Beyond the Podium: Reproductive Health Matters

The potential long-term consequences of MD can significantly impact athletes’ overall well-being and athletic careers (see figure 2).

Long-term Hormonal Contraceptive Use

Hormonal contraceptive (HC) use is prevalent among elite female athletes, and approximately 50% of athletes use some form of HC⁽⁹⁾. The most commonly used types are combined oral contraceptives (CHC), followed by progestin-only methods such as implants and injections^(9,10). The choice of contraceptive method can vary based on factors such as sport type and individual preferences. Long-term HC use has diverse effects on reproductive health, including reversible impacts on fertility, potential risks to bone health in adolescents, and a debated association with breast cancer risk. Long-term use of CHC can lead to reversible suppression of antral follicle count (AFC), which is an indicator of ovarian reserve⁽¹¹⁾. For example, a break from CHC use can improve AFC and potentially increase oocyte yield, suggesting that the suppression is reversible and fertility can be restored after discontinuation. Understanding these effects and providing comprehensive counseling can help women make informed decisions.

Fertility and Pregnancy

Elite athletes often face unique challenges during pregnancy and in the postpartum period. A study involving Norwegian elite athletes found no significant differences in fertility problems or pregnancy complications compared to active controls. However, athletes reported higher body dissatisfaction and drive for thinness postpartum, although the prevalence of eating disorders had decreased⁽¹²⁾. Among retired female footballers, 25% were parents (1-3 children), and most fell pregnant in less than two years following the onset of desire for pregnancy⁽¹⁾. Some retired players gave birth during their playing career, and the mean time to return to competitive matches following delivery was 22 weeks. Despite the unique experiences of elite athletes during pregnancy and the postpartum period, various factors can hinder or support their journey through this life-changing event.

Barriers encountered by elite athletes during preconception and pregnancy include societal attitudes and a lack of support from sports organizations⁽¹³⁾. The societal expectation that female athletes prioritize their careers over motherhood can lead to assumptions regarding their reproductive choices and health. This cultural narrative complicates the understanding of reproductive health and highlights the need for sex-specific post-retirement care. The lack of supportive sports policies for pregnant athletes highlights the need for evidence-based policies to support athletes during pregnancy⁽¹⁴⁾. Enablers for pregnant and postpartum athletes include modified training strategies, family support, paid maternity leave, job security, travel support for caregivers and children, and accessible childcare^(13,15).

“The lack of supportive sports policies for pregnant athletes highlights the need for evidence-based policies to support athletes during pregnancy”

Reproductive Health After Retirement

Overall, the reproductive health of retired female athletes is influenced by a combination of physiological, hormonal, and social factors. Persistent MDs from active sports careers, hormonal imbalances, and societal perceptions all play a role in shaping athletes’ reproductive health outcomes. Menstrual disorders during an athlete’s active career can persist until retirement, potentially affecting fertility. Former athletes with abnormal menstrual cycles have a higher rate of infertility treatment compared to those with normal cycles (17.1% vs. 10.2%)⁽¹⁶⁾. This suggests that menstrual irregularities experienced during an athletic career may continue to impact reproductive health post-retirement. Among retired footballers, there are higher rates of amenorrhea and earlier onset of menopause compared to the general population⁽¹⁾.

Clinical Recommendations

1. Educate athletes on the risks of low-energy availability, menstrual dysfunction, and bone health issues.
2. Balance performance goals with overall health, avoiding excessive calorie restriction and overtraining.
3. Clinicians should regularly screen for menstrual irregularities, bone density, and nutritional deficiencies.
4. Implement a multidisciplinary team approach involving nutritionists, endocrinologists, and sports psychologists.
5. Encourage open communication between athletes, coaches, and medical professionals.
6. Sports organizations should develop and enforce policies that protect athletes’ long-term reproductive health, including policies related to preconception, pregnancy, and the postpartum period.

Conclusion

Menstrual disorders in female athletes can lead to long-term reproductive health issues, including infertility. These disorders are often associated with high training volumes, low energy intake, and hormonal imbalances. Addressing these factors through proper nutrition, stress management, and balanced training can mitigate these risks. Early recognition and intervention are crucial to preserve the reproductive health of female athletes. The need for supportive policies and evidence-based guidelines is clear, as is the importance of further research to better understand the unique needs of athletes who aim to become pregnant, pregnant athletes, and parent athletes.

References

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13.    Br J Sports Med. Published online August 28, 2024
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