The influence of female sex hormones on knee laxity, neuromuscular function, and performance: a systematic review

Background
Female-specific research in sport science is gaining momentum, addressing a historical gap where evidence has predominantly stemmed from male participants. Understanding how female sex hormones influence performance and injury risk is essential for developing training and rehabilitation strategies to the menstrual cycle.

Objective
This systematic review aimed to evaluate the effects of female sex hormones on knee joint laxity, neuromuscular function, and performance, identifying patterns, methodological limitations, and implications for athletic practice.

Methods
Following PRISMA 2020 guidelines, systematic searches of PubMed, MedLine, and CINAHL databases were conducted using defined MESH terms. Studies published between January 2010 and June 2025 were screened against strict inclusion criteria, focusing on eumenorrheic women aged 18–45 years old (26.91 years old ± 4.18). Quality appraisal and risk of bias were performed using the PEDro scale, with a cut-off score of ≥ 6/10.

Results
Evidence suggests that female sex hormones may influence aerobic performance and recovery, with exogenous testosterone supplementation showing notable enhancement. Aerobic training may benefit from alignment with mid-cycle phases, while anaerobic and strength training appear less affected. Neuromuscular function remains largely stable across menstrual phases, though some studies indicate improved rehabilitation outcomes during the ovulatory phase. No consistent evidence was found linking menstrual hormones to changes in knee joint laxity.

Conclusion
Emerging evidence supports hormone-sensitive modulation of aerobic performance and recovery, findings across neuromuscular function and joint laxity remain inconclusive and underpowered. Practical applications are emerging, particularly in endurance training and cycle-informed rehabilitation. Further high-quality, longitudinal research is needed to validate insights and inform evidence-based practice.