Ventilation differences in the menstrual cycle: A systematic review and meta-analysis

Background
Minute ventilation (V̇E) may vary across the menstrual cycle due to cyclical changes in sex hormones, potentially exerting an exercise intensity dependent effect.
Objective
This systematic review and meta-analysis aimed to quantify differences in V̇E, respiratory frequency (RF), and tidal volume (VT) between the follicular and luteal phases at rest, during submaximal exercise (≤90 %V̇O2max), and at incremental maximum (100 %V̇O2max).
Methods
The systematic review adhered to PRISMA guidelines for conducting and reporting systematic reviews. Studies included healthy eumenorrheic females (≥18 years) not using hormonal contraceptives. Studies that reported V̇E in the follicular and luteal phases were included. RF and VT were extracted as secondary outcome measures. Searches were conducted in Cochrane, PubMed, and EBSCO databases in January 2025. Study quality was assessed using the modified Downs and Black checklist for menstrual cycle research. Data were extracted and analysed using maximum likelihood random-effect meta-analyses followed with meta-regressions with intensity and duration as a moderator in submaximal exercise. Publication bias was assessed using Egger’s test. Meta-regressions were also conducted for resting and submaximal datasets using change in progesterone as a moderator.
Results
A total of 35 studies inclusive of 743 participants and 64 paired datasets were included. V̇E was lower in the follicular phase than the luteal phase at rest (ES = −0.64, p < 0.001, I2 = 75.74 %) and during submaximal exercise (ES = −0.89, p < 0.001, I2 = 76.58 %), with no effect of study quality. Meta-regression revealed that duration and intensity did not influence menstrual cycle effect on V̇E in submaximal exercise. At incremental maximum, a small but significant effect was observed towards higher V̇E in the luteal phase than the follicular phase (ES = −0.33, p = 0.03, I2 = 61.5 %) however this effect was no longer observed after removal of low-quality studies. All analyses were coupled with significant heterogeneity. Meta-regression demonstrated that change in progesterone significantly predicted V̇E changes during submaximal exercise (p = 0.02), but not at rest (p = 0.07). RF and VT analyses suggested minimal menstrual cycle effect, with only VT reductions at rest contributing to V̇E differences, this was likely related to the low number of studies included.
Conclusions
The menstrual cycle significantly influences V̇E, with lower values in the follicular phase at rest and during submaximal exercise. Changes in progesterone partially explain the differences in V̇E between menstrual phases during exercise but not at rest. At maximal intensities, hormonal influence on V̇E is minimal which corroborates the hypothesis that physiological mechanisms override hormonal mediation of ventilatory responses at high intensities. These findings suggest potential implications for exercise performance, particularly endurance activities in the luteal phase due to the increased likelihood of hyperventilation.