Sports Medicine (2022) 52:2813–2819

https://doi.org/10.1007/s40279-022-01679-y

CURRENT OPINION

Effects of Follicular and Luteal Phase‑Based Menstrual Cycle

Resistance Training on Muscle Strength and Mass
Julie Kissow1 · Kamine J. Jacobsen1 · Thomas P. Gunnarsson1 · Søren Jessen1 · Morten Hostrup1

Accepted: 20 March 2022 / Published online: 26 April 2022

© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022

Abstract
There is an increasing interest in female athletic performance—especially concerning the impact of the female menstrual
cycle on training response. Indeed, fluctuations in female sex hormones, estrogen and progesterone, during the menstrual
cycle regulate protein metabolism and recovery processes in skeletal muscle and may thus impact exercise training-related
outcomes. Studies demonstrate that anaerobic capacity and muscle strength are greatest during the follicular phase of the
menstrual cycle, when estrogen levels peak. In addition, studies indicate that resistance training conducted in the follicular
phase of the menstrual cycle (follicular phase-based resistance training) may be superior to luteal phase-based training in
terms of enhancing muscle strength and mass. This raises the possibility that the physiological capabilities of skeletal muscle
to adapt to exercise training are dependent on the menstrual cycle and can be important for female athletes in optimizing their
training. In this paper, we critically review the current state of the art concerning the impact of menstrual cycle phase-based
resistance training and highlight why follicular phase-based resistance training possibly is superior to luteal phase-based
training in enhancing resistance training outcomes. Finally, we identify directions for further research.

Key Points 1 Introduction

Fluctuations in female sex hormones during the men- Ever since Gamberale et al. [1] in 1975 showed that pulmo-
strual cycle may affect exercise training response in nary ventilation during submaximal exercise varied across
females. the female menstrual cycle, there has been an increasing
interest in the effect of fluctuations in female sex hormones
Estrogen has an anabolic effect on skeletal muscle and
on performance outcomes in athletes [2, 3]. In eumenor-
may regulate the skeletal muscle hypertrophic response
rheic women, the steroid hormones estrogen and progester-
during resistance training.
one undergo marked fluctuations during ovulatory menstrual
Follicular phase-based resistance training may be supe- cycles (Fig. 1). In the early follicular phase, estrogen and
rior to luteal phase-based resistance training in terms of progesterone levels are low and there is a release of follicle-
enhancing muscle strength and mass, but this warrants stimulating hormone (FSH) and luteinizing hormone (LH),
further studies. both of which stimulate estrogen production. In contrast,
estrogen levels are high, whereas progesterone levels are
low in the late follicular phase. The peak of estrogen results
in a surge in LH and thereby ovulation. After ovulation, the
luteal phase begins where both estrogen and progesterone
are secreted [4].
Julie Kissow and Kamine J. Jacobsen contributed equally.
Fluctuations in estrogen and progesterone potentially affect
* Morten Hostrup physical performance of eumenorrheic females [2]. Maximal
mhostrup@nexs.ku.dk muscle strength appears greater in the follicular phase and at
1
ovulation than in the luteal phase both in untrained [5, 6] and
The August Krogh Section for Human Physiology, trained females [5], and recovery and reconstruction of muscle
Department of Nutrition, Exercise and Sports, University
of Copenhagen, August Krogh Building 2nd floor, fibers have been shown to be faster in the mid follicular phase
Universitetsparken 13, 2100 Copenhagen, Denmark than the luteal phase after eccentric exercise [7]. Accordingly,

Vol.:(0123456789)
2814 J. Kissow et al.

Fig. 1  Fluctuations in female

sex hormones during the men-
strual cycle. LH luteinizing hor-
mone, FSH follicle-stimulating
hormone. The figure is based on
average values over the female
menstrual cycle with inspiration
from Janse de Jonge et al. [9],
Oosthuyse and Bosch [20], and
Meignié et al. [35]

some speculate that fluctuations in estrogen levels impact exer- for further research to advance the field of performance opti-
cise training response [8]. For the same reason, the impact mization in female athletes.
of the menstrual cycle on training responsiveness in female
athletes has attracted particular attention [2, 9, 10]. How-
ever, despite the increased attention to female research and 2 Effect of Phase‑Based Resistance Training
a physiological rationale for fluctuations of estrogen to affect on Muscle Adaptations
training response [7, 11–13], the current evidence concerning
phase-based training is limited and centered around resistance If fluctuations in female sex hormones impact training
training. Nevertheless, the available studies provide intriguing response, one would expect different outcomes to phase-
evidence supporting the notion that resistance training con- based resistance training. While only a few studies have
ducted in the follicular phase of the menstrual cycle may be investigated if this is indeed the case, they collectively
more beneficial for adaptive outcomes than resistance training indicate that follicular phase-based resistance training
conducted in the luteal phase. This suggests that eumenorrheic enhances leg muscle strength gains (Table 1). Typically,
female athletes may effectively improve resistance training these studies randomized eumenorrheic women to high-
outcomes by adapting training strategies according to their frequency resistance training in either the follicular phase
menstrual cycle phase. or the luteal phase and a low-frequency resistance training
In this opinion paper, we critically review the current state period in the opposite phase. For example, when utilizing
of the art concerning menstrual cycle phase-based resist- a within-subject design where one leg performed follicular
ance training and highlight why follicular phase-based resist- phase-based resistance training and the other luteal phase-
ance training may be superior to luteal phase-based training based, Sung et al. [14] observed that the leg performing
in enhancing resistance training outcomes. We present the follicular phase-based training had a greater enhance-
mechanistic basis underlying phase-based differences in train- ment of quadriceps maximal isometric strength than the
ing responsiveness while drawing attention to the inadequate leg performing luteal phase-based training (40% vs. 27%)
amount of research that has been directed toward this issue. during 12 weeks of leg resistance training four times per
Finally, based on the available literature, we identify directions week (4/wk) in the high-frequency period and 2/wk in the
low-frequency period. With a similar phase-based design,
Impact of the Menstrual Cycle on Resistance Training Response 2815

Table 1  Phase-based resistance training in the female menstrual cycle

Study Participants Phase determination Intervention Results

Reis et al. (1995) [16] n=7 Measurements of basal Phase-based resistance Significantly greater
Age: 24 ± 4 years body temperature and training: 8 w improvement in isometric
Regular menstruation urinary LH hormone Leg 1 executed FB training strength after FB training
Physical education students peak 3/wk FP, 1/wk LP No significant difference in
Leg 2 executed PI training CSA between FB and PI
2/wk both in FP and LP training
Sakamaki-Sunaga et al. n = 14 Measurements of basal Phase-based resistance Increased CSA, 1RM and
(2016) [15] Age: 21 ± 2 years body temperature training: 12 w isometric strength after
Regular menstruation Arm 1 executed FB train- FB and LB training
Physically active ing No significant difference
Non-resistance trained 3/wk FP, 1/wk LP between FB and LB
Arm 2 executed LB train- training
ing
1/wk FB, 3/wk LP
Sung et al. (2014) [14] n = 20 Measurements of basal Phase-based resistance Significantly greater
Age: 26 ± 5 years body temperature training: 12 w improvement in isometric
Regular menstruation Leg 1 executed FB training strength and CSA after
Untrained and moderately 4/wk FP, 2/wk LP FB training
trained (< 2 h/wk) Leg 2 executed LB training No difference in fiber type
2/wk FB, 4/wk LP distribution between FB
and LB training
Wikström-Frisén et al. n = 59 (MC n = 32) FP and LP were determi- Phase-based resistance Significantly greater
(2016) [17] Age: 25 ± 4 years nated based on day 1 in training: 16 w improvements in
Trained the cycle FB training isokinetic strength in
Day 1–15 = FP 5/wk FP, 1/wk LP quadriceps in FB and PI
Day 16– < 35 = LP LB training compared to LB training
1/wk FB, 5/wk LP
PI training
3/wk in both FP and LP

BMD bone mineral density, CMJ counter movement jump, CSA cross sectional area, FB follicular phase-based, FP follicular phase, LBM lean
body mass, LB luteal phase-based, LP luteal phase, MC menstrual cycle, PI phase-independent, RM repetition maximum

however, follicular and luteal phase-based resistance train- [17]. The study included both users and non-users of oral
ing of the arms for 12 weeks induced comparable strength contraceptives, but for the non-users, quadriceps maximal
gains of the elbow flexors when training was undertaken isometric strength increased by 2% and 7% after follicular
3/wk in the high-frequency period and 1/wk in the low- phase-based and phase-independent training, respectively,
frequency period [15]. This suggests that the impact of whereas it declined by 9% with luteal phase-based training
phase-based training may depend on muscle group and [17]. From these findings, we infer that follicular phase-
mass. Indeed, a few other studies also demonstrate clear based resistance training is superior to luteal phase-based
phase-based effects on the leg responsiveness to resist- and phase-independent resistance training in enhancing
ance training. Reis et al. [16] observed that follicular muscle strength, but more studies are needed—especially
phase-based training resulted in a greater improvement concerning adaptations for the upper extremities (Fig. 2).
in quadriceps maximal isometric strength than phase-
independent training (32% vs. 13% improvement) during
8 weeks of leg resistance training 3/wk in the high-fre- 3 Estrogen and Progesterone Regulate
quency period and 1/wk in the low-frequency period or 2/ Muscle Mass and Strength
wk for phase-independent training. In addition, a parallel-
group study with females accustomed to resistance train- The superior leg muscle strength gains with follicular
ing found superior effects for follicular phase-based and phase-based resistance training possibly involve greater
phase-independent training than for luteal phase-based muscle hypertrophy. In the study by Sung et al. [14], fol-
training in terms of enhancing quadriceps maximal iso- licular phase-based resistance training resulted in a greater
metric strength during 16 weeks of leg resistance training increase in quadriceps muscle diameter than luteal phase-
5/wk in the high-frequency period and 1/wk in the low- based training (9% vs. 6%). And while phase-based differ-
frequency period or 3/wk for phase-independent training ences in the leg hypertrophic response to resistance training
2816 J. Kissow et al.

Fig. 2  A conceptual diagram of the effect of follicular phase-based high-frequency training in the luteal phase). High-frequency training
resistance training (high-frequency training in the follicular phase consists of 6–10 training sessions and low-frequency training consists
and low-frequency training in the luteal phase) and luteal phase-based of 2–4 training sessions during a period of 28 days. CSA cross-sec-
resistance training (low-frequency training in the follicular phase and tional area

are not always apparent [16, 17], there is a mechanistic basis response than during the luteal phase because of a high level
of estrogen as a regulator of muscle mass. Estrogen engages of estrogen and a low level of progesterone in the follicular
many signaling pathways in skeletal muscle, including phase.
5'AMP-activated protein kinase (AMPK), that regulate tran-
scription [8, 18]. Furthermore, estrogen activates satellite
cells [8, 19] and inhibits protein catabolism [20] (Fig. 3)— 4 Oral Contraceptives Suppress Endogenous
the latter of which is the opposite for progesterone [20]. Levels of Estrogen and Progesterone
Estrogen-deficient mice also recover muscle mass slower
than wild-type mice after hindlimb disuse [21], and estrogen When using oral contraceptives, fluctuations in estrogen and
therapy minimizes immobilization-induced muscle atrophy progesterone are suppressed throughout the oral contracep-
in rats [22]. In healthy adult females, estrogen correlates and tive cycle compared to the regular menstrual cycle [26, 27].
interacts with growth hormone [11, 12], and the potential for Depending on the type of oral contraceptive (monophasic,
recovery and reconstruction of muscle fibers after an eccen- biphasic, or triphasic), the amount of estrogen and proges-
tric exercise period is highest in the mid-follicular phase [7]. terone differs through the oral contraceptive cycle [27].
Moreover, in healthy postmenopausal females, one-legged Furthermore, the androgenic activity also varies in different
resistance exercise enhanced myofibrillar protein fractional types and generations of oral contraceptives. Androgenic-
synthesis rate only in estrogen replacement therapy users ity refers to the capability of progestogen to produce mas-
and not in controls, which supports interaction between culine characteristics, and for that reason, the androgenic
estrogen and exercise on myofibrillar protein synthesis rate activity may affect muscle hypertrophy and strength gains
in skeletal muscle [23]. Lastly, healthy adult females have during resistance training [24]. However, it seems that oral
greater amino acid oxidation and protein degradation during contraceptive formulations do not contain a large enough
the luteal phase than the follicular phase—both at rest [24] androgenic component to influence strength [28]. There-
and after exercise [25]. Thus, resistance training during the fore, the conditions for achieving adaptations to training
follicular phase may induce a more potent muscle anabolic among females using different types and generations of oral
Impact of the Menstrual Cycle on Resistance Training Response 2817

Fig. 3  Physiological mechanisms of estrogen in skeletal muscle. AMPK 5′AMP-activated protein kinase, ER estrogen receptor, GPER G protein-
coupled estrogen receptor

contraceptives compared to females with a regular men- energy systems and metabolic perturbations during a session
strual cycle may be different. The impact of endogenous and of speed endurance training [34], we speculate that a greater
exogenous hormones on muscle hypertrophy and strength training response may well occur with follicular phase-based
gains is still not clear. After a period of resistance training, speed endurance training. Further research should investi-
females using oral contraceptives increased the number of gate responsiveness to different training modalities and most
satellite cells compared to females with a regular menstrual importantly on performance-related outcomes, as this is the
cycle [29]. By comparison, other studies have not shown primary goal for athletes [35]. Additionally, future studies
any differences in strength gains between females using oral should prioritize methods with high reliability to identify
contraceptives and females with a regular menstrual cycle the phases of the menstrual cycle, as this is crucial to reduce
[30, 31]. At present there is not yet a consensus on how oral the risk of including subjects who do not have monthly hor-
contraceptives affect performance-related outcomes com- mone fluctuations despite experiencing regular menstruation
pared to the hormonal fluctuations in the menstrual cycle [36]. Indeed, luteal phase-deficiency, anovulatory cycles, and
[27, 32]. Thus, in future studies, it is important to be aware amenorrhea are highly prevalent in female elite athletes [37].
of the differences in hormone levels depending on whether While indirect methods can be used to identify menstrual cycle
females are using oral contraceptives or experience a regular phases, for research purposes we recommend quantitative
menstrual cycle. analysis of estrogen and progesterone as also highlighted by
others [9]. Such analyses may also be relevant for elite athletes
utilizing phase-based training strategies, as even marginal dif-
5 Future Directions ferences in training response can be crucial for performance.
For recreational athletes, on the other hand, indirect methods,
Although follicular phase-based training appears advantageous such as calendar-based counting and urinary LH measurement,
to luteal phase-based training to improve resistance training seem sufficient to identify the follicular and luteal phase of
response in females, more studies are needed in athletes. Fur- the menstrual cycle. But given the large inter-individual vari-
thermore, the impact of phase-based aerobic and anaerobic ation of the female menstrual cycle, an individual approach is
training, such as speed endurance training, is largely unknown essential [38].
[33]. However, given the major contribution from anaerobic
2818 J. Kissow et al.

6 Conclusion 5. Phillips SK, Sanderson AG, Birch K, et al. Changes in maximal

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