Approach to sport-savvy contraceptive counselling for athletes

Abstract

Objective

To provide a practical approach for primary care physicians counselling female athletes on contraception choice.

Sources of information

A targeted literature search was conducted in PubMed and Google Scholar for articles published until December 2025 and integrated key current research, including a 2024 cross-sectional study on female athletes’ experiences with contraceptive selection and the 2023 International Olympic Committee’s consensus statement on relative energy deficiency in sport (REDs).

Main message

Athletes frequently report sport-specific concerns are overlooked during contraceptive counselling with their physicians, leading to dissatisfaction and information seeking outside of medical settings. While evidence on the impact of contraceptives on athletic performance is limited, clinicians should address known performance-related factors such as iron status, menstrual symptom management, cycle timing manipulation, body composition concerns, and potential injury risk. Awareness of REDs is also essential, as hormonal contraception can impact menstrual changes that signal low energy availability.

Conclusion

Contraceptive counselling that incorporates an athlete’s sport and performance-related considerations can enhance confidence in contraceptive choice while helping to optimize both health and performance.

Case description

A 21-year-old female varsity cross-country athlete with no past medical history presents with questions about contraception. Pregnancy prevention is important to her, but she is hesitant to start an oral contraceptive pill (OCP) due to concerns about impact on performance and advice from teammates to avoid hormone medications. She has regular menstrual cycles with moderate premenstrual cramps, and her most recent ferritin level was 35 μg/L.

Sources of information

A targeted literature search was conducted in PubMed and Google Scholar for articles published until December 2025. Priority was given to systematic reviews, randomized controlled trials, and large observational studies published in English. Athlete-specific studies were included whenever available, and where evidence was limited, data from active women or general populations were considered if clinically relevant. Key references included a 2024 cross-sectional survey of female endurance athletes’ experiences with contraceptive counselling and selection, ¹ along with the 2023 International Olympic Committee (IOC) consensus statement on relative energy deficiency in sport (REDs). ²

Main message

How to approach patient-centred contraceptive counselling for athletes . More than half of female^* athletes are currently using a form of prescribed hormonal contraception. ³ However, athletes often feel frustrated during contraceptive counselling, especially when their physicians fail to consider sport-specific concerns. ¹ In a recent cross-sectional study, over half of female endurance athletes consulted their family physician for contraceptive advice. ¹ However, nearly one-third of these athletes reported seeking out additional information from other sources because their physicians did not adequately consider their athletic performance during contraceptive discussions. ¹ In contrast, those whose providers considered the athletic context when counselling reported feeling more informed and empowered—an approach consistent with evidence supporting shared, individualized decision making. ^1,4

To provide athlete-centred care, clinicians can adapt the Feelings, Ideas, Function, and Expectations (FIFE) of patients framework to understand the role sport plays in contraception selection ( Box 1 ). ⁵

Box 1. Feelings, Ideas, Function, and Expectations of patients framework.

Feelings

• “Are there any worries or concerns you have about how contraception might affect your body, health, or your athletic performance?”

Ideas

• “What have your teammates or coaches told you about different contraceptive options?”

• “Do you have any beliefs about hormones or specific methods that are influencing your decision?”

• “Which method do you think will suit you best?”

Function

• “How important is athletic performance in your life?”

• “Have menstrual symptoms, bleeding, low iron, or cycle timing affected your training, competitions, or other aspects of your life?”

• “Are there upcoming races, playoffs, or training blocks we should consider when choosing or starting contraception?”

Expectations

• “What are you hoping contraception will help with—pregnancy prevention, symptom control, cycle timing, or something else?”

Data from Stewart et al. ⁵

While this sport-centred counselling approach is particularly useful for high-level (elite or international level) adolescent and adult athletes, it can also be beneficial for recreational or local-level athletes. Even if an athlete is not competing at an elite level, they may still place substantial value on their sport performance. Understanding how sport influences their medical decision making helps build trust and supports patient-centred care for all athletes of reproductive age.

How to guide contraceptive selection to optimize athletic performance . Evidence regarding the direct impact of different contraceptive options on athletic performance is limited due to a lack of high-quality studies and the range of physiologic characteristics (eg, maximal oxygen consumption, muscle composition, strength measures) that impact sport performance. ^6-8 While no formal guidelines exist for sport-specific contraceptive counselling, clinicians can still support athlete-centred decision making by addressing factors that may generally influence performance ( Table 1 ). ^1,9-43 This approach should be considered alongside standard factors such as efficacy and safety that are discussed with the general population. ¹⁴

Table 1.

Performance considerations for contraceptive counselling

PERFORMANCE FACTOR	CLINICAL CONSIDERATION	IMPLICATIONS FOR CONTRACEPTIVE COUNSELLING
Iron deficiency and anemia	Heavy menstrual bleeding can lead to anemia and iron deficiency (ferritin levels <30 μg/L), 9,10 which can impair performance via reduced oxygen transport and oxidative capacity 10,11	Consider avoiding copper IUDs in athletes with heavy menstrual bleeding, anemia, or borderline low ferritin levels as copper IUDs can increase blood loss and reduce hemoglobin and ferritin levels. 12,13 Consider hormonal methods to reduce menstrual bleeding volume for patients with heavy menstrual bleeding or iron deficiency anemia (level I*, general population) 12,14-20
Menstrual symptom management	Symptoms such as menstrual irregularity, cramping, bloating, fatigue, and mood changes can disrupt training and competition 21,22	Assess current menstrual symptom severity and symptom impact on training and competition. Consider hormonal contraceptives to reduce symptom burden (level II, general population) 14,20
Cycle manipulation	While menstrual phase effect on objective performance measures is inconclusive, athletes often perceive that menstruating during key competitions or heavy or intense training sessions can negatively impact performance 21,23-25	Cycle control is possible with the combined OCP, patch, or vaginal ring by continuing active treatment beyond the typical 21-day regimen to postpone withdrawal bleeding. 25-27 For patients wishing to fully avoid menstrual bleeding, consider progestin-only methods as drug-induced amenorrhea is common among patients who use hormonal IUDs (50% after 1 year), DMPA (70% after 2 years), and some progestin-only OCPs 27-29
Body composition concerns	In weight-class, endurance, and aesthetic sports, body composition may impact performance and can be a sensitive topic. 30 Even seemingly insignificant changes in weight for the general population could be impactful for these athletes, especially at the elite level	DMPA has substantial evidence of associated weight gain (level II, general population). 31-33 Other hormonal contraceptive options have not been found to be causally linked to substantial weight gain, but cross-sectional studies of athletes report common perception of weight changes with OCPs. 1,22,34,35 IUDs are possibly a more acceptable choice for athletes who are concerned about body composition changes 1,36
Injury risk	Hormone levels of estrogen, progesterone, and relaxin may impact joint laxity, strength, and neuromuscular control. 37 The ovulatory phase of the menstrual cycle may be associated with increased musculoskeletal injury risk 38	Low-certainty evidence suggests a possible association between combined hormonal methods and a small increased risk of future fractures or joint surgeries (level II, general population); however, study quality is low and risk of bias is high, precluding any injury-based recommendations. 39 Overall evidence on soft tissue outcomes also remains poor in quality and inconclusive. 40 DMPA is associated with reversible reductions in bone mineral density (level I, general population); observational data suggest a possible increase in bone injury risk among collegiate athletes, but overall fracture risk remains inconclusive 41-43
Timing contraceptive start	Side effects are common after contraceptive initiation but typically subside. For example, irregular menstrual bleeding and discomfort are frequently reported following hormonal or copper IUD insertion with symptoms resolving within 3 to 6 months 9	When feasible, initiating a new contraceptive outside of major competitions or playoff periods may help minimize performance disruption from early temporary side effects. For athletes without an urgent medical indication for contraception (eg, heavy menstrual bleeding or dysmenorrhea), the off-season is often an ideal start time to reduce impact on training and competition

DMPA—depot medroxyprogesterone acetate, IUD—intrauterine device, OCP—oral contraceptive pill.

^*Indicates level of evidence.

How to factor REDs into contraceptive counselling . REDs is a common syndrome in athletes caused by low energy availability, affecting multiple physiologic systems and impairing athletic performance. ² Menstrual irregularities (eg, oligomenorrhea, amenorrhea) are key clinical indicators that an athlete has REDs, but hormonal contraceptives can mask or obscure these signs. Withdrawal bleeding associated with combined hormonal contraception (OCP, patch, vaginal ring) is not equivalent to a spontaneous menstrual cycle and may conceal underlying REDs. Conversely, contraceptive-induced amenorrhea does not indicate true REDs, but eliminates menstruation as a monitoring tool.

Clinicians should counsel athletes on these limitations and implement alternative REDs monitoring strategies when hormonal contraception is used. The IOC REDs Clinical Assessment Tool–Version 2 (CAT2) recommends clinicians first use questionnaire-based screening (Low Energy Availability in Females Questionnaire; Eating Disorder Examination Questionnaire; Sick, Control, One, Fat, Food questionnaire, etc), ² followed by full evaluation of primary and secondary REDs indicators for those at risk. In addition to menstrual cycle changes, primary indicators include history of bone stress injuries, low bone mineral density (BMD; as measured via a dual-energy x-ray absorptiometry scan), low total or free triiodothyronine level, an abnormal growth trajectory for adolescent or pediatric patients, and an elevated Eating Disorder Examination Questionnaire global score. Secondary indicators include elevated total or low-density lipoprotein cholesterol level, clinical depression, or anxiety. Other potential indicators can include fatigue, frequent illness, unexplained performance plateaus or declines, gastrointestinal symptoms at rest and during exercise, low libido, low body mass index, abnormal vital signs (bradycardia, hypotension <90/60 mm Hg, orthostatic hypotension), poor iron study results, elevated urine cortisol level, and low blood glucose level. ²

Importantly, it is not recommended to prescribe OCPs to treat amenorrhea or low BMD. For further guidance, consult the 2023 IOC consensus statement and REDs CAT2. ²

How to integrate athlete perspective, performance optimization, and REDs considerations into contraceptive selection . After identifying an athlete’s priorities regarding performance, menstrual health, and REDs monitoring, clinicians must help the athlete translate these considerations into a practical contraceptive choice. ⁴⁴ No single option optimizes all performance-relevant factors; thus, counselling involves balancing trade-offs. Table 2 provides a comparative summary of physician-prescribed contraceptive options across athlete-relevant domains to support shared decision making. ^{12,19,20,26,27,33,35,36,39-43} Although depot medroxyprogesterone acetate reliably suppresses ovulation and is included in Table 2 for completeness, ^{12,19,20,26,27,33,35,36,39-43} it should be considered a last-line option for athletes due to its associations with reversible BMD loss and weight gain, with observational data suggesting a possible increased fracture risk. These effects are especially important in athletes who have a higher prevalence of low energy availability and stress fractures.

Table 2.

Point-of-care, sport-savvy contraception comparison matrix

CONTRACEPTION METHOD	KEY CLINICAL AND PERFORMANCE CONSIDERATIONS
	IRON LEVELS OR BLOOD LOSS	CYCLE TIMING CONTROL	WEIGHT CHANGES	BONE HEALTH AND INJURY RISK	REDs TRACKING
	Avoid anemia and low ferritin levels through manipulation of menstrual bleeding	Avoid bleeding during competition through controlling cycle timing	Minimize any body composition changes associated with contraception	Minimize injury risk associated with contraception	Monitor natural cycle for signs of REDs
Copper IUD	Associated with increased menstrual bleeding flow and duration	No cycle control; irregular spotting for first 3 months	Limited data; no strong evidence of weight gain	Limited data; no strong evidence of adverse bone effects	Excellent: Preserves natural menstrual cycle
Hormonal IUD	May reduce menstrual bleeding	No cycle control, but roughly 50% will develop amenorrhea; irregular spotting for first 3 months	Limited data; no strong evidence of weight gain	Limited data; no strong evidence of adverse bone effects	Difficult: induced amenorrhea removes menses as a clinical marker for REDs
Combined OCP	Withdrawal bleeds are predictable; may reduce menstrual bleeding	Direct cycle control: withdrawal bleeds can be delayed to avoid key competitions	No strong evidence of weight gain	Low-certainty evidence suggests possible small association with fracture risk	Masked: withdrawal bleeds can hide underlying functional hypothalamic amenorrhea
Progestin-only OCP	May reduce menstrual bleeding	No cycle control; irregular spotting is common	No strong evidence of weight gain	Limited data; no strong evidence of adverse bone effects	Difficult: induced amenorrhea removes menses as a clinical marker for REDs
Implant	May reduce menstrual bleeding	No cycle control; 22% will develop amenorrhea	No strong evidence of weight gain	Limited data; no strong evidence of adverse bone effects	Difficult: induced amenorrhea removes menses as a clinical marker for REDs
Vaginal ring	Withdrawal bleeds are predictable; may reduce menstrual bleeding	Direct cycle control: withdrawal bleeds can be delayed to avoid key competitions	No strong evidence of weight gain	Low-certainty evidence suggests possible small association with fracture risk	Masked: withdrawal bleeds can hide underlying functional hypothalamic amenorrhea
Patch	May reduce menstrual bleeding	Direct cycle control: withdrawal bleed can be delayed to avoid key competitions	No strong evidence of weight gain	Low-certainty evidence suggests possible small association with fracture risk	Masked: withdrawal bleeds can hide underlying functional hypothalamic amenorrhea
DMPA (last-line option for athletes)	Induced amenorrhea is common	No cycle control, but up to 71% will develop amenorrhea	Associated with weight gain	Associated with reversible BMD loss; requires drug holiday after 2 years of use or BMD monitoring	Possible induced amenorrhea makes it difficult to use menstruation as a REDs marker

BMD—bone mineral density, DMPA—depot medroxyprogesterone acetate, IUD—intrauterine device, OCP—oral contraceptive pill, REDs—relative energy deficiency in sport.

Data from Lowe and Prata, ¹² Black et al, ^19,20 Hicks and Rome, ²⁶ American College of Obstetricians and Gynecologists’ Committee on Clinical Consensus–Gynecology, ²⁷ Lopez et al, ³³ Gallo et al, ³⁵ Silva Dos Santos et al, ³⁶ White et al, ³⁹ Konopka et al, ⁴⁰ Kyvernitakis et al, ⁴¹ American College of Obstetricians and Gynecologists, ⁴² and Cheng et al. ⁴³

Case resolution

Using the FIFE framework, the clinician should first explore the athlete’s perspective, including her concerns surrounding hormone medications. Specific questions could include the following: “What are your concerns about how the OCP or other contraceptive methods might impact your health and your performance?”; “Why did your teammates advise you to avoid hormonal medications? Have they shared any personal experiences that influenced how you feel about contraception?”; and “Besides pregnancy prevention, which aspects of contraception would be most beneficial for your health and athletic performance: menstrual blood flow changes, ability to manipulate timing your cycle, or menstrual symptom reduction?”

Given her borderline-low ferritin levels and dysmenorrhea, avoiding a copper intrauterine device (IUD) and opting for a hormonal method that reduces bleeding and menstrual symptoms is likely preferable. The clinician should review Table 2 with the patient. ^{12,19,20,26,27,33,35,36,39-43} Due to the localized hormone exposure with the hormonal IUD, this is likely a strong option given her concerns shaped by teammate anecdotes. Because peer experience strongly influences her preferences, referencing recent evidence may be persuasive. In a 2024 cross-sectional study of more than 300 female endurance athletes, 39% perceived improved training with hormonal IUDs, while fewer than 5% perceived negative effects. ¹ Discussing the potential benefits such as induced amenorrhea, possible improvement of iron levels, and menstrual symptom reduction may also help alleviate concerns.

Baseline REDs screening should be performed before IUD insertion using IOC CAT2 guidance. The clinician should begin with a population-specific questionnaire and proceed to full assessment if risk is identified. Although IUD-induced amenorrhea may limit future menstrual tracking, REDs can be monitored using alternative clinical, biochemical, and imaging markers (eg, symptoms, iron studies, thyroid function, lipid profile, and BMD when indicated).

Short-term side effects (eg, short-term cramping, irregular bleeding after insertion) should be reviewed and insertion timed to avoid major competitions, ideally early in the off-season given the typical 3-month period of irregular bleeding following insertion. Arrange a routine post-IUD insertion follow-up appointment at 4 to 6 weeks. Athletes should be encouraged to reach out to their clinician for follow-up if they have any persistent or intolerable negative side effects. With regards to ferritin levels, counsel the patient on dietary iron intake and order repeat iron studies in approximately 3 months. Although the patient is not anemic, consider oral iron supplementation to optimize iron stores and aerobic performance if ferritin levels do not improve with the hormonal IUD.

Overall, this tailored counselling to the athlete’s personal athletic goals, peer influences, and health status fosters trust and empowers informed decision making.

Conclusion

Although high-quality evidence directly linking contraceptive type to athletic performance remains limited, contraceptive counselling for athletes of reproductive age can still be done through a sport-centred approach that goes beyond standard efficacy and safety considerations. By proactively incorporating the athlete perspective and discussing performance-relevant factors such as iron status, menstrual symptom management, cycle timing manipulation, body composition concerns, potential injury risk, and REDs monitoring, clinicians can better address athletes’ unique priorities. This approach can help foster trust, support informed decision making, and help patients align contraceptive choice with both performance and health benefits.

Editor’s key points

• ▸ Female athletes whose family physicians considered athletic context when counselling about contraception reported feeling more informed and empowered—an approach consistent with evidence supporting shared, individualized decision making.

• ▸ While the sport-centred contraceptive counselling approach is particularly useful for high-level (elite or international level) adolescent and adult athletes, it can also be beneficial for recreational or local-level athletes.

• ▸ Relative energy deficiency in sport (REDs) is a common syndrome in athletes caused by low energy availability, affecting multiple physiologic systems and impairing athletic performance. Menstrual irregularities (eg, oligomenorrhea, amenorrhea) are key clinical indicators that an athlete has REDs, but hormonal contraceptives can mask or obscure these signs. Clinicians should counsel athletes on these limitations and implement alternative REDs monitoring strategies when hormonal contraception is used.