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HORMONAL CONTRACEPTIVES & FOOTBALL FEATURE / DR TESSA R FLOOD PHD, PROFESSOR KIRSTY J ELLIOTT-SALE PHD What are hormonal contraceptives? Hormonal contraceptives (HC) contain exogenous [external] synthetic hormones that act via negative feedback on gonadotrophic hormones resulting in the chronic downregulation of the hypothalamic-pituitary-ovarian axis and endogenous [internal] ovarian sex hormones. The long-term reduction of endogenous oestrogen and progesterone [the ovarian sex hormones] removes the cyclic fluctuations in these hormones associated with the phases of the menstrual cycle. By inhibiting the production of the ovarian hormones, HC reduce the chance of pregnancy by thickening cervical mucus, thinning the lining of the endometrium, and inhibiting ovulation. HC are designed to prevent pregnancy but are also used for a variety of other reasons, for example: to alleviate symptoms of dysmenorrhea (painful periods), lighten or prevent bleeding, prevent acne, reduce variation in cycle lengths, and to treat other medical issues. When discussing athletic performance and contraceptive choices, it is important to remember that it is a women’s right to choose to take HC.
How common is hormonal contraceptive usage? HC are estimated to be used by around 49% of athletes1 in the United Kingdom (UK) and around 30% of the general population2. In a recent audit of the Women’s Super League in the UK, 28% of players reported current hormonal contraceptive use with 43% being previous users. What are the most common types of hormonal contraceptives? Common types of HC in the UK include the combined contraceptive pill (OCP), progestogen-only pill (mini-pill), patch, vaginal ring, implant, injection, and intrauterine systems. The use of these HC within sport depends on numerous factors, including the location [country] of the athlete. In the UK combined monophasic OCPs are available from pharmacies by prescription and are the most common type of HC used. Table 1 shows the contraceptive types and brand names available in the UK.
Institute of Sport, Manchester Metropolitan University, UK
A cis gendered naturally menstruating women (cycle length 21-35 days) will experience menstruation (also known as menses or having their period) once per menstrual cycle. A period is the shedding of the endometrium layer, which has been built and sustained to allow a fertilised egg to embed. Many women taking HC still bleed; however, these are called withdrawal bleeds and occur due to the fluctuations in synthetic hormones. Withdrawal bleeds do not represent physiological menstruation. As Table 1 shows, many women taking HC stop getting a regular bleed and the effects of HC on bleeding patterns are highly individual. Parker et al.,3 reported that, in 21 elite female Women’s Super League players using HC, 29% (n=6) still got a regular withdrawal bleed and 29% (n=6) stopped bleeding, with the other 42% having infrequent bleeds. Athletic populations have reported using the OCP to manipulate the timing of or omit the withdrawal bleed to reduce the perceived and actual impact of this bleed on performance1.
Table 1: Contraceptive types and further information Type Oral Contraceptive Pills Monophasic combined pill e.g., Microgynon®, Yasmine®, Rigevidon®, Levest, Lucette Monophasic combined pill (28-day preparations) e.g., Microgynon® 30 ED, Femodene® ED Phasic [bi or tri] combined pill e.g., Logynon Phasic [bi or tri] combined pill (28-day preparations) e.g., Logynon® ED, Qlaira®** Progestogen-only pill e.g., Norgeston, Cerazette
Synthetic Hormones Ethinylestradiol & Progestogen Ethinylestradiol & Progestogen Ethinylestradiol & Progestogen Ethinylestradiol & Progestogen Progestogen
How do you take them?
Withdrawal Bleed*
21 pills per packet (constant hormonal exposure) 7-day pill free break 28 pills per packet (21 active, 7 inactive)
Yes, in the 7-day break (lighter) May experience spotting Yes, in the 7 inactive pills
21 pills per packet (3 sections with different concentrations of hormones) 7-day pill free break 28 pills per packet (3 or 4 sections with different concentrations of hormones) Contains active and inactive pills 28 pills per packet, no break between pill packets
Yes, in the 7-day break (lighter) May experience spotting Yes, in the inactive pills
Less Frequent (lighter, less heavy) May experience spotting
Cyclic Contraceptives Ethinylestradiol & Each ring lasts 21 days Yes, in the 7-day break Vaginal ring Progestogen (lighter) 7-day break e.g., NovaRing Ethinylestradiol & Each patch lasts 7 days (use for 21 days) Yes, in the 7-day break Patch Progestogen 7-day break e.g., Evra Long-Acting Reversible Contraceptives Progestogen 3 years Stop or less frequent Implant (lighter) e.g., Nexplanon® Progestogen One injection every 8-13 weeks Irregular or stop (heavier Injection or lighter) e.g., Depo-Provera, Noristerat Progestogen 3-5 years Stop or less frequent Intrauterine System (IUS) (heavier 3-6 months) (depending on brand) e.g., Mirena®, Jaydees®, Levosert®, Kyleena® *Please note, this is just the general advice on withdrawal bleeds, however, this response is highly individual and can differ both between and within women. ** Qlaira contains 26 active pills and 2 inactive, Logynon® ED contains 21 active and 7 inactive pills
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