Hormonal Contraception and Bone Health in Athletes of All Ages

For adolescent and young adult athletes, the teenage and early adult years are critical for building peak bone strength. Nearly half of lifetime bone mass is gained during adolescence, and this process depends on adequate energy availability, mechanical loading from sport, and optimal hormone levels. Because of this, hormonal contraception can have different implications for different groups, such as athletes, adolescents and women around peri and post menopause.

Research shows that combined oral contraceptives (COCs) and depot medroxyprogesterone acetate (DMPA) may slow bone mineral accrual or cause temporary bone loss in adolescents and young women—particularly during the early years after menarche, when bones are most responsive to training and nutrition. This is important because reduced bone density and altered architecture can be irreversible and will increase the risk of traumatic fractures, stress fractures and delay recovery from injury.

DMPA is consistently associated with bone loss during use, especially in younger users, although bone density generally recovers after discontinuation. Low-dose oral contraceptives may also blunt normal bone gains in adolescents and in energy-deprived females, possibly by suppressing insulin-like growth factor-1 (IGF-1), a hormone essential for bone formation. In contrast, long-acting reversible contraceptives (LARCs) such as hormonal IUDs and implants appear to have minimal impact on bone health, likely because they do not significantly suppress IGF-1levels. The caution with LARCs is that they may mask REDs related menstrual disturbance.  This an essential consideration in athletes of all ages, including those in perimenopause.

For athletes with menstrual disruption related to low energy availability  (such as REDs or functional hypothalamic amenorrhea), or perimenopause, oral contraceptives do not reliably improve bone density. The estrogen in the Combine Oral Contraception (COC), does not positively impact bone, while the individual is in a catabolic state (low energy availability). Addressing energy intake, training load, sleep and overall health remains the most effective strategy for protecting bone health. The bleed that occurs when on the COC, is a COC-induced withdrawal bleed.  It is NOT a “period”. The COC will mask REDs related menstrual disturbance.  The COC is not a management strategy in REDs related menstrual disturbance.

Bottom line: Athletes of all ages should choose contraception with bone health in mind, especially during adolescence and perimenopause. Adequate fueling, strength-building activity, calcium and vitamin D intake, and individualized medical guidance are essential to support both performance and long-term skeletal health.