Menstrual-Related Symptoms, Not Hormonal Phases, Drive Perceived Condition in Female Athletes: A 14-Year Cohort Study

Background Although the effects of menstrual cycle phases on objective exercise performance are generally trivial, athletes frequently report substantial subjective impairment. We examined 14-year temporal trends in menstrual-related symptoms and menstrual cycle dysfunction in elite Japanese athletes and tested whether perceived optimal condition is better explained by symptom burden than by hormonal phase timing. Methods We analyzed 9,130 records from 3,693 female athletes (2008–2021) derived from 9,455 annual medical check-ups using a standardized retrospective questionnaire, excluding records indicating continuous use of hormonal preparations (e.g., combined oral contraceptives or progestin-only preparations). Temporal trends in menstrual-related symptoms (dysmenorrhea, premenstrual symptoms (PMS), heavy menstrual bleeding (HMB)) and menstrual cycle abnormalities (irregular menstrual cycle, secondary amenorrhea, primary amenorrhea) were assessed using multivariate logistic regression. We also evaluated associations between symptom burden (0 symptoms vs. 3 symptoms) and the self-reported timing of best condition. Results From 2008 to 2021, the prevalence of secondary amenorrhea (AOR: 1.089, p  < 0.001) and dysmenorrhea (AOR: 1.040, p  < 0.001) increased, whereas irregular menstrual cycles (AOR: 0.956, p  < 0.001) and PMS (AOR: 0.934, p  < 0.001) decreased. Over the same period, reports of “No Relation” between the menstrual cycle and condition increased (AOR: 1.155, p  < 0.001), while reports of “Post-Menstruation” decreased (AOR: 0.875, p  < 0.001). Perceived condition was strongly symptom-dependent: athletes with three symptoms predominantly reported “Post-Menstruation” as their best condition (68.4%), whereas those with no symptoms most frequently reported “No Relation” (51.1%). A clear dose–response pattern was observed; having three symptoms increased the odds of reporting “Post-Menstruation” by 3.54-fold versus no symptoms ( p  < 0.001). In models including all three symptoms, PMS was the strongest predictor of reporting “Post-Menstruation” (AOR: 2.53), exceeding HMB (AOR: 1.51) and dysmenorrhea (AOR: 1.15). Conclusions Athletes’ perceived condition is better explained by menstrual-related symptom burden—particularly PMS—than by hormonal phase timing, supporting a symptom-driven model of subjective condition. The long-term increase in “No Relation” responses, alongside rising gynecological consultations, suggests that improved literacy and symptom management may be mitigating the perceived impact of the menstrual cycle, even as secondary amenorrhea increased over time.