Menstruation Challenges for Female Para-Athletes

In the world of para sports, athletes overcome physical obstacles every day—but one significant challenge remains largely hidden: managing menstruation with a disability. For female para-athletes, periods are not just a natural cycle; they represent a complex intersection of physiological changes, physical limitations, and performance-related obstacles. Our recent focus group discussions and a workshop with female para-athletes in Karnataka, on the 17th of February and 23rd of February respectively have uncovered powerful, real-life experiences highlighting these issues across different disability categories.

When a spinal cord injury (SCI) occurs, the body enters a phase called spinal shock—a period characterised by the sudden loss of reflexes, sensation, and motor function below the level of injury. During this phase, the hormonal balance that regulates the menstrual cycle can be severely disrupted, often resulting in amenorrhea (the absence of menstruation). Although many women eventually resume their cycles within one to six months as spinal shock resolves, the experience is far from typical.

For athletes with injuries above the T10 level, the physiological process of menstruation continues, but the sensory experience may be altered or even absent. One Paralympic medalist with SCI explained, “I don’t feel menstrual cramps the way I did before my injury, which sounds like a benefit—but it creates issues because I may not realize I’ve started bleeding until it’s visible.” This altered sensory feedback makes it challenging to monitor menstrual health and adapt training routines accordingly.

For athletes with injuries at or above the T6 level, menstruation brings an additional, serious medical consideration: autonomic dysreflexia. This condition involves sudden, dangerous spikes in blood pressure triggered by stimuli such as menstrual cramps or the insertion of internal menstrual products. Autonomic dysreflexia poses significant health risks and demands immediate attention, further complicating menstrual management for these athletes.

Moreover, SCI athletes are at a substantially higher risk for urinary tract infections (UTIS). Frequent catheterisation, essential for managing bladder function, can weaken the urinary tract’s natural defences. The anatomical proximity of the urinary and reproductive tracts in women facilitates bacterial transfer, especially during menstruation. In India, where accessible hygiene facilities are often limited, and prolonged wheelchair sitting can impede proper bladder emptying, these risks are even more pronounced. The Australian Institute of Sport (AIS) and the Australian Paralympic Committee (APC) recommend individualised bladder management plans and regular monitoring to help mitigate these challenges.

Female athletes with cerebral palsy face a distinct set of challenges rooted in motor control and coordination. Hormonal fluctuations during puberty and the menstrual cycle can worsen spasticity, a condition where muscles remain continuously contracted. Many CP athletes report that during the initial days of their period, their spasticity increases noticeably. One national-level swimmer shared, “During the first days of my period, my spasticity increases sometimes. Movements I perfected in training become much harder.” This increased muscle tone not only affects physical performance but also complicates the management of menstrual products.

Medication management in CP athletes is another layer of complexity. Anti-spasticity medications, such as baclofen, are commonly used to reduce muscle tone. However, their effectiveness can vary with hormonal changes throughout the menstrual cycle. Although research on this specific interaction is limited, many athletes have observed that their medication needs fluctuate during menstruation. Additionally, the fine motor skills required to insert tampons or handle menstrual cups are often compromised by the loss of selective motor control in CP, making menstrual hygiene a significant challenge.

For para-athletes with limited hand function—whether due to quadriplegia, limb differences, or severe CP—managing menstrual care presents practical challenges. Many conventional menstrual products require fine motor skills for application and removal. As a result, these athletes often face restricted product options and must rely on adaptive solutions like period panties or even adult diapers. This reliance on caregiver assistance can compromise privacy and reduce the athlete’s sense of independence. One wheelchair basketball player with quadriplegia remarked, “The logistics of menstrual care mean I need to schedule assistance during competitions. It adds another layer of coordination that my teammates don’t have to consider.”

Female wheelchair athletes encounter unique positioning challenges as well:

• Extended Sitting Pressure: Prolonged sitting in a wheelchair creates pressure dynamics that affect menstrual product positioning, increasing leakage risks.

• Transfer Complexities: Multiple transfers are often required to manage menstruation, yet many training venues lack facilities designed for easy transfers.

• Temperature Regulation: Many wheelchair athletes already struggle with impaired temperature regulation below their injury level, and hormonal fluctuations during menstruation can exacerbate discomfort.

The physical environment further compounds these challenges. In many parts of India, training facilities and public restrooms are designed for able-bodied individuals. Conventional Indian-style toilets, insufficient space for transfers, and the absence of proper disposal facilities hinder effective menstrual management. These infrastructural shortcomings not only compromise hygiene but also create constant stress and distraction for the athletes.

The psychological impact is equally significant. Female para-athletes face a double stigma—navigating both disability-related challenges and the societal taboos surrounding menstruation. This dual burden can lead to:

• Performance Anxiety: Fear of leakage or accessibility to washrooms during training/competing sessions can distract athletes during competitions.

• Social Isolation: In male-dominated training environments, the lack of peer support can leave athletes feeling isolated.

• Reduced Self-Confidence: The need for caregiver assistance and difficulties in managing menstrual hygiene can undermine an athlete’s sense of independence and self-worth. As one sports psychologist noted, “The cognitive load of managing menstruation alongside disability-specific concerns creates an additional mental burden that can affect performance and overall enjoyment of sport.”

The insights from our focus group discussions underscore an urgent need for targeted interventions:

• Disability-Specific Research: We must conduct studies focused on the menstrual health needs of Indian para-athletes across different disability categories.

• Accessible Infrastructure: Immediate improvements in facility design are needed to provide clean, private, and accessible restrooms and changing areas.

• Specialised Education: Comprehensive training for athletes, coaches, and support staff on adaptive menstrual management strategies is essential.

• Product Innovation: The development of adaptive menstrual products tailored to the needs of para-athletes must be prioritised.

• Medical Protocols: Establish standardised guidelines for UTI prevention and menstrual management to safeguard athlete health.

By addressing these critical issues, the Simply Periods initiative aims to ensure that managing menstruation does not remain an insurmountable barrier to athletic excellence. Our vision is to create a supportive environment where every female para-athlete can focus on achieving her highest potential.

1. Charls, A. C., Rawat, N., & Zachariah, K. (2022). Menstrual changes after spinal cord injury. Spinal Cord, 60(8), 712–715. https://doi.org/10.1038/s41393-022-00765-2

2. Sipski, M. L. (1991). The impact of spinal cord injury on female sexuality, menstruation, and pregnancy: A review of the literature. The Journal of the American Paraplegia Society, 14(3), 122–126. https://doi.org/10.1080/01952307.1991.11735841

3. Allen, J. B., Stover, S. L., Jackson, A. B., & Richards, J. S. (1991). Autonomic dysreflexia and the menstrual cycle in a woman with spinal cord injury. NeuroRehabilitation, 1(4), 58-62.

4. Gray, S. H., Wylie, M., Christensen, S., Khan, A., Williams, D., & Glader, L. (2021). Puberty and menarche in young females with cerebral palsy and intellectual disability: A qualitative study of caregivers’ experiences. Developmental Medicine & Child Neurology, 63(2), 190-195. https://doi.org/10.1111/dmcn.14698

5. Ertzgaard, P., Campo, C., & Calabrese, A. (2017). Efficacy and safety of oral baclofen in the management of spasticity: A rationale for intrathecal baclofen. Journal of Rehabilitation Medicine, 49(3), 193-203.

   About the author:

   Manasi Satalkar, a movement and physiology enthusiast, is a dancer, runner, and blog writer with a master’s in sports rehab from Manipal. She has worked with swimmers, track and field athletes, and elite women’s football players from Odisha. With experience in both individual and team sports, she advocates for an individual-specific approach to advancing Indian women’s sports performance.