Twenty competitive UK-based female cyclists were recruited by purposive (criterion-based) sampling (24) based on the following: (a) competitive female cyclist, (b) 18 years and older, and (c) assigned biologically female at birth. Participation level was categorized according to McKay et al.’s (25) tier system. The participants consisted of three elite cyclists (tier 4, competed for a Union Cycliste Internationale (UCI)-registered cycling team), seven sub-elite cyclists (tier 3, competed in national-level domestic competitions), and ten club cyclists (tier 2, competed for an amateur cycling club). The participants were aged 35.1 ± 7.7 years (range 21–45 years). Participants’ training history, characteristics, and racing frequency are detailed in Table 1. The participants competed across a range of cycling disciplines (number of participants competing in discipline in brackets) including road racing (11), criteriums (4), time trials (12), hill climbs (3), indoor racing (e-sports) (4), track (1), gravel (1), mountain bike (3) and cyclo-cross (5), with some participants also competing in triathlon (4) and duathlon (2). All participants regularly rode a road bike in training. Eleven of the participants had a coach, of whom eight were male and three were female.

The study was approved by the Northumbria University Faculty of Health and Life Sciences Research Ethics Committee (project number: 6056). The participants were recruited through the lead researchers’ networks with national cycling federations, cycling teams, and clubs. They were provided with the details of the study, and written informed consent was obtained. The participants were sent a short pre-interview questionnaire which took approximately 10 min to complete to obtain their demographic information and bicycle and saddle makes and models.

To address the research aim, a combination of epistemological constructionism and ontological relativism to inform an interpretivism research paradigm was adopted (26). The lead researcher (a female cyclist, to help build rapport with the participants) conducted semi-structured interviews in English with open-ended questions to allow participants to express thoughts and expand on topics (26). The first part of the interview asked participants about their menstrual cycle and its effect on training and competition based on questions from Brown et al. (27), which are reported separately. This was followed by questions on bicycle setup, overuse injuries, and saddle sores reported in this current study (see Supplementary Material). The interviews lasted 26.1 ± 7.0 min (range 15.3–44.1 min) and were conducted by the lead researcher either face-to-face or online via Microsoft Teams. Interviews were recorded using Microsoft Teams which also produced a transcript of the interview.

The interview transcripts produced by Microsoft Teams were checked by the lead researcher for accuracy and removal of personal identifying information, and where necessary, small grammatical changes were made to improve the flow of the text. They were then re-read by the lead researcher to ensure immersion in the data. The lead researcher (LB) undertook an initial analysis and coding of the transcripts using inductive reasoning in the software program NVivo (QSR NVivo 14). A thematic analysis was conducted following the steps outlined in the study of Sparkes and Smith (26) which is based on a previous study (28). Phase 1: immersion—the lead researcher (LB) immersed herself in the data by rereading the interview transcripts. Phase 2: generating the initial codes—the lead researcher systematically went through the interview transcripts and inductively coded the data into initial codes. Phase 3: searching for and identifying themes—the lead researcher then grouped the initial codes into main and sub-themes. Phase 4: reviewing themes—the lead researcher then reviewed, reworked, and refined the themes by repeatedly reviewing the generated themes and the original data to check that the themes generated captured the essence of the underlying data. Phase 5: defining and naming themes—the lead researcher then reviewed the theme names to check they accurately and concisely summarized the essence of each theme. Phase 6: writing the report—the lead researcher wrote the combined results and discussion sections using this as a further opportunity to refine the themes. A second researcher (NB) acted as a critical friend (29), by reviewing interview transcripts and initial codes and themes. NB and LB then discussed the themes resulting in a few changes to the themes and theme names before the final themes were agreed. The whole research team reviewed the themes, results, and discussion section and agreed with the final themes as decided by LB and NB.

All of the participants reported having suffered saddle sores, which is higher than previously reported where 39%–89% of female cyclists reported saddle sores (6, 14, 17, 18, 30). Previous research has typically involved larger cohorts than this study and was often part of an assessment of all overuse injuries in cycling. Therefore, we acknowledge that one part of this study was focused on researching saddle sores; this may have contributed to a recruitment bias, where cyclists who suffered from saddle sores were more likely to take part. The level of cyclists included in the current study is also a key consideration, as higher-level cyclists spend proportionately more time on their bike training (31), increasing the risk and likelihood of experiencing saddle sores which may explain the variation compared with previous literature.

Nine of the participants who get saddle sores have said their saddle sores are manageable, but this involves them tolerating some pain, discomfort, swelling, and chafing:

Three participants have resolved their saddle sore problems and do not currently suffer from saddle sores:

The type of saddle sores suffered by the participants was wide ranging, and causes were suggested to be due to pressure, friction at saddle contact points, and sweat or a combination of all three, which is similar to the causes suggested by medical consultants (3). The types of saddle sores and vulva symptoms reported by participants were similar to those reported previously by female recreational cyclists (5). Sixty percent of the participants reported suffering saddle sores that were spots, boils, cysts, lumps, and ingrown hairs, which for some participants then became infected:

Fifty-five percent of participants reported suffering discomfort, tenderness, numbness, pain, and swelling in the areas in contact with the saddle such as the vulva, upper thigh, and sit bones.

Some participants also reported suffering blisters and chafing:

Three participants had suffered permanent unilateral vulva hypertrophy where the outer labia is larger and swollen on one side because of cycling. This has been reported previously as a medical issue that affects female cyclists (10, 11). Vulva swelling is speculated to be caused by repeated microtrauma from vibrations and locations of high pressure due to poorly fitted saddles and biomechanical imbalances and asymmetries resulting in loading one side of the vulva more than the other (10–13). The participants suggested that their unilateral vulva hypertrophy was the result of riding poor-fitting saddles for their anatomy and riding style, riding in a time trial position, and prolonged indoor static training. Two participants had sought medical advice, but they reported receiving poor or conflicting advice.

The participants reported saddle sores most occurred in the vulva region (65%) predominantly the outer labia, but some on the inner labia and urethra. This is similar to previous reports in female cyclists where the labia and vulva were the most common location for saddle sores in female cyclists (53%) (6).

Forty percent of the participants reported saddle sores at the upper thigh, which is higher than previously reported (22%) (6); however, this should be interpreted with caution due to variation in methodologies (interviews vs. surveys):

Thirty-four percent of the participants reported saddle sores on the buttocks mainly the sit bones but also the gluteal fold, again higher than previously reported (22%) (6):

The higher percentage of participants reporting saddle sores in different locations is probably because all participants in this study reported suffering from saddle sores in comparison with Gaither et al. (6), where only 39% of the female cyclists said they had suffered saddle sores. This may be due to the different methods in gathering the data. Gaither et al. (6) used a survey which does not allow the researcher to probe the participants for detail or clarify with the participants who may have a different understanding of what constitutes a saddle sore, whereas interviews allow a much richer capture of participant experiences (32).

The biggest impact of saddle sores was that they reduced the enjoyment of cycling due to pain and discomfort (4), with 75% of the participants reporting they just put up with the discomfort and pain of saddle sores.

In more severe cases, the participants reported having to take a break from cycling due to saddle sores which can result in loss of fitness (5, 16).

Long bicycle rides were the most reported factor to increase the risk of saddle sores developing along with high training volume agreeing with previous research (3, 5, 12, 16). Elite cyclists typically have higher weekly cycling volumes compared with club cyclists (Table 1), potentially putting them at higher risk of saddle sores.

Another risk factor mentioned by the participants was ill-fitting cycling shorts and poor chamois design:

Another risk factor reported was ill-fitting saddles for a rider’s anatomy and riding position and poor saddle design which has been previously reported (16).

One participant commented that it is often the combination of the cycling shorts and saddle that increases the risk of saddle sores developing:

The participants reported that time trial position and riding on the drops increased the risk of saddle sores particularly in the vulva and upper thigh region:

This agrees with previous research that has found having the handlebars lower relative to the saddle increases perineum saddle pressures and decreases genital sensation (17, 19). Additionally, when riding on the drops, female cyclists have a significant increase in maximum pressure on the anterior of the saddle which does not occur in male cyclists (21).

The participants also reported indoor cycling on a static trainer as a risk factor for saddle sores and increasing discomfort due to the fact that you do not move around and change position as you would on an outdoor ride:

Another factor that participants mentioned influences saddle discomfort and pain is rough road surface and off-road cycling which has previously been reported to increase the odds of saddle sores developing compared with urban road cycling (6).

Wet weather was another factor mentioned by a few participants that increased the risk of saddle sores developing:

Another risk factor mentioned by a few participants was that biomechanical or strength asymmetries can increase the risk of one-sided saddle sores, and this has been highlighted previously (4).

A popular treatment for saddle sores used by 65% of the participants was treatment creams in particular Sudocrem (barrier and antiseptic healing cream for skin), which has previously been mentioned by UK female recreational cyclists (5):

For more serious saddle sores, six participants had sought medical treatment such as medicated creams with steroid formulations or antibiotics for infected saddle sores (3, 16). As mentioned previously, saddle sores are not well understood by general medical practitioners or gynecologists, and four participants reported receiving poor or conflicting advice:

One participant's large saddle sores required surgical drainage several times. A combination of excess fluid drainage and antibiotics is standard treatment for this type of sore (16).

In line with Bury et al. (3), the participants reported that for severe saddle sores, they took a break from riding their bicycles or missed some sessions. However, they tended only to do this for severe cases to avoid missing training and the potential loss of fitness (16). This has the potential to have a greater impact on elite cyclists as cycle racing is their occupation; taking a break from cycling could mean missing races and also loss of fitness which could impact race results on return from saddle sore injury and professional cycling contract renewal.

Additionally, the participants reported modifying their training either by reducing cycling volume by making sessions shorter, riding out of the saddle, or cross-training off the bicycle. Again, modifying training has previously been reported as a method to manage saddle sores (16):

One participant reported cold water helped for bruising and swelling-type saddle sores, and it has been recommended to apply a cold compress to the vulvoperineal region to reduce swelling (12).

Another participant who suffered one-sided saddle sores found that addressing leg length difference with a pedal/cleat shim and physiotherapy to address strength imbalances resolved their one-sided saddle sores. Addressing asymmetries was one of the key recommendations of Fallon et al. (4) to help prevent saddle sores.

Unsurprisingly, when participants experienced saddle sores, they would often change their saddle, sometimes going for a bike fit to address this issue. This is in line with previous recommendations that cyclists have a professional bike fit to adjust position to help address saddle sore issues (4, 5).

Most participants treated and managed saddle sores by themselves, sometimes talking to their coach to get training modified or a bike fitter to help advise with saddle choice and bicycle setup. Several researchers have commented on the lack of quality information and education for cyclists, coaches, and medical practitioners on treatment, management, and prevention of saddle sores for female cyclists (3, 5, 16, 18). Harrison and Edey (5) highlighted that effective management of early symptoms may prevent more significant symptoms from developing that potentially require surgical management or cause permanent damage.

The participants highlighted that well-fitting cycling shorts with a chamois pad that suited their anatomy helped prevent saddle sores. This has been reported previously by other cyclists as helpful (5) and has been recommended by medical consultants to help prevent saddle sores (3, 4, 10, 16).

One participant highlighted that not wearing underwear beneath cycling shorts helped improve saddle comfort. It has been recommended that cyclists do not wear underwear beneath cycling shorts (4, 16). However, as this participant highlighted, this is not known to novice cyclists, and therefore education is required.

Forty percent of the participants reported using anti-chafing or chamois creams to help prevent saddle sores which is similar to previous reports by female recreational cyclists where 37% used chamois cream (5).

Medical consultants have recommended using anti-chafing creams (3), and a review by Napier and Heron (16) found the most commonly cited method to prevent saddle sores was using chamois cream. However, there is a lack of evidence for the use of anti-chafing creams as the only study that assessed anti-chafing creams did not have a comparison control group where the cyclists used no creams (7). Additionally, there have been reported negative effects for some riders with chamois creams causing skin pore blockage leading to folliculitis (16), as reported by one participant in this study:

Several participants mentioned personal hygiene and getting showered and changed straight after completing a ride, and avoiding café stops was important to prevent saddle sores from getting infected. Good personal hygiene has been recommended by researchers and medical consultants previously, e.g., showering straight after cycling and removing and washing the kit to prevent infections associated with saddle sores such as folliculitis and ulcerations (3, 4, 16). There is a lack of objective evidence to support this recommendation; however, several participants reported that this was important:

Several participants mentioned how stopping shaving pubic hair had a massive beneficial effect if they suffered spots and ingrown hair type saddle sores, and this has been recommended by medical consultants and other female cyclists (3, 5).

It has been suggested that elevating the lower limbs during rest periods to promote lymph drainage of the perineum and pelvis and physiotherapy to simulate alternative lymph drainage pathways could help prevent vulva lymphedema (12). However, none of the participants in this study mentioned either of these prevention and management methods.

Several participants suggested changing riding position and pedaling out of the saddle for periods of a ride can help prevent saddle discomfort. Previous research has found that standing >20% of the time when cycling reduced the odds of genital numbness (6). Additionally, as mentioned previously, addressing strength and mobility asymmetries in the lower body and leg length difference can prevent saddle sores (4).

One of the key prevention methods to stop saddle sores from developing is getting a saddle and bicycle setup that suits a rider's anatomy and riding position (3, 16), as highlighted by this participant:

It has been suggested that females use a wider saddle without an anterior nose (10). However, four participants reported suffering saddle sores specifically when they rode a wide saddle without an anterior nose. Often, these saddles are too wide for a rider's anatomy, as reported by this participant who cable-tied the nose of the saddle to make it narrower:

Several participants talked about the lack of information on female saddle sores and the difficulty in finding advice on how best to prevent and manage saddle sores and guidance on saddle choice for female riders.

Fifty-five percent of the participants in this study highlighted that they want more research into female saddle design and bicycle setup to prevent saddle sores and make it easier to find a comfortable saddle. This echoes the call for more research and products designed to address female saddle sores by Great Britain female cyclists (33). In the scientific literature, saddle sores are a male-dominated issue (16), and there is limited quality research into female-specific saddles (5). The existing research has various limitations: small sample size, limited time of participants riding the saddles [can be as little as 4 min, only two studies had a follow up after real world riding (8, 34)], some studies were observational so participants were riding their existing saddle, lack of standardized bicycle setup, and lack of variables measured [in particular, pelvic and vulva morphology (21, 35) and effect of pressure on vulva tissue oxygenation and vibratory thresholds (34)] to help determine what makes a saddle more comfortable (8, 17, 34, 36–39). This lack of underpinning research results in a shortage of information and guidance for female cyclists.

The participants rode 2 ± 1 different types of saddles across their bicycles. Five of the participants rode saddles sold as women's specific only, three participants rode a mixture of women's specific and unisex (or men's) saddles, and twelve participants only rode unisex (or men's) saddles. This is different from what has recently been reported for national-level Spanish cyclists where there was a 50% split between women's specific and unisex; however, more experienced cyclists tended to favor a unisex saddle (30). The saddles were from 14 brands and varied in saddle shape, but 95% of the participants rode saddles with a central cutout or channel through the middle of the saddle, with some saddles designed specifically for riding in time trial position or aggressive aerodynamic road position. This is a large change from what has previously been reported, where only 45% of female cyclists used a saddle with a cutout and the rest a traditional saddle which is solid and domed along its length (37). This reflects the development in saddle design and the greater range of saddles available over the last 15 years.

Different shaped saddles have been demonstrated to influence peak and mean saddle pressures and the location of peak pressures (37–39), genital–perineal vascular perfusion (34), and also saddle comfort (8, 30). Saddles with cutouts or channels can relieve pressure on the center of the vulva and soft tissues which is important as the vulva is not designed to be weight-bearing (5). However, previous research has demonstrated that a cutout saddle can increase mean perineal saddle pressures with the highest pressures along the edge of the cutout (37). In this study, although 95% of the participants rode a saddle with a cutout, 85% still suffered problems with saddle sores. A female-specific saddle or cutout may not resolve the issues. There is a wide variety in vulva morphology (35, 40), so it is highly unlikely that one saddle design will suit all females, and this is probably why saddle type has not been shown to be associated with the prevalence of saddle sores (6).

Eight participants had specifically had a bike fit due to saddle sores and discomfort. The bike fitters used two systems to try and identify suitable saddles. These were systems to measure the sit bone (ischial tuberosity) width and saddle pressure mapping. However, as mentioned above, vulva morphology is also important in saddle fitting and is probably a reason why a participant reported that having a saddle chosen solely on sit bone width was not successful:

Saddle pressure mapping can assist a bike fitter in identifying locations of high pressure that may indicate the likelihood of a saddle sore developing (4), which can help in saddle selection and bicycle setup:

However, although saddle pressure mapping can be helpful, as this participant mentioned even after trying lots of saddle options, the best option still didn't provide a perfect solution, so the success of the bike fit also depends on having appropriate saddle choices for females and highlights the need for more research into female saddle design:

Several participants reported receiving poor advice from the bike fitter:

Often participants were frustrated that they had not been able to find a comfortable saddle and therefore rode a saddle that for them the discomfort was manageable:

The participants often asked for saddle recommendations from other riders:

Another method used by participants to try and find a comfortable saddle was researching online for information on saddles. However, this can be limited because of no specific advice based on individual anatomy.

Some participants rode for teams with saddle sponsors, and this could create challenges in getting a comfortable saddle, as two riders reported they had to ride a team saddle even though it gave them severe saddle sores:

Whereas another participant reported that, because several members of their team had suffered severe saddle sores on team sponsor saddles, they were allowed to choose their own:

Only the elite riders reported having a saddle sponsor for their teams; therefore, this is an issue that is only relevant to professional cyclists, and the influence on riders' comfort depends on the professional cycling team's approach to saddle choice.

Ultimately, for most participants (65%), their current saddle was chosen through a process of trial and error often based on bike fits and recommendations. Due to the complexity in determining the best saddle and setup for an individual rider, this is often the recommended process (4).

However, several participants mentioned that the long trial-and-error process of purchasing and then trying different saddles, going for bike fits, and modifying bicycle setup is expensive and can be a barrier to finding a comfortable saddle and bicycle setup. This in particular can deter recreational cyclists or those from lower-income backgrounds preventing them from cycling if they cannot find an affordable and comfortable setup (5).

The participants owned on average 3 ± 1 bicycles from a range of 27 manufacturers. Four of the participants rode bicycles sold as women's specific only, six participants rode a mixture of women's specific and unisex (or men's) bicycles, and ten participants only rode unisex (or men's) bicycles. Fourteen of the participants had a professional bike fitting. Typical changes participants had made to their bicycle setup were narrower handlebars, shorter crank length, stem length changes, and changing saddles. Some of the participants struggled to describe specifically what had been changed on their bicycle because their partner or bike fitter had made the changes.

Bicycle position can influence saddle comfort (3), so this needs to be assessed in conjunction with saddle choice. It has been suggested that having the saddle too high may tilt the pelvis laterally to a rider’s dominant side, which could increase the risk of saddle sores on one side (4). A couple of studies have recommended the saddle nose tilted slightly downwards to reduce the incidence and symptoms of saddle sores (4, 10). Of the eleven participants who discussed saddle angle, six had a downward tilt and five a level saddle. One participant mentioned a downward tilt was important for comfort; however, another participant noted that for them a level saddle was better for power production:

Several participants mentioned the role of bicycle position in conjunction with the saddle to improve comfort while in an aerodynamic position for performance.

Six of the participants mentioned discussing saddle sores with their coach, often so the coach could modify their training and to get alternative saddle recommendations.

One participant mentioned her coach was not interested in the fact that she suffered saddle sores:

Several participants said they do not discuss saddle sores with their coach as they do not want to miss training:

One participant highlighted that most bike fitters are male which can be a barrier to conversations, as female riders may be embarrassed or uncomfortable discussing exactly where is sore. It has been reported that elite athletes do not discuss saddle sores with support staff and saddle sores are deemed a taboo subject (18). Additionally, some male bike fitters can lack understanding of female saddle sores, and several participants reported being given poor advice. This highlights the need for education for coaches and bike fitters to provide female riders with appropriate advice on saddle choice and bicycle setup and guidance on how to broach this topic with female riders and the correct terminology for female anatomy.

It is important to note some limitations in the application of the current findings. Although a relatively small sample size, this is a unique population group, and given the high level of athletes included, it limits the sample size available to interview. All the participants in this study were UK-based, and therefore their experiences may not be representative of cyclists in other countries and from different cultural backgrounds. This study does not include older female cyclists who are perimenopausal, menopausal, and post-menopausal, and increased age is a risk factor for increased vulva discomfort (14). Therefore, the experiences of the participants in this study may differ from those of older female cyclists. As previously mentioned, saddle sores are seen as a taboo topic (18), which may mean the participants did not share their full experiences due to embarrassment. Additionally, we only interviewed the participants once about their experiences of saddle sores, and therefore, due to the retrospective nature, there is the possibility of recall bias (41).

The lead researcher is a female cyclist and conducted all the interviews. Her knowledge and personal experiences helped build a rapport with the participants and may have helped participants' comfort levels to share their experiences which is important in qualitative research (42). However, it is important to acknowledge that, as a co-creator of the data, the lead researcher's personal experiences had the potential to shape the direction of the interviews and exact questioning (43). The lead researcher was reflexive and discussed the findings and interpretations of the data with the research team to get an outside perspective.