Hormonal preparations for female athletes
Oral Contraceptives
In preventing pregnancy, oral contraceptive pills (OCPs) combining an oestrogen and a progestogen (“combined oral contraceptives”) are the most effective preparations to use. None of the OCPs available on prescription in the UK are on the list of banned drugs. Although there have been claims in the past that a “positive” doping test has been due to an athlete’s OCP, there is no data available to suggest that any of the OCPs currently available in the UK could give rise to a “positive” test. As is always the case, it is important that all current medication, including the OCP, is noted on the sample collection form when an athlete is being tested.
Advantages of combined oral contraceptives include:
In some athletes, menstrual disturbances can develop as a consequence of the intensity of training. This depression in ovarian function leads to low levels of oestrogen and can have an effect on calcium deposition in bones and as a result bone strength may be affected. Combined OCPs are generally considered to be good source of oestrogen for the oestrogen-deficient individual. However, the effect of oral contraceptives on bone density in the amenorrheic athlete remains controversial due to the lack of adequate clinical studies.
The available evidence suggests that the particular phase of an athlete’s menstrual cycle does not have an influence on athletic performance. Nevertheless, for a few athletes it may be inconvenient to be menstruating at the time of an important competition. It is possible to regulate the timing of the anticipated menstrual period using the OCP. If this is really thought to be necessary, advice on how to do this should be obtained from your doctor.
Combined OCPs may contain a fixed amount of an oestrogen and a progestogen in each active tablet or may contain varying amounts of the two hormones according to the stage of the cycle. There is a large choice of OCPs available. Your doctor will discuss which is the most suitable for you.
Full details of the possible side effects of each OCP are provided on the appropriate package insert.
Missed Pill
The following advice is now recommended by family planning organisations:
“If you forget a pill, take it as soon as you remember, and the next one at the normal time. If you are 12 or more hours late with any pill (especially the first in the packet) the pill may not work. As soon as you remember, continue normal pill taking. However, you will not be protected for the next seven days and must either not have sex or use another method such as a condom. If these seven days run beyond the end of your packet, start the next packet at once when you have finished the present one, i.e. do not have a gap between packets. This will mean you may not have a period until the end of two packets but this shouldn’t cause any harm. Nor does it matter if you see some bleeding on tablet-taking days. If you are using everyday (ED) pills – miss out the seven inactive pills. If you are not sure which these are, ask your doctor”
In addition to these precautions, emergency contraception is recommended if:
- 2 or more combined oral contraceptive tablets are missed from the first 7 tablets in a packet:
- 4 or more tablets are missed mid-packet.
Diarrhoea and Vomiting
Vomiting up to 3 hours after taking an oral contraceptive or very severe diarrhoea can interfere with its absorption. Additional precautions should therefore be used during and for 7 days after recovery. If the vomiting and diarrhoea occurs during the last 7 tablets, the next pill-free interval should be omitted (in the case of ED tablets the inactive ones should be omitted).
Progestogen-Only Contraceptives
If oestrogens are contra-indicated it is possible to provide contraception by means of progestogen-only contraceptives. This can take the form of the Progestogen only pill (“POP”). These have a higher failure rate than combined preparations. Progestogens can also be given as an injection or implant or may be delivered directly to the womb by means of a hormone releasing intra-uterine device. There are no issues regarding the doping regulations with any of these progestogen only contraceptives.
Emergency Contraception
The so-called morning-after pill can actually be taken within 3 days (72 hours) of unprotected sexual activity although taking the first dose as soon as possible will increase the chance of success. Neither of the “morning-after” pills available in the UK contains banned substances.
Hormonal Replacement Therapy (HRT)
There are a number of reasons for considering the use of HRT in women whose periods have stopped. HRT, given in tablet form or worn as a patch may help to prevent bone loss. The addition of 1000 to 1500 mg of calcium daily to the diet together with HRT will help to prevent osteoporosis in the majority of post- menopausal women. The advantages of HRT should be weighed against the risks of HRT such as a small increased risk of breast cancer and an increased risk of thrombosis in the deep veins. A full discussion of the risks and benefits of HRT is, however, beyond the scope of this article.
HRT should, in almost all cases, not cause any problems in terms of doping regulations and no special permission is required. The exception is the very small percentage of women on HRT who are prescribed testosterone. As this is a banned substance, special dispensation is required from the appropriate authorities (for international competition this would be the IAAF).
References
British National Formulary
The Female Athlete. Ireland, ML, Nattiv A. Saunders, Elsevier Science, USA 2002.
