Female football has never been more visible, with growing audiences, rising professionalism and increasing demands on players. Yet questions surrounding female athlete health remain difficult to answer, particularly when it comes to injuries that can sideline players for months.
Anterior cruciate ligament (ACL) injuries have become a major talking point in the women's game, prompting renewed interest in whether hormonal fluctuations and the menstrual cycle influence injury risk. But as research continues to develop, the conversation risks becoming too narrow.
Could focusing too heavily on hormones mean other important factors are overlooked? And how can research help female footballers understand their bodies without creating unnecessary fear about their health?
Speaking to Striver, Dr Karli Richards, Roma van der Walt and biomechanics PhD researcher Blake Rivers discussed the gaps in female athlete research, the importance of individualised monitoring and why improving player welfare requires a much broader approach than simply tracking the menstrual cycle.
Their message is not that hormonal health should be ignored. It is that female footballers deserve evidence-based answers, practical support and research that recognises the complexity of their bodies.
Why ACL injuries cannot be solely reduced to the menstrual cycle
The relationship between female hormones and injury risk is an important area of ongoing research. However, the existence of a potential relationship does not mean the menstrual cycle can be used to predict when an individual player will sustain an injury.
Van der Walt, a former Team Germany modern pentathlon athlete and founder of women's health platform Vitelle, warned against allowing a complex subject to become an oversimplified narrative.
"I just don't like it when female athletes in particular get reduced to hormones and get reduced to menstrual cycle," she explained.
She highlighted how claims about specific phases of the cycle and ligament laxity can circulate online, sometimes becoming accepted as fact despite uncertainty in the underlying evidence.
A player might remember sustaining an ACL injury while menstruating, for example, but that experience alone cannot establish that menstruation caused the injury. Without reliable evidence, anecdotal accounts can contribute to a narrative that is more definitive than the science supports.
Van der Walt added: "I almost feel like the older women have pushed the hormones more into the limelight, which is great. But I don't want to create this fake confluence where we just talk about the hormones and these injuries."
Her concern is that female athletes could once again be defined by their biology, rather than supported through a comprehensive understanding of their performance and health.
Rivers, whose PhD research explores the relationship between menstrual-cycle hormones and ACL-related biomechanics in female footballers, also stressed the importance of looking beyond one potential explanation.
He pointed out that ACL ruptures occur frequently in male athletes, too, and that the physical demands of sport must remain central to discussions about injury.
"I think we can't overlook the fact that athletes are exposing themselves to significant forces, significant loads, significant positions, torsioning the knee, placing themselves in all of the environments that create a perfect storm for an ACL rupture," he said.
Rivers noted that anatomical and mechanical differences may also be relevant when investigating why injury rates differ between male and female athletes. Meanwhile, the increasing number of women participating in sport means more athletes are exposed to the demands that can lead to injury.
He believes the issue requires a more integrated approach, including better injury-prevention programmes, equipment strategies and player scheduling.
The message is clear: hormones may be one part of the picture, but the available evidence does not justify treating menstrual-cycle timing as a definitive explanation for an ACL injury.
Understanding hormones without making assumptions
That does not mean hormonal health is unimportant. In fact, understanding how hormones affect the body throughout a woman's life could help improve athlete care in several areas.
Dr Richards, whose work focuses on female athlete health and lower-limb injury prevention, explained that oestrogen plays a role in tendon and bone health. Changes in hormone levels may influence how these tissues respond, although the precise relationships and implications for individual injury risk remain areas for further investigation.
She also highlighted the importance of adequate fuelling.
When an athlete does not consume enough energy to meet the demands placed on her body, this can affect menstrual function and oestrogen levels.
Low energy availability and disrupted menstrual function can have consequences for bone health, including an increased risk of stress fractures.
Hormonal changes also matter beyond an athlete's playing career, including during perimenopause and menopause, when some women experience persistent tendon-related problems.
For Richards, this demonstrates why female health cannot be understood through the menstrual cycle alone.
"It's not the menstrual cycle. I mean, it's related, but it's the hormone fluctuations throughout a female's life," she explained.
The challenge is understanding what those changes mean for each individual.
Two players may experience different symptoms, energy levels and training responses despite being at a similar point in their cycles. Even the same person can experience considerable variation between cycles.
Rivers highlighted that a conventional 28-day cycle should not be treated as a universal template. His research involves verifying menstrual-cycle phases, and he said the participants he has worked with have not experienced identical cycles from one month to the next.
This makes broad predictions about performance, recovery or injury risk particularly difficult.
Van der Walt also warned that commercial tracking products can create a false sense of certainty. Wearables may estimate certain physiological patterns, but they cannot simply reveal an individual's hormone levels continuously from a wristband.
When technology presents generic recommendations as personalised insights, athletes risk receiving information that does not accurately reflect their own physiology.
The priority, therefore, is not to give every player the same instructions based on a predicted cycle phase. It is to understand individual patterns and interpret them alongside other relevant information.
A more holistic approach to female athlete health
If menstrual-cycle tracking cannot explain injury risk on its own, what should clubs and researchers be considering?
The contributors pointed to a combination of factors, including training loads, fatigue, recovery, nutrition, playing surfaces, footwear, biomechanics and the demands of travelling between club and international football.
The modern women's game places significant physical demands on athletes, with congested schedules and international commitments potentially complicating recovery and communication between teams.
Van der Walt questioned whether the focus on hormones sometimes distracts from wider structural issues, including the demands placed on players and the need for better protection.
An athlete might be fatigued, under-fuelled or struggling to recover adequately. She might also be exposed to demanding changes of direction or other high-load movements during a match. Hormonal factors could be relevant in some circumstances, but understanding the full context is essential.
Rivers believes the value of research ultimately lies in whether it improves decisions and outcomes.
"The practical value of a metric, it lies in whether it improves decision making," he explained.
Collecting more data is not enough if clubs cannot interpret it or use it to support their players. Equally, identifying a potential relationship in a study does not automatically mean a particular intervention will prevent injuries.
Research must establish which differences matter, what can realistically be changed and whether those changes improve athlete health and performance.
That requires studies capable of examining multiple interacting factors, alongside more opportunities for female athletes to participate in research.
Rivers acknowledged that recruiting female footballers for his PhD project has been challenging, despite the interest in female-specific research and the support his work has received through a FIFA Research Scholarship.
The gap between calling for more research and recruiting enough participants to conduct it remains a significant obstacle.
Education and trust must come first
Alongside research, the contributors agreed that education is essential to improving female athlete health.
Richards highlighted how menstrual health can remain a taboo subject, particularly among younger players who may feel uncomfortable discussing symptoms with coaches.
That discomfort can prevent athletes from communicating when they are struggling, even when simple adjustments or support could make a difference.
She believes clubs should establish open conversations from the outset, involving players, coaches, medical staff and strength and conditioning teams.
Practical measures can help, too. Richards suggested that coaches make menstrual products and other basic supplies available, helping normalise conversations and giving players confidence that their needs will be taken seriously.
The objective is not to make every training decision revolve around the menstrual cycle. It is to create an environment where athletes can discuss their health without embarrassment or fear of being treated differently.
Van der Walt added that trust must extend to the collection and use of personal data.
Athletes should understand what information is being collected, why it matters and who can access it. They should also be able to retain access to their own performance and health information as they move between clubs and national teams.
Without continuity, valuable information can be lost, making it harder to build a complete picture of an athlete's health over time.
She also encouraged women to take an active interest in their health beyond their playing careers, including through different reproductive stages.
For Rivers, research participation should be a positive experience, with athletes understanding how their involvement could contribute to better knowledge and future care.
The aim is not to promise immediate answers or guaranteed injury prevention. It is to build an evidence base that can help athletes and practitioners make better-informed decisions.
Turning research into meaningful change
There is still considerable work to do before researchers can confidently explain how hormonal variation interacts with biomechanics and injury risk in individual female footballers.
The contributors identified education, funding, female-specific technology and better integration of research into everyday practice as priorities for progress.
Richards believes education should begin when girls are young, helping players and coaches become comfortable discussing menstrual health before they enter elite environments.
Rivers stressed that research must move beyond identifying differences between male and female athletes and establish which findings can be translated into practical improvements.
Van der Walt's message was equally focused on giving athletes greater understanding and ownership of their health.
Together, their perspectives offer a constructive way forward for women's football. Rather than treating hormonal research as something to fear, the focus should be on developing better evidence, challenging assumptions and ensuring that individual athletes receive appropriate support.
Female footballers should not have to choose between acknowledging the importance of their hormones and recognising the many other factors that influence their health and performance.
The menstrual cycle is one part of a much bigger picture. Understanding that picture requires researchers, clubs, coaches and athletes to work together, with the shared goal of making women's sport healthier, better informed and more sustainable for the players at its heart.
How to get involved in ACL research
As researchers continue to investigate the factors influencing ACL injury risk in female footballers, greater participation will be important in building a stronger evidence base.
Blake Rivers, a biomechanics PhD researcher at Kingston University London, is seeking female footballers to take part in research exploring the relationship between menstrual-cycle phase and neuromuscular and biomechanical indicators of ACL injury risk.
The project aims to improve understanding of why female athletes experience a higher risk of ACL injury and contribute to more informed approaches to injury prevention.
Female footballers interested in finding out more about participating can contact Blake Rivers at B.Rivers@kingston.ac.uk or senior lecturer Simon Augustus at S.Augustus@kingston.ac.uk.
By encouraging more athletes to get involved, researchers hope to build a clearer picture of female-specific injury risk without reducing the issue to hormones alone.