The contraceptive pill and exercise: A complete guide

Wimbledon 2022 has officially come to an end, and for the first time – 145 years after the very first tournament – players spoke out about the stress of having to wear an all-white uniform while on their period.

Responding to a tweet about why ‘menstruation is never talked about as a possible factor in discussions about top seeds losing in the women’s draw’, Olympic gold medallist Monica Puig said: ‘Definitely something that affects female athletes! Finally bringing it to everyone’s attention! Not to mention the mental stress of having to wear all white at Wimbledon and praying not to have your period during those two weeks.’

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Alicia Barnett, 28, who defeated Jamie Murray and Venus Williams with her partner Jonny O’ Mara in the Mixed Doubles to reach the Quarter Finals this year said: ‘Personally, I love the tradition of all-whites and I think we will handle it pretty well. I think being on your period on the tour is hard enough, but to wear whites as well isn’t easy, but girls can handle it. We’re pretty tough when it comes down to it,’ adding that she hopes the taboo around periods will continue to be worn down by players increasingly speaking about it, leading to funding for more female-focused research into training techniques.

Sports reporter Catherine Whitaker said she’d also like the all-white Wimbledon dress code to change: ‘If they had a clothing policy that affected men in the way that it does women, I don’t think that particular tradition would last. I cannot imagine going into the biggest day of my life, with my period, and being forced to wear white,’

GB tennis player Heather Watson, meanwhile, previously pointed out that she was in a constant state of worry that she’d be photographed leaking through her clothes, when playing at the Australian Open.

We put out an Instagram post about the most recent quotes, and the comments were interesting. One wrote: ‘We used to take the pill 28/28 days to stop the bleed when it was important not to bleed,’ while a further three people liked it, and many athletes have admitted to doing the same, to coincide with training and competitions.

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Menstruation could affect performance in sport and exercise in various ways (which we’ll come onto in more detail below), so it makes sense that women may feel the need (or want) to take the contraceptive pill in order to miss bleeds. But you shouldn’t have to, and if you knew more about it, you wouldn’t need to. 95% of research into training performance is based on males, meaning that a lot of you know no better than to, essentially, hack your bodies to replicate a male’s.

Dr Anita Biswas, a consultant in Sports and Exercise Medicine explains: ‘Less than 5% of training research has been carried out on women, so women end up trying to train the same as males. This is physiologically impossible – women have much lower levels of testosterone and so it’s rare that they’ll be able to maintain as much muscle as men, for example, which can lead to overload and injury.’

The difference between male and female hormones also plays a big part. Dr Stacy Sims, a physiologist and female exercise specialist and author of ROAR, says: ‘Hormone levels affect your recovery, heart-rate variability, how well you adapt to stress, the strength of your immune system, the efficiency of your circadian rhythm (how well you sleep), and how easily you acclimatise to different temperatures – all of which affect how effectively you exercise and recover.’ Cultural expectations compound the physiological oversights. ‘Having to wear white uniforms, for example, could affect how comfortable you are and how well you perform in sport,’ Dr Sims adds.

Sports and exercise medicine consultant Dr Rebecca Robinson explains further ways in which the female body differs to men’s: ‘Women have smaller hearts and a smaller cardiac output, as well as a smaller lung capacity and a higher percentage body fat to men, to sustain the reproductive hormones that make your body stronger. The lack of research means women are less aware of their performance limits, and how to train effectively.’

Dr Sims works closely with female athletes and has first-hand experience in the industry’s male bias. ‘Every training protocol, every test, every recovery modality is based on male data and generalised to women. We need specific protocols based on female physiology.’

Said lack of research no doubt contributes to the fact that lots of women take pill packs back-to-back in order to avoid a bleed and any side effects that come with it, despite advice to take a 7-day break on most combined pills (a pill ‘designed to mimic the natural 28-day menstrual cycle by having 21 pill-taking days followed by 7 pill-free days,’ and the most ‘common form,’ so says McNulty). But is that a problem? And how will taking the contraceptive pill in general, even with a 7-day break, affect your exercise performance?

‘Taking the pill is a very personal and individual choice and sometimes might even be a medical choice, so everyone’s perspectives in terms of positive effects vs. negatives will be different,’ says Kelly McNulty, founder of The Period of the Period.

Some potential plus sides of taking a contraceptive pill when it comes to performance in sport and exercise, according to McNulty, include: ‘Alleviating the prevalence of side-effects associated with the naturally occurring menstrual cycle, such as cramps and/or pain, bloating and headaches, and the ability to eliminate unpredictable menstruation.’

Dr Biswas concurs on all of the above, adding that the use of a contraceptive pill could also help avoid ‘fluid retention’ and ‘iron deficiency’. ‘Elite athletes use more iron because their red blood cells are damaged during intense exercise, so they use more iron to replace them, and loss of blood during menses can cause fatigue and a lack of energy, which can be avoided if you intentionally miss your bleeds with a contraceptive pill.’

(Dr Sims, however, counters that while doctors may advise women to take oral contraceptives to ‘help with iron deficiency, most often it only brings them up to the very low end of normal, which isn’t enough for athletes.’)

Dr Sims adds: ‘Another study found that women using an oral contraceptive showed an increase in muscle hypertrophy as compared to those naturally cycling but, interestingly, there wasn’t a synonymous increase in strength with that increased muscle.’

There’s more. Dr Ashfaq Khan, founder and clinical director of Harley Street Gynaecology, explains that ‘Oestrogen – one of the hormones in the contraceptive pill – can decrease the risk of stress fractures during exercise, as it promotes the activity of osteoblasts – the cells that produce bone, while some pill users have experienced an increase in muscle mass by virtue of oestrogen strengthening the type one muscle fibre and increasing the collagen content of connective muscle tissue.’

So far, so good. But what about the other side?

There’s a common concern in answers from all five of the experts we consulted when it comes to any possible negatives of taking a contraceptive pill on sport: the research is lacking.

Dr Khan poses the ‘possibility of fluid retention, muscle loss, bone density loss, weight gain, breast tenderness and headaches, as well as decreased VO2 max performance,’ but the key is in the word ‘possibility’; there isn’t enough research to give us a definitive answer.

McNulty says: ‘Generally, hormonal contraceptives work by altering the naturally occurring menstrual cycle by changing our internal hormonal milieu. In other words, the concentrations of your endogenous (natural) oestrogen and progesterone are downregulated or suppressed, and because of this altered hormonal profile, it’s possible that hormonal contraception might influence performance, training, and recovery in an entirely different way compared to a natural cycle.

‘For example, a recent systematic review that we authored showed that some women who use oral contraceptives might see a very small decline in their performance (strength and endurance) compared to naturally menstruating women.’

Dr Sims cites a few further studies that suggest there is certainly a difference in how females who take the contraceptive pill recover, compared to those who don’t.

‘We know that the patterning of recovery is different for women on hormonal birth control, in that the first 5-6 days of the active pill is a relatively low hormone profile as it takes time for the hormones to increase baseline saturation levels, and for the second 2 weeks of active pills, for each subsequent day, recovery is reduced and your ability to regulate strain vs recovery is more difficult, then the 2nd day of the withdrawal phase, your hormones have dropped (as your body has excreted them) and it is back to really good stress resilience and recovery. This is a completely different pattern to natural cycles.’

The contraceptive pill masks the function of your natural menstrual cycle, and this can pose an additional problem. ‘One of the critical points to consider is that when women downregulate their ovarian hormones through the use of oral contraceptives, there is no way to determine if they are in low energy availability/RED-S (relative energy deficiency in sport) because the natural cycle is a significant indicator if there is an imbalance between stress and nutritional recovery,’ says Dr Sims.

‘This is the biggest concern for health professionals working with elite athletes, as RED-S can cause a significant increase in soft tissue injury, bone stress reactions/fractures, mood and mental health issues, gut disturbances, cardiovascular disturbances.’ Whether you fall into the ‘elite’ category or not, these are all things you may want to keep in mind.

McNulty concludes: ‘Overall, because of a lack of research and the amount of conflicting research it’s very difficult to make general recommendations on the use of the oral contraceptive pill for exercising women, and the question of whether this pill helps or hinders our performance, training, and recovery remains largely unanswered.’

When it comes to taking pill packs back-to-back without allowing yourself a withdrawal bleed, every expert wagers that there’s no evidence of this being harmful. But, if we keep in mind everything the experts have advised so far, it’s likely that this is due to insufficient studies altogether, as opposed to studies proving that it isn’t dangerous.

Dr Biswas tells us: ‘There is no current evidence that taking back-to-back pill packets affect sports performance, although it would mask any issues such as loss of periods due to RED-S (Relative energy deficiency in sport), which would have an impact on various aspects of exercise performance including strength gains, endurance, decision-making and mood. There is a suggestion that avoiding the withdrawal bleed may also affect bone health in athletes, but again, insufficient research has been done in this area and if it is the case, it may be due to a similar masking effect as what may happen with RED-S.’

Dr Sims adds: ‘Various endocrinologists that I work with have advised that there’s no real harm from backing up pill backs, because the 7-day break is only a placebo.’ This ties in with Dr Biswas’ advice: the withdrawal bleed you experience on an oral contraceptive pill isn’t ‘real’. You’re effectively cloaking your natural menstrual cycle from the get-go, so allowing yourself a bleed won’t necessarily do anything for your body or signal anything that you need to know. ‘The hormone profile a contraceptive pill gives you isn’t natural and doesn’t indicate if your natural endocrine system is healthy,’ says Dr Sims. ‘A withdrawal bleed isn’t a “real” period.’

It’s clear that real change needs to be made in the research world in order to cement the dos and don’ts of taking a contraceptive pill and whether or not you should allow yourself a bleed, but there are certainly things that you can do to bolster your performance in the meantime.

‘The key takeaway is to get to know how your own body is feeling by tracking your pill use,’ McNulty tells us.

Dr Biswas breaks it down for you.

‘Monitor your cycle using a period tracking app, or just by noting down in your phone where you are in your cycle, how motivated you feel, how recovered you are after your last training session and how your session feels, so that you can use that to understand your body more,’ she tells Women’s Health.

For example, if you find that you feel more consistently stronger when you allow yourself a withdrawal bleed, you’re probably better off having one, even if you may experience PMS symptoms for a couple of days. On the other hand, if you haven’t taken a contraceptive pill before but decide you’d like to try one for the consistency it offers in that you’ll always know when you’re due on, but after a few months you’re feeling considerably weaker, maybe it’s not for you.

Where apps are concerned, Dr Biswas adds: ‘Some apps give advice about what to eat and the type of training you should do at different points in your cycle, but beware that there isn’t strong evidence for this advice, and it doesn’t take into account individual responses to hormonal change.’

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