International Journal of

Environmental Research
and Public Health

Commentary
Menstrual Cycle Hormonal Changes and Energy Substrate
Metabolism in Exercising Women: A Perspective
Anthony C. Hackney 1,2

1 Department of Exercise & Sport Science, University of North Carolina, Chapel Hill, NC 27599, USA;
ach@email.unc.edu; Tel.: +1-919-962-0334
2 Department of Nutrition, Gillings School of Global Public Health, University of North Carolina,
Chapel Hill, NC 27599, USA

Abstract: This article discusses the research supporting that the hormonal changes across the men-
strual cycle phases affect a woman’s physiology during exercise, specifically addressing aspects of
energy substrate metabolism and macro-nutrient utilization and oxidation. The overarching aim is to
provide a perspective on what are the limitations of earlier research studies that have concluded such
hormonal changes do not affect energy metabolism. Furthermore, suggestions are made concerning
research approaches in future studies to increase the likelihood of providing evidence-based data
in support of the perspective that menstrual cycle hormonal changes do affect energy metabolism in
exercising women.

Keywords: estrogens; progesterone; sports; performance; female; eumenorrhea







Citation: Hackney, A.C. Menstrual

Cycle Hormonal Changes and Energy 1. Introduction
Substrate Metabolism in Exercising The number of women engaged in physical exercise for health and sporting endeavors
Women: A Perspective. Int. J. Environ. has grown exponentially in recent decades [1]. Coinciding with this occurrence, the number
Res. Public Health 2021, 18, 10024. of research studies examining female physiological responses to exercise has grown too.
https://doi.org/10.3390/ijerph181910024
The total amount of female-based research is less than that conducted in men, and far
more research is needed [1]. This last point is especially warranted due to the unique
Academic Editors: Stacy T. Sims,
characteristics of female physiology, specifically the influence of the fine-tuned interactions
Christopher T. Minson and
of the menstrual cycle, ovarian cycle, and female reproductive hormonal changes found
Paul B. Tchounwou
in women. Evidence has mounted in recent years that these unique hormonal changes
may preclude the application of many of the physiological findings in male-based studies
Received: 5 July 2021
Accepted: 16 September 2021
directly to women [1–3].
Published: 24 September 2021
Physiologically, the female sex steroid hormones (i.e., estrogens, progesterone) have a
variety of biological roles other than regulating just reproductive function (i.e., pleiotropic
Publisher’s Note: MDPI stays neutral
effects) [4–6]. In exercising women one of these alternative roles is influencing the substrate
with regard to jurisdictional claims in
metabolism of carbohydrate and fat utilized in ATP energy production [6,7]. To this end, it is
published maps and institutional affil- well established that the availability and utilization of energy substrates during an exercise
iations. session are critically instrumental in enhancing human physical performance capacity [8,9].
This latter point is especially true for carbohydrates since the storage capacity in humans
for this macro-nutrient is limited, and it is essential in exercise metabolism, especially at
higher intensities of activity [8,9].
Copyright: © 2021 by the author.
The circulating levels of female sex steroid hormones (FSSH) fluctuate in eumenorrheic
Licensee MDPI, Basel, Switzerland.
women during their reproductive years as they progress through the phases of their
This article is an open access article
menstrual cycle (i.e., menses, follicular, ovulation, luteal) [5,10]. As such, these changes
distributed under the terms and in FSSH across the menstrual cycle can potentially mediate aspects of carbohydrate and
conditions of the Creative Commons fat metabolism at rest or in response to an exercise bout at different times in the cycle.
Attribution (CC BY) license (https:// Researchers have examined such effects in animals and humans for nearly 50 years. Notedly,
creativecommons.org/licenses/by/ while both estrogens and progesterone have non-reproductive functions [11], exercise
4.0/). studies have primarily focused on the aspects of estrogens to influence metabolism (N.B.,

Int. J. Environ. Res. Public Health 2021, 18, 10024. https://doi.org/10.3390/ijerph181910024 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 10024 2 of 8

the term “estrogens” is used herein collectively to refer to estrone, estriol, and estradiol-β-
17; the latter being the predominate hormonal form in women [11]). Animal-based evidence
clearly supports the impactful actions of estrogens on metabolism, and some, but not all
human-based research concurs [4–6,11]. To date, due to conflicting findings between human
studies, no consensus in the research community exists on the efficacy, uniformity, and
magnitude (if any) of the effect of estrogen changes throughout the menstrual cycle phases
on substrate metabolism. As a consequence, many scientists in the research community
can essentially be divided into two schools of thought:
• Those who believe menstrual cycle hormonal changes do affect a woman’s metabolism
during exercise, and
• Those who believe the menstrual cycle hormonal changes do not affect a woman’s
metabolism during exercise.
Accordingly, the intent of this commentary article is to address select aspects of this
topic. Especially, it presents those factors that have historically led potentially to the
ambiguity in the research findings on this topic and to argue for the perspective that the
menstrual cycle hormonal changes do affect a woman’s energy metabolism during exercise.
Organizationally this article presents, (a) background evidence of the do affect research
studies supporting menstrual cycle hormonal changes on energy substrate metabolism,
(b) factors in prior do not affect studies confounding and limiting their findings, and (c)
commentary (recommendations) throughout for improving research in this area. For those
readers unfamiliar with the physiology and endocrinology of the menstrual cycle, select
review articles [5,10] are recommended for an overview of these topics.

2. Research Background
2.1. Muscle Glycogen—Glucose
Most studies in women have not detected any difference in energy substrate metabolism
at rest between menstrual cycle phases [12], but stored energy reserves are reported to differ.
Especially, muscle glycogen content (vastus lateralis) at rest is higher in the luteal phase
(LP, high FSSH levels) than in the follicular phase (FP, low FSSH levels) of the menstrual
cycle when dietary carbohydrate intake is standardized [13]. This was speculated to be
an LP induced glycogen sparing effect brought on via an enhanced reliance on fat as an
energy source. However, other researchers noted that resting (free-living) food selection
in physically active women shifts towards greater levels of carbohydrate consumption in
the LP, thereby perhaps leading to increases in glycogen synthesis and storage [14]. In
agreement with this last point, Becket et al. found estrogens increase muscle glycogen
synthase activity in rodent-model research [15].
A number of studies report submaximal steady-state exercise when performed in the
LP versus FP results in differences in muscle glycogen utilization [16–18]. For example,
during a standardized 60-min cycling bout (~70% maximal oxygen uptake [VO2max ] in
both the LP and FP), a muscle glycogen sparing effect was observed in the LP [17]. Again,
this is presumed to be due to increasing fat utilization occurring and as such inducing the
glycogen sparing during the LP. Supportively, Zderic et al. found the rate of appearance
(Ra; from hepatic glycogenolysis) and disappearance (Rd) of glucose were lower in LP
than FP during cycling exercise (at ~90% lactate threshold) [19]. Similarly, Devries et al.
reported glucose Ra and Rd and total glycogen utilization were lower in LP than FP during
endurance exercise (90 min cycling at 65% of VO2max ) [18]. These authors also attributed
their findings to the higher concentration of estrogens in the LP promoting increased muscle
glycogen storage (rest) and sparing during exercise [18,20]. Interestingly, the influences of
the estrogens to affect hepatic glucose output has been detected only at exercise intensities
that are sufficiently elevated to increase the glucose utilization demand above a certain
level [19,21].
Int. J. Environ. Res. Public Health 2021, 18, 10024 3 of 8

2.2. Substrate Oxidation

Hackney et al. found higher circulating estrogens levels (either via endogenous
(menstrual phase) or exogenous (pharmacological estrogens administration)) resulted in
higher fat oxidation and lower carbohydrate oxidation during endurance running (60 min
at 65% of VO2max ) compared with lower estrogens conditions [22]. Similarly, Zderic et al.
found the carbohydrate oxidation rates were lower and fat oxidation rates higher in LP
than in FP during cycling exercise (at ~90% of the lactate threshold) [19]. These findings
were supported by several other studies [7,23–26]. Furthermore, Wenz et al. found that the
greater fat oxidation in LP exercise is magnified by a period of low carbohydrate dietary
intake [26]. Additionally, the variance in substrate oxidation between the LP and FP seems
intensity-dependent, and as exercise exceeds the lactate threshold the demand for increased
carbohydrate consumption outstrips the influence of estrogen [7]. While most investigators
in these studies attribute the shift toward reduced carbohydrate oxidation, Lariviere et al.
noted increased oxidation of the amino acid leucine during LP, could be an additional
mechanism for carbohydrate sparing [27].

2.3. Lactate
For decades, lactate has been viewed as a mainstay of assessing anaerobiosis in an
exercising individual. Forty years ago, Jurkowski and associates first demonstrated that
peak lactate response to a standardized exercise session was lower in the LP versus FP [28].
The authors attributed this to the Ra of lactate and carbohydrate substrate turnover being
less in LP due to changing FSSH concentrations. These results were confirmed in later
studies by McCracken et al. [24] and Berend et al. [25] involving intensive/exhaustive
exercise. Furthermore, others have reported comparable findings for submaximal exercise
levels occurring near the lactate threshold [26,29,30].

2.4. Mechanism of Estrogens Action

The physiological mechanisms for estrogens to influence substrate metabolism are
attributed to both direct and indirect actions of the hormone. The direct actions comprise
those influences on the lipolytic enzymes involved with the regulation of fatty acid mo-
bilization at the adipose and muscular tissues leading to greater fat than carbohydrate
utilization [4,31]. For example, in humans estrogens promote (1) increased lipoprotein
lipase and hormone-sensitive lipase activity, (2) increase catecholamine-induced lipolysis,
and (3) down regulation of lipogenic-related genes [31]. The indirect actions are those
ascribed to the role estrogens play in facilitating other hormones which promote lipol-
ysis as well as glycogenesis (at rest) and mitigating glycogenolysis during exercise (see
Figure 1) [4–6]. Interestingly, during pregnancy when extremely large increases in FSSH
occur, the impact on these indirect hormonal factors is magnified at rest as well as in
response to exercise [32]. Regrettably, this latter topic is not well studied.
As noted, both estrogens and progesterone are reported to alter metabolic responses.
However, evidence supports the observation progesterone exhibits a largely anti-estrogenic
effect [33–35]. To this point, D’Eon et al. proposed that a metabolic response to changes
in the FSSH occurs only when the estrogens to progesterone ratio is adequately elevated
and the magnitude of the increase in estrogen from the FP to LP is in the order of 2-fold
or more [36]. However, more research is necessary to assess this interesting supposition
before it can be completely accepted or refuted.
Int. J. Environ. Res. Public Health 2021, 18, 10024 4 of 8

Figure 1. The figure illustrates the direct (____ ) and indirect (—-) effects of estrogens (E2 ) on a variety
of hormones and physiological processes important to exercise energy metabolism; e.g., energy
substrate availability-mobilization, Abbreviations: FFA = free fatty acids, G = glucagon, GH = growth
hormones, I insulin, TG = triglycerides. Symbols: ↑ = increase, ↓ = decrease, ∆ = change. Taken
from [5], used with permission.

3. Factors Affecting Research Studies

The prior reviewed evidence supports the do affect scientific group, but there is as
noted a do not affect school of thought group, who propose that the research evidence to
support the hormonal changes of the menstrual cycle are inconsequential and demonstrate
no menstrual cycle effects on metabolism. In looking back over the last 50 years of research,
it is now evident that a number of these such studies have limitations in their approach to
the research that calls into question the interpretation of their findings. What follows is my
perspective and opinion on some of the most notable limitations found in some of these
studies, calling into question the interpretation of these do not affect studies and school
of thought.

3.1. All Women Are Not Alike and as Such, Menstrual Cycles Are Not Alike
Historically, many researchers have assumed that the menstrual cycle in eumenorrheic
women is approximately 28 days long, and always shows the classic FSSH changes (i.e.,
model textbook patterns of responses). As such, if one knows the first day of menstruation,
then using a simple forward counting method, and assumes there is ovulation, and that
the main phases of the cycle (FP, LP) are equally distributed before and after ovulation,
then the cycle phases and hormonal changes can be known approximately. This approach
was used for many years in early menstrual cycle research studies. The problem here lies
with the assumptions made, which can be totally wrong as evidence shows, for example:
• Cycle length varies between women (cycles can be 21 to 35 days, with 2 to 7 days
of menses).
• Cycle length can vary within a woman by up to 8 days.
• Cycle phase length can also vary within women (FP = ±6 days, LP = ±4 days).
• Eumenorrheic women may not always ovulate (e.g., annually with 10–13 cycles a year,
a healthy woman could still see one anovulation during this period of time, and as
such not see hormonal changes) [37–39].

3.2. What’s in A Name?—Menstrual Cycle Terminology Confusion

Elliott-Sale and associates in their recent consensus article denoted that one of the
problems with past (and some present) menstrual cycle research studies was the lack of
Int. J. Environ. Res. Public Health 2021, 18, 10024 5 of 8

clear, definitive terminology on menstrual cycle status and precise operational definitions of
cycle phases [10]. This last point is extremely relative; i.e., causing difficulty in comparing
study outcomes concerning metabolism (e.g., trying to compare the early FP with the late
FP when FSSH values differ greatly is not valid). Furthermore, because of the variability in
cycle phase length (discussed prior) some studies have not clearly and specifically indicated
the exact point in a menstrual phase when data are collected, creating ambiguous time
points for comparisons.

3.3. Inadequate Screening for Medical Conditions

Women who appear to be healthy and eumenorrheic may not actually be so. Simply
asking if a woman has had her “period” on a regular basis is inadequate screening, but
this limited approach to screening has been utilized in past studies [11,37]. Women with
polycystic ovary syndrome (PCOS) are an example of how something major can be missed
without appropriate medical screening. The prevalence of PCOS is ~6–9% of adult women,
and the condition can involve infrequent or prolonged menstrual cycles; but, some women
with PCOS have regular monthly cycles [40]. These PCOS women, however, also typically
have abnormal FSSH levels which affect their physiological responses to exercise. N.B.,
readers unfamiliar with the physiology and endocrinology of PCOS and related medical
conditions affecting FSSH are directed to the review article of Liepa et al. [41] for a synopsis.

3.4. A Hormone Is a Hormone, but Biological Specimens Differ

Hormones can be measured in many bodily fluids such as blood, saliva, sweat, urine,
and cerebral spinal fluid. Historically, blood has been considered the reference biological
specimen that serves as the gold standard. The cost of blood analysis, as well as participant
needle phobia, has hampered past research studies, resulting in infrequent hormonal
assessments (N.B., research on female exercise physiology has been grossly underfunded).
Since FSSH levels can vary dramatically across the menstrual cycle, infrequent specimen
assessment can mean a researcher may miss the optimal time in a menstrual cycle phase
for testing (i.e., the window of peak hormonal change and receptor expression impacting
on “down-stream” physiological events (e.g., translation, protein expression, etc.)) [11,42].
Saliva assessment is viewed as the best non-invasive means to overcome the needle-phobia
issue and allow more frequent hormonal assessment. Regrettably, saliva hormone level
and blood hormone levels do not always perfectly align [42–44], for several reasons:
• Saliva is good for assessing free levels of FSSH, while in blood you can examine free,
bound, and total levels of such hormones.
• Saliva and blood hormone levels are not always in perfect equilibrium and therefore do
not always reflect each other (i.e., efflux from the blood to the saliva can be impeded).
• Not all hormones can be measured in saliva (i.e., molecular weight prevents transport
into the saliva).
• Contamination of saliva specimens can be a problem (e.g., blood from brushing teeth,
food particles).
• Reference standards for saliva hormone levels are not well established yet.
• Historically early salivary hormonal assays used in prior research studies were prob-
lematic, lacking good sensitivity and accuracy.

3.5. Statistical Miss-Steps

It is well accepted that research studies require statistical analysis to support the
probability of whether the findings are due to experimental design approaches, and are
employed to test hypotheses. Statistical analysis is also an accepted tenet and requirement
for the publication of most scientific articles. In many exercise studies, the design approach
has often been to look at and report group responses, and test those for statistical signif-
icance. A problem with such an approach in hormonal work is that studies may have
participants who are responders and some who are non-responders (i.e., hormone changes
vs. no hormonal changes (i.e., or changes are less than the detection sensitivity of the
Int. J. Environ. Res. Public Health 2021, 18, 10024 6 of 8

bioanalytical procedure) [42,45]. Lumping these individuals together dilutes the potential
effects of examining the hormonal changes on the physiological outcome measurements
(e.g., metabolism). Too many studies (past and present), in attempting to have adequate
sample sizes, have kept non-responders in their study sample in an attempt to have ade-
quate statistical power (perhaps being entirely unaware of the fact they have subjects who
could be considered non-responders). In lieu of group responses, individual responses
should be assessed, and the removal of non-responders considered. Some would consider
this “cherry-picking” of the data, but the underlying premise of studying the influence of
menstrual cycle hormonal changes is simply that such changes are necessary if a physiological
response is going to be evoked.

4. Discussion
Obviously, the points raised herein are a one-sided perspective. It is important to
state that not all studies which fall into the do not affect category (school of thought) are
poor scientific research. To take that stand would be a gross misrepresentation of one
of the tenets of the Scientific Method (i.e., not being open to alternative opinions). That
said, over the years there have been a substantial number of these do not affect studies
that have not carefully considered the nuances of female physiology in their menstrual
cycle and hormonal research. Yes, these are peer-review published research, but that does
not make them without limitations (i.e., scientific weaknesses in approach, execution, or
interpretation). As such, these limitations have resulted in part to the ambiguous nature
of the current body of literature on exercise and the menstrual cycle. The do affect studies
cited herein are also not without limitations either. For example, many of the substrate
oxidation studies previously reviewed used respiratory gases to assess carbohydrate and
fat contributions to exercise metabolism, which was questioned by some [46]; although the
method has been validated in this context [47].
Perhaps most importantly, the scientific community and the public at large have
finally started to “listen to women” who are exercisers and athletes and take seriously their
reports that their training and competition performance are affected by the phases of their
menstrual cycle and the resulting hormonal changes [48]. It seems remarkable that it has
taken so long for this to occur and scientists are no longer being tone-deaf to the issue.
As just noted, women athletes feel their competitive performance is affected by their
menstrual cycle phase. This commentary article does not address performance per se,
but this topic is a logical off-shoot of exercise energy substrate metabolism. McNulty
and associates conducted an extensive and thorough review of the available literature
on this topic and concluded the effects on performance were trivial, but perhaps could
nonetheless be important for the elite female athlete [49]. I do not refute their conclusions,
but some of the limitations noted herein as well as those reported by Elliott-Sale et al. on
the methodology utilized in this research area indicate that past poor scientific approaches
in studies hamper how robust the conclusions can be on the performance topic [10].
Finally, in way of summation, it is clear that evidence-based data exist that show the
energy substrate metabolism of exercising women is affected by their menstrual cycle phase
and the associated FSSH hormonal changes. Elevations in estrogens, in particular, across
the cycle seem to promote carbohydrate sparing and increased fat utilization as an energy
source. The complete consequences of this occurrence remain to be seen, but certainly
have implications for the training and dietary practices of exercising women, especially
competitive athletes (see [50] for dietary discussion). Such findings are not universal to all
women and research by some refute the influence of the menstrual cycle phase on female
exercise physiology all together, however, poor application of the Scientific Method calls
one to question these counter perspectives.

5. Conclusions
In conclusion, further study is needed on the role of the menstrual cycle on the exercise
physiology of women. There is an important need to ensure this research is of the highest
Int. J. Environ. Res. Public Health 2021, 18, 10024 7 of 8

quality and standard, and not to continually repeat the mistakes of the past [10]. To this
end, it is important to develop a new generation of scientists who will pursue this line of
work robustly. Furthermore, in my opinion, we need more of these scientists to be women
as they are vital stakeholders who have been in the minority of research ranks for far
too long.

Funding: This research received no external funding.

Institutional Review Board Statement: This article does not produce original research data, and as
such, an Institutional Review Board Statement is not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: Aspects of this paper were presented at the 2021 Female Athlete Conference
(Director, Kathryn Ackerman, MD) by the author. My thanks are given to Dr. Ackerman for the
opportunity and encouragement to present this work.
Conflicts of Interest: The author declares no conflict of interest.

References
1. Mujika, I.; Taipale, R. Sport Science on Women, Women in Sport Science. Int. J. Sports Physiol. Perform. 2019, 14, 1013–1014.
[CrossRef] [PubMed]
2. Stachenfeld, N.S. Including women in research. It’s necessary, and really not so hard to do. Exp. Physiol. 2018, 103, 1296–1297.
[CrossRef] [PubMed]
3. Sims, S.T.; Heather, A.K. Myths and Methodologies: Reducing scientific design ambiguity in studies comparing sexes and/or
menstrual cycle phases. Exp. Physiol. 2018, 103, 1309–1317. [CrossRef]
4. Bunt, J.C. Metabolic actions of estradiol: Significance for acute and chronic exercise responses. Med. Sci. Sports Exerc. 1990, 22,
286–290. [CrossRef]
5. Davis, H.C.; Hackney, A.C. The hypothalamic-pituitary-ovarian axis and oral contraceptives: Regulation and function. In Sex
Hormones, Exercise and Women; Hackney, A.C., Ed.; Springer: Berlin/Heidelberg, Germany, 2017; pp. 1–18.
6. Newell-Fugate, A.E. The role of sex steroids in white adipose tissue adipocyte function. Reproduction 2017, 153, R133–R149.
[CrossRef] [PubMed]
7. Hackney, A.C.; McCracken-Compton, M.A.; Ainsworth, B. Substrate responses to submaximal exercise in the midfollicular and
midluteal phases of the menstrual cycle. Int. J. Sport Nutr. 1994, 4, 299–308. [CrossRef]
8. Costill, D.L.; Hargreaves, M. Carbohydrate Nutrition and Fatigue1. Sports Med. 1992, 13, 86–92. [CrossRef]
9. Wolfe, R.R. Fat metabolism in exercise. Adv. Exp. Med. Biol. 1998, 441, 147–156. [PubMed]
10. Elliott-Sale, K.J.; Minahan, C.L.; de Jonge, X.A.K.J.; Ackerman, K.E.; Sipilä, S.; Constantini, N.W.; Lebrun, C.M.; Hackney, A.C.
Methodological considerations for studies in sport and exercise science with women as participants: A working guide for
standards of practice for research on women. Sports Med. 2021, 51, 843–861. [CrossRef] [PubMed]
11. Melmed, S.; Koenig, R.; Rosen, C.; Auchus, R.; Goldfine, A. William’s Textbook of Endocrinology, 14th ed.; Elsevier Publishing:
New York, NY, USA, 2019.
12. Isacco, L.; Boisseau, N. Sex hormones and substrate metabolism during endurance exercise. In Sex Hormones, Exercise and Women:
Scientific and Clinical Aspects; Hackney, A.C., Ed.; Springer: Berlin/Heidelberg, Germany, 2016; pp. 35–58.
13. Hackney, A.C. Effects of the menstrual cycle on resting muscle glycogen content. Horm. Metab. Res. 1990, 22, 647. [CrossRef]
14. Chappell, S.; Hackney, A.C. Association between menstrual cycle phase, physical activity level and dietary macro-nutrient intake.
Biol. Sport 1997, 14, 251–258.
15. Beckett, T.; Tchernof, A.; Toth, M.J. Effect of ovariectomy and estradiol replacement on skeletal muscle enzyme activity in female
rats. Metabolism 2002, 51, 1397–1401. [CrossRef] [PubMed]
16. Nicklas, B.J.; Hackney, A.C.; Sharp, R.L. The Menstrual Cycle and Exercise: Performance, Muscle Glycogen, and Substrate
Responses. Int. J. Sports Med. 1989, 10, 264–269. [CrossRef] [PubMed]
17. Hackney, A.C. Influence of oestrogen on muscle glycogen utilization during exercise. Acta Physiol. Scand. 1999, 167, 273–274. [CrossRef]
18. Devries, M.C.; Hamadeh, M.J.; Phillips, S.M.; Tarnopolsky, M.A. Menstrual cycle phase and sex influence muscle glycogen
utilization and glucose turnover during moderate-intensity endurance exercise. Am. J. Physiol. Regul. Integr. Comp. Physiol. 2006,
291, R1120–R1128. [CrossRef] [PubMed]
19. Zderic, T.W.; Coggan, A.R.; Ruby, B.C. Glucose kinetics and substrate oxidation during exercise in the follicular and luteal phases.
J. Appl. Physiol. 2001, 90, 447–453. [CrossRef]
20. Oosthuyse, T.; Bosch, A.N. The effect of the menstrual cycle on exercise metabolism: Implications for exercise performance in
eumenorrhoeic women. Sports Med. 2010, 40, 207–227. [CrossRef]
Int. J. Environ. Res. Public Health 2021, 18, 10024 8 of 8

21. Horton, T.J.; Miller, E.K.; Glueck, D.; Tench, K. No effect of menstrual cycle phase on glucose kinetics and fuel oxidation during
moderate-intensity exercise. Am. J. Physiol. Metab. 2002, 282, E752–E762. [CrossRef] [PubMed]
22. Hackney, A.C.; Muoio, D.; Meyer, W.R. The effect of sex steroid hormones on substrate oxidation during prolonged submaximal
exercise in women. Jpn. J. Physiol. 2000, 50, 489–494. [CrossRef]
23. Hackney, A.C.; Curley, C.S.; Nicklas, B.J. Physiological responses to submaximal exercise at the mid-follicular, ovulatory and
mid-luteal phases of the menstrual cycle. Scand. J. Med. Sci. Sports 1991, 1, 94–98. [CrossRef]
24. McCracken, M.; Ainsworth, B.; Hackney, A.C. Effects of the menstrual cycle phase on the blood lactate responses to exercise.
Graefe’s Arch. Clin. Exp. Ophthalmol. 1994, 69, 174–175. [CrossRef] [PubMed]
25. Berend, J.Z.; Brammeier, M.R.; Jones, N.A.; Holliman, S.C.; Hackney, A.C. Effect of the menstrual cycle phase and diet on blood
lactate responses to exercise. Biol. Sport 1994, 11, 241–248. [PubMed]
26. Wenz, M.; Berend, J.Z.; Lynch, N.A.; Chappell, S.; Hackney, A.C. Substrate oxidation at rest and during exercise: Effects of
menstrual cycle phase and diet composition. J. Physiol. Pharmacol. 1997, 48, 851–860. [PubMed]
27. Lariviere, F.; Moussalli, R.; Garrel, D.R. Increased leucine flux and leucine oxidation during the luteal phase of the menstrual
cycle in women. Am. J. Physiol. Metab. 1994, 267, E422–E428. [CrossRef] [PubMed]
28. Jurkowski, J.E.; Jones, N.L.; Toews, C.J.; Sutton, J.R. Effects of menstrual cycle on blood lactate, O2 delivery, and performance
during exercise. J. Appl. Physiol. 1981, 51, 1493–1499. [CrossRef]
29. Mesaki, N.; Sasaki, J.; Shoji, M.; Iwasaki, H.; Asano, K.; Eda, M. Effect of menstrual cycle on cardiorespiratory system during
incremental exercise. Nihon Sanka Fujinka Gakkai Zasshi 1986, 38, 1–9.
30. Dombovy, M.L.; Bonekat, H.W.; Williams, T.J.; Staats, B.A. Exercise performance and ventilatory response in the menstrual cycle.
Med. Sci. Sports Exerc. 1987, 19, 111–117. [CrossRef]
31. Oosthuyse, T.; Bosch, A.N. Oestrogen’s regulation of fat metabolism during exercise and gender specific effects. Curr. Opin.
Pharmacol. 2012, 12, 363–371. [CrossRef]
32. Bessinger, R.C.; McMurray, R.G.; Hackney, A.C. Substrate utilization and hormonal responses to moderate intensity exercise
during pregnancy and after delivery. Am. J. Obstet. Gynecol. 2002, 186, 757–764. [CrossRef]
33. Campbell, S.E.; Febbraio, M.A. Effect of the ovarian hormones on GLUT4 expression and contraction-stimulated glucose uptake.
Am. J. Physiol. 2002, 282, E1139–E4640. [CrossRef]
34. Campbell, S.E.; Febbraio, M.A. Effect of ovarian hormones on mitochondrial enzyme activity in fat oxidation pathway of skeletal
muscle. Am. J. Physiol. 2001, 281, E803–E841. [CrossRef]
35. Hatta, H.; Atomi, Y.; Shinohara, S.; Yamamoto, Y.; Yamada, S. The Effects of Ovarian Hormones on Glucose and Fatty Acid
Oxidation during Exercise in Female Ovariectomized Rats. Horm. Metab. Res. 1988, 20, 609–611. [CrossRef]
36. D’Eon, T.M.; Sharoff, C.; Chipkin, S.R.; Grow, D.; Ruby, B.C.; Braun, B. Regulation of exercise carbohydrate metabolism by
estrogen and progesterone in women. Am. J. Physiol. Endocrinol. Metab. 2002, 283, E1046–E1055. [CrossRef]
37. Hacker, N.F.; Gambone, J.C.; Hobel, C.J. (Eds.) Hacker & Moore’s Essentials of Obstetrics and Gynecology, 6th ed.; Elsevier:
Amsterdam, The Netherlands, 2015.
38. Cole, L.A.; Ladner, D.G.; Byrn, F.W. The normal variabilities of the menstrual cycle. Fertil. Steril. 2009, 91, 522–527. [CrossRef] [PubMed]
39. Marcinkowska, U.M. Importance of daily sex hormone measurements within the menstrual cycle for fertility estimates in cyclical
shifts studies. Evol. Psychol. 2020, 18, 1474704919897913. [CrossRef] [PubMed]
40. Pundir, C.S.; Deswal, R.; Narwal, V.; Dang, A. The prevalence of polycystic ovary syndrome: A brief systematic Review. J. Hum.
Reprod. Sci. 2020, 13, 261–271. [CrossRef]
41. Liepa, G.U.; Sengupta, A.; Karsies, D. Polycystic ovary syndrome (PCOS) and other androgen excess–related conditions: Can
changes in dietary intake make a difference? Nutr. Clin. Pract. 2008, 23, 63–71. [CrossRef]
42. Hackney, A.C.; Viru, A. Research methodology: Endocrinologic measurements in exercise science and sports Medicine. J. Athl.
Train. 2008, 43, 631–639. [CrossRef] [PubMed]
43. Streckfus, C.F. Advances in Salivary Diagnostics; Springer: Berlin/Heidelberg, Germany, 2015.
44. Wilson, D.W.; Walker, R.F.; Griffiths, K. Saliva as a medium for chronobiological studies: Its particular potential in steroid
endocrinology. Ann.-Ist. Super. Sanita 1993, 29, 607–611. [PubMed]
45. Viru, A.; Hackney, A.C.; Valja, E.; Karelson, K.; Janson, T.; Viru, M. Influence of prolonged continuous exercise on hormonal
responses to subsequent intensive exercise. Eur. J. Appl. Physiol. 2001, 85, 578–585. [CrossRef]
46. Nathalie, B.; Laurie, I. Substrate metabolism during exercise: Sexual dimorphism and women’s specificities. Eur. J. Sport Sci. 2021, 17, 1–21.
47. Romijn, J.A.; Coyle, E.F.; Hibbert, J.; Wolfe, R.R. Comparison of indirect calorimetry and a new breath 13C/12C ratio method
during strenuous exercise. Am. J. Physiol. 1992, 263 Pt 1, E64–E71. [CrossRef]
48. Solli, G.S.; Sandbakk, S.B.; Noordhof, D.A.; Ihalainen, J.K.; Sandbakk, Ø. Changes in self-reported physical fitness, performance,
and side effects across the phases of the menstrual cycle among competitive endurance athletes. Int. J. Sports Physiol. Perform.
2020, 15, 1324–1333. [CrossRef] [PubMed]
49. McNulty, K.L.; Elliott-Sale, K.J.; Dolan, E.; Swinton, P.A.; Ansdell, P.; Goodall, S.; Thomas, K.; Hicks, K.M. The effects of menstrual
cycle phase on exercise performance in eumenorrheic women: A systematic review and meta-analysis. Sports Med. 2020, 50,
1813–1827. [CrossRef] [PubMed]
50. Moore, D.R.; Sygo, J.; Morton, J.P. Fuelling the female athlete: Carbohydrate and protein recommendations. Eur. J. Sport Sci. 2021, 1–13.
[CrossRef] [PubMed]