Menstruation is a biological process with cultural and social meaning, often negative,^1,2 that plays an important role in the construction of the female identity and body image.³ The effects of menstruation on physical and mental health, and on sexuality, as well as the perceived limitations it imposes on spare time, are part of the situations to which women are exposed during this stage.⁴ In spite of its relevance, menstruation is a subject that is little considered in scientific spheres, perhaps due to factors such as the silence that women keep about everything it implies or the little education they have about it.⁵

Women have competed in the Olympic Games since 1900,⁶ and from then on, their participation has increased, so much so that for the 2016 Rio Olympics, they represented 45% of the competitors.⁷ However, it should be noted that women's sport performance differs from that of men for biological, psychosocial, and cultural reasons related to the sports environment.^8-10

In Colombia, Konovalova & Rivera-Echeverry¹¹ report that more than 91% of female athletes compete and train while they are on their period. On the other hand, Maturín-López & Landázuri-Munares¹² describe that 24.8% of the analyzed athletes perceived they had a worse physical performance, while 13% felt that their performance was better. The latter finding could be related to the fact that the athletes perceive an increase in flexibility, as stated by Prado-Seoame.¹³ During the premenstrual and menstrual phases, the levels of estrogens and progestins decrease, producing psychological changes such as depression and irritability, and physical discomforts such as breast tension and abdominal pain, which negatively affect sports performance.^14-16

Regarding the regularity of the menstrual cycle, no alterations have been found in elite swimmers.^17,18 However, Coste et al.¹⁹ found that in this population there is a relationship between highly demanding training sessions and increased energy expenditure, on the one hand, and the increase in cases of hyperandrogenism (polycystic ovarian syndrome), on the other.

Using oral contraceptives is common among sports women so that their periods do not coincide with competitions since they consider that during those days, they must deal with pain and the discomfort its treatment implies;²⁰ besides, if bleeding is controlled, anxiety diminishes.^21-23

Menstruation, from the experience of female athletes, has been little studied. Some of the few investigations on this subject were carried out by Moreno-Black & Val-lianatos,²⁴ who found that the participants in their study felt uneasy about the possibility of having their clothes stained with blood and that their sanitary pads would "notice." In turn, Suee-Held²⁵ showed that female athletes are concerned about the perception that their male counterparts have on menstruation and that they fear using tampons during competitions because leaks could occur, and the string can be exposed.

Menstruation affects swimmers in a particular way, so their experience needs to be analyzed in a specific way. In this sense, the objective of this research was to describe the experience of a group of elite female swimmers belonging to a sports league in Bogotá D.C., Colombia, with respect to menstruation and its impact on sports practice.

This is a qualitative study with a descriptive phenomenological approach, in which the experience of female swimmers concerning menstruation and sports practice was analyzed.^26,27

In-depth interviews were conducted^28,29 to ask questions about the menstrual education received, experience of menarche, menstrual hygiene methods (MHM) used, experiences with menstruation in the sports environment, pain management, and possible solutions to difficulties. The interview script was reviewed by an expert and subjected to a pilot test with a senior female swimmer and a junior female swimmer.

The criteria for inclusion were women swimmers in the senior category (between 18 and 29 years old) who belonged to a sports league in Bogotá D.C. and carried out more than three training sessions per week. Given the characteristics of the study and the subject matter to be explored, the sample was defined using the snowball strategy, a non-probabilistic sampling technique in which existing study subjects provide referrals to recruit future subjects,³⁰ that is, qualified persons are asked to identify individuals or groups with special knowledge of the phenomenon;^26,31 this is a very useful strategy to access groups that are difficult to reach or when participants do not want to expose themselves publicly.

Three coaches were contacted through the Bogotá Swimming League to select the participants, referring the first three; they, in turn, helped to contact other swimmers. Data collection was stopped when the content saturation criteria were reached; consequently, nine swimmers were included in the final sample, three for each modality: swimming races, water polo, and open water swimming. Swimmers from three different modalities were included to control bias.

The interviews lasted two hours, were carried out in non-sporting places according to the participants' time and availability, and were carried out by the principal researcher, who had no previous contact with the interviewees. The interviews were recorded and transcribed verbatim. The obtained narrations were entered in text into the NVivo Pro^® program to facilitate the work and ensure transparency between the coding work and the information analysis.

The thematic analysis was done following the Giorgi's method for phenomenological studies, which seeks to describe the experiences of the interviewees.³² Each emerging theme was contrasted with relevant literature and illustrated with quotes from participants.

As per Mora,²⁹ criteria of credibility were applied, on the one hand, by supporting the analysis of the narrative material obtained and comparing the findings with those reported by other authors. Furthermore, criteria of confirmability were applied by practicing the reflexibility inherent to the agreement between researchers with different professional backgrounds and by receiving feedback from the participants on the results.

The narratives were ordered within the units of meaning identified from the objectives of the study and categorized according to the main axes of meaning; likewise, the descriptions were compared and contrasted to later recognize units with common meanings.³⁰ Each participant was given a pseudonym to preserve their identity when quoting them.

This research followed the ethical principles for medical research in humans stipulated in the Declaration of Helsinki 2013³³ and was considered of minimal risk according to the Resolution 8430 of 1993 of the Ministry of Health of Colombia.³⁴ The interviewees read and signed the informed consent. The Research Ethics Committee of the University El Bosque approved this work through Minutes No. 005-2017 of March 23, 2017. The confidentiality and anonymity of the data and the protection of the privacy and identity of the participants were guaranteed.³⁵

The results were arranged into six main themes: characterization of the participants, experience of menarche, MHM, accidents and leaks, physical discomfort of menstruation, and solutions given by the participants. They are described below.

This study describes the perceptions of a group of elite female swimmers regarding how they experience menstruation while training or competing. For this group of athletes, as for Beauvoir,³⁶ menstruation is a biological process that limits women's freedom and its clinical signs and symptoms have implications at the physical and emotional level; it also reflects social and cultural prejudices. As described by Ortega et al.,³⁷ the shame reported by the interviewees, together with the need to hide their periods from coaches and male counterparts, is related to the ancestral rejection of menstruation, which, according to Nussbaum,³⁸ is tied to a misogynist culture that considers the feminine as shameful and the woman's body and its fluids as repugnant and close to animality.

Menstruation is a subject with little visibility in sports medicine. This may be because, according to Costello et al.,³⁹ only 39% of studies in sports medicine have been conducted on female athletes and many of them probably do not address this physiological process. Likewise, menstruation in the analyzed population is endowed with negative social and cultural meanings, which is consistent with what was stated by Brantelid et al.⁴⁰ and Lamborn.⁴¹ In addition, the results suggest that issues related to the menstrual experience are ignored, thus hindering the approach to women's health in a comprehensive manner, as stated by Valls-Llobet.⁴²

Menarche in the participants occurred at an age similar to the Colombian average (between 11.3 and 12.7 years);^11,43 before this event, the swimmers experienced the same feelings of uncertainty described by González & Montero.⁴⁴ This could be explained by the fact that, despite advances in sex education, young women still perceive the arrival of the first menstruation as a strange and unexpected situation, and it is generally associated with the end of childhood and the beginning of fertile life.⁴⁵

Menstruation as an impediment, according to Rodriguez-White,⁴⁶ is a concept reinforced by the menstruation-discomfort-aversion triad that entails the idea of denying any impact that menstruation may have and reinforces negative attitudes in the imaginary. Similarly, according to Puyana-Villamizar,⁴⁵ this situation, is related to suffering, dirtiness, and concealment.

Menstruation can alter sporting performance, not only because women feel the need to hide it, but because it causes physical and psychological symptoms and the discomfort derived from handling them.^24,25,47 For Young,⁴⁸ menstrual blood is a fluid that challenges physical and social boundaries, and when women menstruate they risk losing their emotional stability (normality), so swimmers demand MHM to ensure their safety and protection. Regarding these methods, it was found that using tampons made the interviewed swimmers feel more secure, although they were cautious when they had to stay underwater for a long time because there is a great risk of blood leaking out when coming out of the water.⁴⁹

The knowledge of MHM is limited to the traditional ones: only one participant knew about the menstrual cup and although she had not used it, she had the perception that it was safer. Several authors have presented studies on this particular issue and on the fears and benefits of using different methods.^50-56

Young women trust those who live and understand female processes (other female swimmers, coaches, and health staff). This situation, reported by Fernan-dez-Olguin,⁵⁷ allows us to understand why blood leaks in front of men are embarrassing for female athletes.

The physical experience is related to pain, tiredness, and discomfort. In this respect, Konovalova & Rivera-Echeverry⁵⁸ found that Colombian sportswomen suffer from abdominal pain, mastalgia, lumbago and general malaise during their periods. In the present study, six interviewees said that menstruation limits their performance, while three claimed to have better results in terms of speed; this coincides with what was reported by Prado-Seoane.¹³

Menstrual irregularities such as oligomenorrhea and amenorrhea, although present, were not of concern to participants as they were attributed to environmental factors. Other studies, such as Mountjoy et al.,⁵⁹ Humphrey,⁶⁰ Weiss-Kelly & Hecht⁶¹ and Ranson et al.,⁶² do not directly correlate high performance sports to menstrual irregularities, but associate them with other factors involved such as increased energy expenditure and caloric restriction, which cause hormonal changes.

The little attention paid to the menstrual period in the sports environment and the scarce empathy that some coaches have for the participants regarding their clinical signs and symptoms make it necessary to have a better understanding of this phenomenon. This, added to the scarce information that swimmers receive,⁵⁸ makes the female experience more difficult and produces psychological and social insecurities, so it can be said that menstruation education helps female athletes.⁶³

The group of swimmers interviewed suggested the implementation of comprehensive sex education policies tailored to their experiences and concerns. As stated by Chrisler et al.³ and Britton,⁶⁴ this process requires including issues such as the concept of secrecy, social isolation, safe handling of MHM, and the benefits and negative effects of menstruation. Other recommendations for the formulation of these policies include pain management, access to modern MHM, reducing the stigma of menstruation, and educating colleagues, coaches, and family members to provide support, as proposed by Bobel.⁴

While significant progress has been made regarding women's equality in sports, it is important to build more spaces for equity. Menstruation is a physiological process organized and interpreted in a social and cultural way that has a specific impact on the sports environment and on the quality of life of female athletes. Specifically, the problems faced by female swimmers are related to physical aspects (menstrual cramps and back pain), psychological aspects (depression and irritability) and social aspects (concern about keeping menstruation hidden). Therefore, these issues must be addressed by health professionals, coaches, and family members to provide comprehensive care to women from the beginning of their sporting career.

There is a gap in knowledge about menstrual physiology, MHM and their alternatives, and treatment of cramps and other associated symptoms that impact sports performance. Participants perceive that in the sports environment more importance is given to their performance than to their overall well-being, which is why more guidance and support is needed.

Based on the testimonies of the interviewed female swimmers, it could be said that it is necessary to improve the perception of menstruation in the sports environment, recognizing its biological, psychological and social implications, and thus help athletes in general to lead a fuller and more satisfactory life.

This article derives from the master's degree work entitled "Sexual health from the experiences of a group of female swimmers of a sports league in Bogotá D.C., 2017," authored by Alexandra Caballero-Guzmán.⁶⁵