As an active woman, you may consider how things like your diet, workout split, or supplements contribute to how well you perform in the gym, on the track, or wherever you're showing up and being active. Something that isn't talked about much is the possible impact of hormonal birth control on athletic performance and what option is the best for any woman looking to optimize her fitness.

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What Are Some Considerations For Active Women When It Comes To Birth Control And Athletic Performance?

Depending on the sport, an athlete may be constantly tracking markers of performance like muscle mass, amount of weight lifted, VO2 max, mileage completed, reaction time, and more. Considering how hormonal birth control might be impacting various markers of athletic performance is an important metric to add into the mix, with roughly 14% of women of reproductive age utilizing the birth control pill and another 8-10% using an IUD as their main contraceptive methods.  

Many elite athletes may be prescribed birth control to help "manage" their periods, yet studies on the actual impact of birth control on female athletic performance have just started to scratch the surface.

3 Ways Hormonal Birth Control Can Affect Athletic Performance

It's important to note that the effects of birth control on athletic performance are likely to vary depending on the individual and the specific type of birth control being used. Some women may experience side effects from hormonal birth control that could affect their athletic performance.

Masking Overtraining or Under-Recovery

One of the benefits of having a natural hormonal cycle as a female athlete is that changes in the cycle can indicate that tweaks to a woman's training routine are necessary. Loss of a period, changes in cycle length, and appearance of hormone-related symptoms like PMS can all indicate a need to evaluate nutrition, training schedule, recovery time, and other factors that affect athletic performance.  

Relative Energy Deficiency in Sport (RED-S) is a situation in which the body perceives too large of a gap between energy intake and energy expenditure, leading to drops in estrogen levels that can result in amenorrhea (loss of a period), decreases in bone density, and even symptoms like fatigue, muscle cramping, or anxiety. If a woman is adapting to her training routine adequately, she won't be experiencing disruption of her menstrual cycle as a result of training. However, when caloric needs are not meeting the energetic demands of training or a woman is not recovering and adapting to training, the loss of a period can be a red flag for needing to change up an athlete's routine and/or increase caloric intake to meet training needs. A woman who is experiencing a withdrawal "period" on hormonal birth control may miss those signs, as she is either bleeding during the placebo week of her pill or rarely bleeding at all, as happens with some hormonal birth control options.  

Impact Of Hormonal Birth Control On VO2 max

VO2 max is a measure of how much oxygen you use during training. Generally, the higher the VO2 max, the better - it means the body is more efficient at delivering oxygen to muscles. There is some evidence that a combination oral contraceptive (one that contains estrogen and progestin) may lower VO2 max in female athletes, which may possibly make it feel like the athlete can't give 100% during her sport.  

Effects On Testosterone And Muscle Growth

Studies show that hormonal birth control can decrease total testosterone and free testosterone while increasing sex hormone-binding globulin. While this is a reason that oral contraceptives are often prescribed to manage conditions of high testosterone in women (like PCOS), androgens like testosterone are considered beneficial for female athletic performance. Testosterone has an anabolic effect on the body, helping women to build muscle and bone density, as well as to take up hemoglobin and support optimal oxygen delivery to the tissues. Women with low testosterone may experience fatigue, muscle weakness, depression, or other mood disorders, all of which may negatively impact athletic performance.  

Additionally, in another study, women on hormonal birth control containing progestin gained less lean muscle mass in a 10-week training program designed to build strength. They also experienced higher stress hormone (cortisol) levels during and after workouts, as well as lower DHEA, DHEA-S, and insulin-like growth factor (IGF-I) (which play a role in muscle growth) when compared to non-oral contraceptive users. While strength output itself did not vary significantly, in sports where muscle mass is important (Olympic lifting, any sport with weight classes, etc.), athletes may see a decreased ability to build and maintain lean muscle.

Functional Medicine Labs for Athletes on Hormonal Birth Control

There are several functional medicine labs that female athletes can consider to help identify issues that may be impacting hormone health, as well as to stay on top of potential health concerns that may accompany prolonged use of hormonal birth control.  

If an athlete is using birth control to "regulate hormones," the following tests may be an alternative to help discover the underlying reasons for hormonal imbalances:

• Micronutrient evaluation to assess levels of important minerals and vitamins needed for basic metabolic needs and hormone production, including zinc, selenium, magnesium, vitamin C, and B vitamins
• Comprehensive female hormone testing to evaluate levels of sex hormones and their metabolites for a more detailed picture of hormone health
• Thyroid panel to assess for any need to add nutritional intervention or added recovery to meet intense training periods
• Comprehensive Digestive Stool Analysis (CDSA) to assess the gut microbiome for inflammation or dysbiosis that can contribute to hormone imbalances

If an athlete is using hormonal birth control for contraceptive purposes or because she wants a predictable cycle for her sport, the following functional medicine labs can help mitigate any side effects of hormonal birth control:

• Micronutrient evaluation to assess common drug-induced nutrient depletions that can occur as a result of oral contraceptive use, including magnesium, zinc, folic acid and other B vitamins, and more.
• Comprehensive Digestive Stool Analysis (CDSA) to monitor the potential impact of hormonal birth control on gut microbiome diversity and health, as some studies suggest oral contraceptive use may be linked to changes in gut microbiome health in otherwise healthy individuals.

Other Beneficial Testing For Female Athletes

Depending on an athlete's specific sport, competitive level, and goals, several other tests may be helpful in painting a bigger picture of how hormonal birth control can be impacting performance.

• VO Max testing: For athletes where endurance is essential for performance - like runners, cyclists, cross-country skiers, and swimmers - VO max testing can help women understand if their hormonal birth control could be impacting their performance.
• DEXA/body composition scan: While studies evaluating the impact of hormonal birth control on weight gain are still inconclusive, there is evidence that female athletes are more likely to experience increased fat gain while on hormonal birth control, which may impact performance when compared to non-athletic women.
• Regular blood pressure readings: Hormonal birth control can increase blood pressure in women, and athletes with high blood pressure are at higher risk of experiencing adverse cardiovascular events compared to those with healthy blood pressure ranges.  

Birth Control Options for Female Athletes

Ultimately, many studies that look at the impact of birth control on female athletic performance are grouping all types of birth control together rather than focusing in on specific types (combination vs. progestin-only vs. non-hormonal). Moreover, every woman may respond differently to various birth control methods based on her unique physiology - some women may not notice any impact on their athletic performance, while others may experience detrimental effects.  

The decision to utilize hormonal birth control is a highly personal decision that should be discussed with your doctor. There are different options available if the only reason for birth control is to prevent pregnancy.  

• The progestin-only IUD appears to have minimal systemic effects when compared to combination birth control pills, with many women continuing to ovulate and have an actual period (whereas oral contraceptive pills work by preventing ovulation and affecting various hormone levels).  
• While the copper IUD does not release any hormones, many women will experience heavier bleeding, which may not be favorable for some athletes.  
• There is also the ability to track ovulation and combine that tracking with barrier methods like condoms or a diaphragm if pregnancy prevention is the main goal since a woman only has a few days out of the month when she can actually get pregnant.  

It's important to discuss your athletic goals as part of the conversation around birth control methods so that you and your doctor can make the best possible decision for your unique situation.

Functional Medicine Treatment for Female Athletes on Hormonal Birth Control

A functional medicine approach take the whole person into consideration. An individualized plan is made based on intake, lab results, and specific needs of each patient. A common functional medicine treatment plan for female athletes consist of the following:

Nutrition

A balanced, anti-inflammatory nutrition plan that's high in protein and has adequate levels of healthy fats and carbohydrates can help provide the fuel for athletic performance, muscle mass maintenance, and hormone production. Protein needs can be calculated based on individual body weight and body composition and can be sourced from grass-fed lean meats, poultry, fish, shellfish, supplemental powders, or vegetarian sources.

In addition to quality protein sources, a variety of fruits, vegetables, nuts and seeds, healthy fats like avocado, and whole grains can also help ensure adequate micronutrient intake of minerals like zinc, iron, selenium, and magnesium, as well as vitamin C and B vitamins - all of which are important for athletic performance and also at risk of depletion for hormonal birth control users.

A varied diet rich in nutrient-dense foods has been linked to a healthier gut microbiome, which may help to offset any negative impact of hormonal birth control on the gut. For athletes, meal timing can also be important to consider to support optimal training sessions and recovery.

Lifestyle

Stress management is an important component of any athlete's lifestyle and may be especially important for athletes using hormonal birth control. As mentioned earlier, oral contraceptive users may experience higher cortisol during and after workouts, so regulating the stress response when not training is important so that she is not continually in a high-cortisol state. Chronically elevated cortisol could negatively impact training goals, muscle mass, and other hormone levels that may impact performance and increase the risk of injury or illness in athletes.  

Hydration is also an important lifestyle factor for female athletes. Making sure active women meet their hydration needs based on their body weight and training needs can positively impact performance. Since hormonal birth control may impact blood pressure and electrolyte status, it's important for athletes using birth control to evaluate their fluid intake and supplement with electrolytes when needed.

Supplements for Female Athletes

Supplementing with any vitamins identified as deficient in micronutrient testing can be helpful to offset drug-induced micronutrient depletions and to support a balanced, nutrient-dense diet that meets the training and adaptation needs of a given sport. Some specific examples include:

Iron

Iron supplementation has been shown to improve iron status and performance in athletes, and is a common nutrient deficiency seen in menstruating active women both on and off hormonal birth control.  

Zinc

Another commonly depleted micronutrient in those using birth control, inadequate zinc levels in athletes has been linked to lower bone density, higher risk of illness, and lower VO2 max.

B Vitamin Complex

Female athletes on hormonal birth control may be at higher risk of low B vitamin status, so supplementing alongside a balanced diet can help support optimal health and performance.  

Magnesium

Increased magnesium intake through magnesium-rich foods and supplementation in female athletes has been shown to improve athletic performance and recovery. As magnesium is depleted by hormonal birth control, a supplement with dosages based on functional lab testing can help restore adequate magnesium to meet training needs.  

Creatine

Creatine has been linked to improved athletic performance as well as brain health benefits in female athletes.

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Summary

It's important to consider athletic goals in choosing a birth control option for female athletes. While many female athletes may be prescribed birth control pills to "fix" hormone imbalances or to make their cycles more predictable, there is growing evidence that some women's performance may be negatively impacted by hormonal birth control. Hormonal birth control use may also mask important symptoms that the body isn't recovering or adapting to training intensity, putting users at higher risk for RED-S, illness, and injury over time. For female athletes using hormonal birth control, functional medicine labs and a functional-medicine approach to mitigating the potential side effects of oral contraceptives can help to optimize performance based on each woman's individual needs.