Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States

Abstract

Background Menstrual irregularity (MI) is common in female athletes and is a component of the Female Athlete Triad (Triad). Many athletes with the Triad are started on hormonal contraceptives (HC) for MI, but this interferes with the ability to monitor menstrual cycle regularity and can mask other causes of MI. There are limited studies investigating the relationship between MI, HC use, and injury in female collegiate athletes. Objective To examine the prevalence of and relationship between HC use, MI, and bone stress injuries in female collegiate athletes in the United States. Design Cross‐sectional study. Setting Online survey. Participants 1020 U.S. female collegiate athletes (age ≥ 18 years). Methods or Interventions Assessment of risk factors for menstrual irregularity and bone stress injuries was conducted via a one‐time survey. Main Outcome Measures HC use, MI, history of stress fractures. Results Current HC use prevalence was 65% (95% confidence interval [CI], 61.9%, 67.8%). Of all athletes, 47% reported past MI. Of the athletes who were not currently using HCs, 32% had current MI. Compared with athletes without past MI, more athletes with past MI reported current HC use (73% vs. 57%) and indicated menstrual cycle consistency as the primary reason for use (24% vs. 4%) (P < .001). Additionally, 25% of athletes reported a history of stress fractures, which was associated with lean/aesthetic sports participation (odds ratio [95% CI]: 1.9 [1.4, 2.5]; P < .001) and less oral contraceptive pill (OCP) use (0.7 [0.5, 1.0]; P = .043). Compared with OCPs, injectable HCs were associated with greater odds of a history of stress fractures (4.5[1.6, 12.3]; P = .004). Conclusions HC use was prevalent among this cohort of female collegiate athletes, and almost half of the athletes reported past MI. A goal of menstrual cycle regularity was cited by 24% of athletes as a primary reason to use HCs, which shows that more athlete education is needed to avoid masking MI and the Triad with HCs. Further studies elucidating the relationship between HC use, MI, and sports‐related injury are warranted.

Prevalence of Female Athlete Triad Risk Factors among Female International Volunteers and College Age-Matched Controls

“…Following volunteer service, some lost BMD may have been recovered. Volunteers' study period (2.6%) and lifetime (11%) stress fractures rates were lower than reported among athletes (4.6-25%) [12,37,38]. Athletes may be at higher risk for stress fracture due to more intense physical activity and a longer duration of SA compared to volunteers.…”

“…The Triad occurs in female high school, collegiate, and elite athletes [6,7]. In collegiate athletes, Triad components have the following prevalence estimates: Low EA (11.8-67%) [8,9], MI (16-36%) [8,[10][11][12][13], and low BMD (Z-score < −1) (1-3.5%) [14].…”

The Specificities of Elite Female Athletes: A Multidisciplinary Approach

“…Between 20 and 70% of elite female athletes use hormonal contraception, with a significant variation depending on the country (Australia, Denmark, Norway, Sweden, United States) and the sports discipline (football, basketball, track and field…) [ 7 , 9 , 10 , 11 ]. A large majority (68–75%) of these athletes take second-generation combined estrogen-progestin oral contraceptives (COCs), rather than progestin-only contraceptives (20–30%) [ 7 , 10 , 11 ].…”

“…Progestin-only contraception is used continuously, either in tablet form or with an intrauterine device (IUD), and the main progestins are levonorgestrel and desogestrel. A significant number of elite athletes use hormonal contraception primarily to regulate their MC (24%), particularly those with a history of menstrual disturbances [ 9 ]. Moreover, a majority of COC users report having deliberately manipulated timing, frequency, and amount of menstrual bleeding, with a prevalence of 60–77% among competitive athletes, who most often cited special events and holidays, convenience, and sports competition as the reasons [ 7 , 11 , 13 ].…”

Influence of Female Sex Hormones on Ultra-Running Performance and Post-Race Recovery: Role of Testosterone

“…It has been reported that many elite female athletes use hormonal contraception, with figures varying from 20% to 70% depending on the country and sport [ 18 , 19 , 20 , 21 ]. However, little is known about the impact and prevalence of HC use and the effects of intermittent treatment.…”