Performance, training and recovery, and the oral contraceptive pill

This article was written by one of The Food Medic team; female health writer – Kelly McNulty.

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There’s been a lot more conversation around the effects of the menstrual cycle on sporting performance and recovery, but often this conversation excludes women who take hormonal contraception, such as the pill. This article aims to shed some light on this topic. 

Hormonal contraception (e.g., oral contraceptive pills, injections, implants, patches, vaginal rings, and intrauterine systems) are used by many active women for the purpose of preventing an unplanned pregnancy as well as other reasons, such as alleviating the symptoms of the natural menstrual cycle (1).

Generally, hormonal contraceptives work by altering the naturally occurring menstrual cycle by changing our internal hormonal milieu. For example, they provide exogenous (synthetic) oestrogens and progestins, which act on the hypothalamic-pituitary-ovarian axis (HPO axis for short) by negative feedback meaning that concentrations of endogenous (natural) oestrogen and progesterone are downregulated or suppressed (2). Because of this altered hormonal profile it’s possible that hormonal contraception might therefore influence the likes of performance, training, and recovery in an entirely different way compared to a natural cycle.

How does the oral contraceptive pill work?

The most common type of hormonal contraceptive used and the type most researched, is the combined monophasic oral contraceptive pill (1). This pill was designed to mimic the natural 28-day menstrual cycle by having 21 pill-taking days followed by 7 pill-free days. Put simply, this pill alters our physiology in two main ways (2):

1. By suppressing the natural hormones which we produce throughout the pill cycle. For example, instead of having our natural sex hormones rise and fall across the menstrual cycle, our natural levels of oestrogen and progesterone are down regulated almost like a flat line throughout the cycle for the 21 pill taking-days; and
2. By providing us with an artificial oestrogen and progestin during the 21 pill-taking days. For example, every time you consume your pill, on your 21 pill-taking days, you’re putting some synthetic oestrogen and progestin into your body, which builds up over time, until the 7 pill-free days when you don’t get this daily spike and instead experience a withdrawal bleed.

The oral contraceptive pill & performance

Despite the prevalence of oral contraceptive pill use, the effects of this pill on exercise performance are poorly understood and the research available is conflicting. To provide some guidance, a recent systematic review and meta-analysis (3) (a type of study which pools the available research we have on a topic, summarises and analyses the quality of evidence) investigated: 

1. The effects of oral contraceptive use vs. naturally menstruating women on performance; and 
2. The effects of oral contraceptive pill-taking days vs. oral contraceptive pill-free days on performance

The results showed that some women who use oral contraceptives might see a very small decline in their performance compared to naturally menstruating women. But, because of the large variation between the studies, the poor quality of the studies included, and the very small effect size, the authors concluded that the focus should be on the individual’s response to their oral contraceptive, as some individuals might experience no performance-related side-effects whatsoever, whereas others might experience substantial performance related side-effects. Additionally, this study also showed that there was no difference in performance between pill-taking and pill-free days.

The oral contraceptive pill & training outcomes

Starting with the caveat – when it comes to training, there are very few studies available which have investigated the influence of the oral contraceptive pill on training outcomes. But caveat aside, in terms of strength training, studies typically report that there are no differences in adaptation to strength training with oral contraceptive pill use compared to non-use (4,5) this means you’re likely to reap the same benefits from training whether you’re on the pill or not. Other studies have shown both positive (i.e., one study found that after 10-weeks of strength training muscle size was increased in women using OCP vs. non-users (6) and negative (i.e., another study showed diminished lean mass gains in response to 10 weeks resistance training and lower anabolic hormone concentrations in pill users (7) effects.

Interestingly though, training responses appear to depend on the type of pill  you’re using. For example, pills that have androgen (meaning hormones that contribute to growth, like testosterone) suppressing progestins might reduce your ability to respond and adapt to strength training, when compared to contraceptives with androgenic actions (7). When looking at endurance training, one study highlights that cardiovascular benefits of sprint interval training might be dampened by pill use when compared to non-use (8), although other studies have shown no differences (5).

The oral contraceptive pill & recovery

Recovery is an essential aspect of all training programs and there’s some evidence to suggest that recovery following training might be affected by oral contraceptive pill use, although – again – studies have provided varying results. For example, a study in female athletes competing at the Olympic Games reported that those taking an oral contraceptive pill had substantially higher markers of inflammation and tissue damage heading into the Rio Games, which might be associated with reduced recovery compared to non-users (9). Likewise, a recent study showed that women using the oral contraceptive pill had higher oxidative stress markers than naturally menstruating women (10).

In contrast, other studies have reported no change in muscle damage markers and recovery in pill users (4,11). Moreover, there’s also some evidence to suggest that markers of muscle damage are greater during the pill-free days compared to pill-taking days which might indicate a change in recovery between pill ‘phases’ (12). In contrast to this, a recent study found that recovery is elevated and drops off quickly during the pill-free days, rising throughout the pill-taking days (13).

Takeaway message

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. As such, from a practical perspective, the key takeaway is to get to know how your own body is feeling by tracking your pill use (i.e., symptoms, performance, training, and recovery effects etc.). Additionally, this might be more impactful if you record this information when you’re taking the pill, then compare it with when you’re not. Finally, if you have any questions about your choice of hormonal contraceptive, or if you’re experiencing any issues, then please always speak with a healthcare professional.

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References 

1. Martin, D., Sale, C., Cooper, S. B., & Elliott-Sale, K. J. (2018). Period prevalence and perceived side effects of hormonal contraceptive use and the menstrual cycle in elite athletes. International Journal of Sports Physiology and Performance, 13(7), 926-932.
2. Elliott-Sale, K. J., & Hicks, K. M. (2018). Hormonal-based contraception and the exercising female. In The Exercising Female (pp. 30-43). Routledge.
3. Elliott-Sale, K. J., McNulty, K. L., Ansdell, P., Goodall, S., Hicks, K. M., Thomas, K., … & Dolan, E. (2020). The effects of oral contraceptives on exercise performance in women: a systematic review and meta-analysis. Sports Medicine, 1-28.
4. Thompson, B., Almarjawi, A., Sculley, D., & de Jonge, X. J. (2020). The effect of the menstrual cycle and oral contraceptives on acute responses and chronic adaptations to resistance training: a systematic review of the literature. Sports Medicine, 50(1), 171-185.
5. Myllyaho, M. M., Ihalainen, J. K., Hackney, A. C., Valtonen, M., Nummela, A., Vaara, E., … & Taipale, R. S. (2021). Hormonal contraceptive use does not affect strength, endurance, or body composition adaptations to combined strength and endurance training in women. The Journal of Strength & Conditioning Research, 35(2), 449-457.
6. Oxfeldt, M., Dalgaard, L. B., Jørgensen, E. B., Johansen, F. T., Dalgaard, E. B., Ørtenblad, N., & Hansen, M. (2020). Molecular markers of skeletal muscle hypertrophy following 10 wk of resistance training in oral contraceptive users and nonusers. Journal of Applied Physiology, 129(6), 1355-1364.
7. Riechman, S. E., & Lee, C. W. (2021). Oral Contraceptive Use Impairs Muscle Gains in Young Women. Journal of Strength and Conditioning Research.
8. Schaumberg, M., Jenkins, D., Janse de Jonge, X., Emmerton, L., & Skinner, T. I. N. A. (2017). Oral contraceptive use dampens physiological adaptations to sprint interval training. Medicine and Science in Sports and Exercise.
9. Larsen, B., Cox, A., Colbey, C., Drew, M., McGuire, H., Fazekas de St Groth, B., … & Minahan, C. (2020). Inflammation and oral contraceptive use in female athletes before the Rio Olympic Games. Frontiers in Physiology, 11, 497.
10. Quinn, K. M., Cox, A. J., Roberts, L., Pennell, E. N., McKeating, D. R., Fisher, J. J., … & Minahan, C. (2021). Temporal changes in blood oxidative stress biomarkers across the menstrual cycle and with oral contraceptive use in active women. European Journal of Applied Physiology, 1-14.
11. Savage, K. J., & Clarkson, P. M. (2002). Oral contraceptive use and exercise-induced muscle damage and recovery. Contraception, 66(1), 67-71.
12. Romero-Parra, N., Rael, B., Alfaro-Magallanes, V. M., de Jonge, X. J., Cupeiro, R., & Peinado, A. B. (2021). The Effect of the Oral Contraceptive Cycle Phase on Exercise-Induced Muscle Damage After Eccentric Exercise in Resistance-Trained Women. The Journal of Strength & Conditioning Research, 35(2), 353-359.
13. Sims, S. T., Ware, L., & Capodilupo, E. R. (2021). Patterns of endogenous and exogenous ovarian hormone modulation on recovery metrics across the menstrual cycle. BMJ Open Sport & Exercise Medicine, 7(3), e001047.