized sport environment, which likely positively impacted mood.

Due to the higher prevalence of menstrual dysfunction in our study than in other studies, it is possible that we saw more stress in these athletes due to poor perceived sleep quality. On the other hand, poor perceived sleep quality could have led to more stress in these athletes. During adolescence, there is also an abundance of outside stress that is individual to each athlete, such as parental pressure, pressure from peers and friends, academic goals, and pressure to conform to societal norms that could be heightened from a myriad of outside variables. Thus, future research should further identify specific stressors in adolescent female athletes and track these variables over time with specific perceived sleep quality ratings.

Limitations of this study include a small sample size, particularly in the menstrual dysfunction group, which could limit detection of statistically significant findings between groups. Additionally, we used a 10-point slider visual analog scale for ratings of weekly perceived stress, mood, sleep quality, and energy, which provides objective data points for subjective information and thus can vary across individuals. For example, an athlete might perceive a higher rating as more or less severe than another individual. Furthermore, the visual analog scale was used as a brief and feasible method to obtain well-being data through the season but has not yet been validated. However, strengths of our study include the prospective study design and examination of quality-of-life measures in the growing sport of flag football among adolescent female athletes.

CONCLUSION

Adolescent female athletes participating in flag football reported significantly worse perceived sleep quality and significantly more stress in-season than those without menstrual dysfunction. We found no significant differences in weekly ratings of energy or mood between those with and without menstrual dysfunction. We recommend health care providers regularly monitor for and address menstrual dysfunction and be aware of how menstrual dysfunction may relate to stress and perceived sleep quality in adolescent female athletes. It is imperative to identify screening practices preseason to help improve quality of life in all female adolescent athletes, including those who participate in flag football. As flag football grows in popularity, future directions include prospectively examining the relationships between menstrual dysfunction, quality-of-life measures, and injury risk in female athletes who participate in flag football.