Birth Control to the Rescue? How Oral Contraceptives REALLY Impact An Athlete
Emily R Pappas, MS
“I’ll do just about anything to make sure I get my period. I’ll eat an entire jar of peanut butter if I have to!”
That’s a quote from ironman champion and triathlete Meredith Kessler.
Meredith has always loved running. At 14, she would run up to ten miles before school everyday. Her passion for sports continued into high school where she became a four-sport athlete in track, field hockey, swimming, and lacrosse.
But at the age of 19…something was wrong.
Meredith hadn’t had her first period.
Now we know this should have been a BIG RED FLAG. In The Danger of RED-S, we talked about how absent or unpredictable periods mean your body is being under-fueled.
But Meredith’s doctor did what most medical professionals do: prescribed oral birth control.
Girls, it’s time we talk about it. Period issues like missed periods or abnormal cycles are a SIGNAL.
Taking an oral contraceptive for period regulation is a BANDAID- NOT a solution.
Oral Birth Control: Quick Fix For A Long Term Problem
Fresh from High School, Meredith discovered she had borderline osteoporosis.
“I had borderline osteoporosis because I wasn’t getting those regular doses of estrogen,” she explained. “I was breaking things so easily…I remember how devastated I was when I broke my hip while competing and my dad had to carry me off the track.”
The bottom line is that female athletes who sustain high training loads are more likely to see changes in the menstrual cycle. These changes, like oligomenorrhea (irregular cycles) and amenorrhea (complete absence) mean BIG RISKS to your long term health.
No one thing causes menstrual changes. But, most of the time, it comes down to STRESS on your body (from training, competition, school, family, etc.), coupled with inadequate recovery (lack of sleep, lack of downtime, low energy intake, etc.).
Your body is trying to SURVIVE.
When stress levels never let up, you aren’t recovering. Your body’s survival instincts kick in.
Anything your body doesn’t deem “vital” for survival doesn’t get the energy it needs to function…and one of these systems, you guessed it, is your reproductive system. (3)
If you aren’t trying to get pregnant, this might not look like a problem.
But it IS a problem.
Your body is an INTEGRATED system. It doesn’t just use hormones like estrogen for making babies. Hormonal trouble can lead to gastrointestinal problems, cardiovascular risks, and, most important to the longevity of your athletic career…severe damage to your bone health.
Now, we want to dive into the practice of taking oral contraceptives to “fix” period problems. And how OCPs can put your performance- and career- at risk.
Bones 101: How Hormones Change Your Skeleton
“Amenorrhea is also linked to a reduction in the body’s capacity to absorb calcium, decreases bone density and increases the risk of musculoskeletal injury.” (8)
Your body starts building bone mass during puberty and reaches its peak around the age of 26.
What does this have to do with missing a period?
Estrogen, the hormone your body produces during your normal cycle, does more than help your ovaries mature an egg. It also affects BONE FORMATION.
The Life Cycle of A Bone
Did you know your bones undergo a recovery process, too?
Mature bone tissue is broken down and reabsorbed by the body and new bone tissue is formed to take its place. This happens throughout your entire life. The building cycle is called Bone Formation, and the breaking down is called Ossification.
Your bones are broken down by cells called Osteoclasts.
Estrogen has a unique impact on osteoclast cells. It slows their activity down enough that the body is able to not only rebuild but increase formation and mineralization. (4)
During puberty, estrogen, coupled with growth hormones and insulin-like growth factors, give the body a tremendous boost in the bone-building process. Estrogen also drives the end of puberty where the epiphyseal opening of the bones is closed.
When this happens, your body is pretty much done creating bone mass. 90-99% of your lifetime bone mass has been built. (2) Post-puberty, healthy women with good estrogen levels balance ossification and bone formation, maintaining bone density through adulthood.
You see, you shouldn’t have to worry about things like osteoporosis until after menopause… when the loss of estrogen during menopause throws this balance off.
Weak bones mean high risk of injury. The fact that high-school aged female athletes are seeing signs of osteoporosis before they’re 20 means that something is seriously wrong!
How Bone Mass Gives You A Lifetime Advantage
When you mix sports training with puberty, estrogen, and the right amount of fuel for recovery…you not only build the best platform for your next competition, you give yourself a lifetime advantage in strength and health.
Studies show that adolescent females who participate in competitive sports and strength training have a HIGHER BONE MINERAL DENSITY in adulthood than those who don’t. (9)
Here’s the catch:
You ONLY get this advantage if your body is primed to build bone mass during puberty.
Getting Enough Fuel to maintain good energy balance
If your period is missing because of stress, your body isn’t making the estrogen it needs to build bone mass.
This means a high risk of injury now…and throughout your entire career! (5)
ORAL CONTRACEPTIVES TO THE RESCUE……OR ARE THEY?
Constant injuries made Meredith Kessler rethink ovulation. She decided to ditch the oral contraceptives at 26 and make a commitment to solving what was really holding her performance back: under-fueling.
Was the doctor wrong to prescribe them to her in the first place?
Prescribing oral contraceptives to female athletes is a common way to address period problems. Cognitively, it makes sense why the oral contraceptive pill (OCP) containing estrogen and progestin would help those suffering from amenorrhea.
The problem? Studies on OCP’s effects on bone mineral density is not only INCONCLUSIVE (3) but also have demonstrated a DECREASE in bone mineral density when administered to athletes during this pubescent period (10).
The reasons why are still unclear. But we do know this:
When athletes take an OCP they are putting what is called an “exogenous synthetic hormone” into their body. When your body gets an outside hormone, it stops making its own.
To get technical, the OCP systemically controls concentrations of endogenous sex hormones by reducing your natural production of estrogen and progesterone via the inhibition of the hypothalamus-pituitary-gonad axis (5).
Basically, the OCP inhibits ovulation…so there isn’t any egg available to fertilize.
“But I still get my period on the pill!?!”
Yes and no.
The period that you are getting while on the pill isn’t a real period.
It’s a withdrawal symptom from the lack of hormones your body is getting during the blank pill week!
Now…just to be clear….there are MANY OCPs out there that differ in hormone type (estrogen only, PROGESTIN* only, combo pills) as well as hormone fluctuations (monophasic, biphasic, triphasic).
Unfortunately, modern science has not performed enough research on the different type of SYNTHETIC hormones in these pills as well as the different fluctuating pill types. But what we do know is that OCPs are an EXOGENOUS HORMONE that STOPS OVULATION.
What does missing a period mean for an athlete?
If you are missing a period…you are not ovulating.
If your body is not doing something it should be doing…don’t you think the first questions we SHOULD be asking is “WHY?”
Taking an OCP to “just put the hormones back in the system” doesn’t fix WHY the problem is happening in the first place. In fact, OCP drastically decreases the production of your natural hormones completely. (2)
For a growing adolescent, this could be disastrous to long term health.
Remember, your body is an INTEGRATED SYSTEM. Even when we consider just estrogen, we know it has an effect not just on your reproductive system, but also your bone health, your metabolism, and your energy levels (3).
When you take an exogenous hormone and stop your natural production of that hormone, you are tampering with more than just your reproductive health.
When considering your bone health, it would make sense why doctors believed the OCP would help females who are missing their periods receive the estrogen needed to inhibit osteoclast activity.
BUT HERE’S THE THING: the estrogen in your OCP is not the same as the estrogen your gonads produce.
That means it’s very possible that exogenous or outside hormones don’t work the same in this bone growth process. In a study performed by Nazem and colleges, athletes suffering from the female athlete triad who were provided with oral estrogen showed a DECREASE in systemic IGF-1 (an essential bone remodeling hormone) and therefore had NO benefit on bone health (6) .
But even these studies are unclear about how OCP relates to bone mineral density. If a girl is given OCP because she is missing her period due to RED-S (i.e. she doesn’t have enough fuel), she’s also missing the energy and nutrients she needs for bone formation in the first place.
Long story short….taking an OCP because you’re missing your period doesn’t address the actual problem you’re having.
If putting a girl at risk for fractures and injuries wasn’t bad enough, taking OCP during this pubescent period can have LONG TERM effects on total Bone mineral density. A long term study in 1995 demonstrated athletes on OCP for 5 years showed a decreased peak BMD (bone mineral density) when compared to non-OCP counterparts (8).
Another more recent study in 2001 showed that those athletes taking OCP and following a resistance training protocol had a DECREASE in peak bone mineral density compared to non-OCP counterparts participating in resistance training (10).
Although EVERY athlete is different, it is important to understand regardless of the positive or negative effects on bone health, OCPs are just a BANDAGE for the larger concern of females missing their menstrual cycle.
A WORD ON OCPs For OTHER REASONS Beyond Irregular Menstrual Cycles
Just to be clear: I’m NOT against birth control.
So maybe you don’t have menstrual cycle issues, but you have other physical issues like extreme cramps, a heavy flow, or acne. Maybe OCP is the easiest choice for personal sexual wellbeing.
When it comes down to it, this is completely up to YOU and your doctor.
I’m just here to equip you with the right information.
NEVER, never ever go to your doctor and hide the fact that your cycles aren’t regular or that they’ve stopped. And, make sure you tell your gynecologist about your level of training!
Remember hormones affect one another. And reducing the production of your own hormones CAN and WILL have effects on your other hormones both NOW and in the future.
So before you jump on the OCP train, make sure you consider the risk to reward ratio.
If taking the pill is the best way to handle other decisions or physical issues, then go for it!
But if you’re an athlete considering OCP or are on it to regulate missing or infrequent menstruation, you need to get to the root of the problem before it’s too late.
Are you a high-performance athlete with missing or irregular periods? You might be under-fueled. My passion is helping women get to the best level of performance now and helping them build their bodies for a full athletic career. Let’s talk about your training level and your nutrition schedule and get you on the track to success.
(1)Burrows, Melonie, and Charlotte E Peters. “The Influence of Oral Contraceptives on Athletic Performance in Female Athletes.” Sports Medicine, vol. 37, no. 7, 2007, pp. 557–574., doi:10.2165/00007256-200737070-00001.
(2)Cromer, Barbara A. “Menstrual Cycle and Bone Health in Adolescents.” Annals of the New York Academy of Sciences, vol. 1135, no. 1, 2008, pp. 196–203., doi:10.1196/annals.1429.032.
(3) Eguiguren, Maria L, and Kathryn E Ackerman. “The Female Athlete Triad.” YOUNG FEMALE ATHLETE, SPRINGER, 2018, pp. 57–68.
(4)Hadjidakis, DJ, and II Androulakis . “Bone Remodeling.” Ann N Y Acad Sci., vol. 1092, 2006, pp. 385–396., doi:10.1007/springerreference_307955.
(5) Korsten-Reck, U. (2016, 03). The IOC Consensus Statement: Beyond the Female Athlete Triad – Relative Energy Deficiency in Sports (RED-S). Deutsche Zeitschrift Für Sportmedizin, 2016(03), 68-71. doi:10.5960/dzsm.2016.222
(6) Nazem TG, Ackerman KE. The female athlete triad. Sports Health. 2012; (4): 304-11
(7) Office of the Surgeon General (US). Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): Office of the Surgeon General (US); 2004. 6, Determinants of Bone Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK45503/
(8) Polatti, Franco, et al. “Bone Mass and Long-Term Monophasic Oral Contraceptive Treatment in Young Women.” Contraception, vol. 51, no. 4, 1995, pp. 221–224., doi:10.1016/0010-7824(95)00036-a.
(9) Stracciolini, Andrea, et al. “Resistance Training for Young Female Athletes .” YOUNG FEMALE ATHLETE, SPRINGER, 2018, pp. 29–41.
(10) Weaver, Connie M., et al. “Impact of Exercise on Bone Health and Contraindication of Oral Contraceptive Use in Young Women.” Medicine and Science in Sports and Exercise, vol. 33, no. 6, 2001, pp. 873–880., doi:10.1097/00005768-200106000-00004.