Menstrual Cycle and Hormonal Contraceptives in Female Athletes: Should Symptoms and Nutrition Matter More than Cycle Phase? A Narrative Review

Background: Understanding how endogenous hormonal fluctuations and exogenous hormonal modulation influence exercise-related outcomes in women is essential for developing individualized and evidence-informed training and nutritional strategies. This narrative review summarizes the endocrine physiology of the eumenorrheic menstrual cycle and hormonal contraceptive (HC) use and critically examines their implications for athletic performance, neuromuscular function, injury risk, and metabolic regulation in physically active women. Methods: A non-systematic literature search was conducted in PubMed, Scopus, and Web of Science for articles published up to January 2026. Search terms combined menstrual cycle-related, hormonal contraceptive, performance, and metabolic/nutritional keywords, and relevant studies were selected based on their relevance to the scope of this narrative review. Results: Estradiol and progesterone fluctuations may modulate substrate utilization, connective tissue properties, central fatigue regulation, and symptom expression; however, evidence indicates that performance-related effects across menstrual phases are generally small and inconsistent, reflecting both the modest magnitude of physiological effects and the methodological heterogeneity in menstrual cycle phase classification and verification across studies. Similarly, although HC use suppresses endogenous hormonal variability, current findings do not support consistent benefits for performance, injury prevention, or metabolic outcomes, and responses remain heterogeneous. From a nutritional perspective, the endocrine context may contribute to modest changes in energy expenditure, insulin sensitivity, appetite regulation, inflammation, and recovery-related processes. Importantly, symptom burden—including pain, fatigue, sleep disturbances, gastrointestinal discomfort, and fluid retention—emerges as a practical driver of day-to-day training tolerance. Conclusions: We propose an integrative framework in which sex hormones define a physiological context rather than deterministic performance regulators, while nutrition acts as a key modifiable factor influencing metabolic responses, symptom severity, and performance consistency.