Curious about coming off the pill?

Coming Off the Pill: Considerations for Runners

Let’s start with covering off what the combined oral contraceptive pill (COCP or pill for short) is. When taking the pill you're receiving synthetic versions of oestrogen and progesterone, which replace your body's natural production of these hormones. Now, not all pills are created equal, in fact there are many formulations of the pill, each containing different types and doses of oestrogen and progestin. Some contain progestins with androgenic or anti-androgenic properties - meaning they can either stimulate or block testosterone receptors - which can have implications for mood, performance, and other physiological processes.

What happens when you decide to come off the pill? 

For most people your natural menstrual cycle typically resumes within one to three months. If this does not occur and your period is MIA it’s important to seek medical evaluation. Once your cycle returns, your oestrogen and progesterone levels will fluctuate throughout the cycle, unlike the steady hormone levels experienced on the pill.

No two people are the same and the experience of coming off the pill varies for all! It is dependent on lots of factors like; the individual, the reason the pill was prescribed initially, and the specific formulation used. For example, if you started the pill for endometriosis, PCOS, or severe PMS, those symptoms may return after you stop, potentially affecting your running performance. Conversely, some women report improved mood, energy, and even enhanced training responsiveness after stopping the pill. They may also notice distinct phases of their cycle where they feel stronger or more energised.

As for how the pill impacts performance? 

The research comparing athletes on the pill versus those with natural cycles is mixed. Variability in study design, pill formulations, and individual responses all contribute to these inconsistencies. Some studies suggest improved strength gains off the pill, potentially due to increased levels of endogenous testosterone and growth hormone in naturally cycling women. These hormones may support enhanced recovery and strength development.

One meta-analysis comparing naturally cycling women to those on the pill found a very slight decline in performance in the latter group, though the effect size was generally trivial. Still, having a natural cycle does come with a pretty cool bonus, particularly for athletes, in that it provides a useful physiological marker of adequate energy availability. A regular menstrual cycle suggests that a woman is not at risk for Relative Energy Deficiency in Sport (RED-S) or functional hypothalamic amenorrhoea (FHA).

In this context, a regular period is often referred to as the “sixth vital sign” for women. It indicates that the body feels safe to support a pregnancy, a proxy for good nutritional status, sufficient recovery, and an absence of excessive physiological or psychological stress. It's important to note that the withdrawal bleed experienced on the pill is not a true menstrual period and cannot be used as a marker for FHA.

Now, is coming off the pill the right move for you? 

The truth is - it’s highly individual. If you are not using it for contraception, do not have a medical condition that is improved by the pill, and are not experiencing issues such as iron deficiency, I often encourage my female athletes to aim for a natural menstrual cycle. It helps keep tabs on energy availability and may add a boost in your strength and recovery.

With that being said, if you're currently on the pill, don’t panic - any impact on performance is usually minimal, if there's any at all. However, when selecting a pill, both the type and dose of oestrogen and progestin should be considered. Unless there is a clinical indication such as PCOS or acne, I typically advise against anti-androgenic pills, as they may have a greater negative impact on performance. Additionally, pills containing cyproterone acetate carry a higher risk of venous thromboembolism compared to standard formulations.

If you're thinking about stopping the pill, or just not sure whether it’s the right form of contraception for you, have a chat with your doctor. The decision should be based on you, your individual health, your training goals and personal circumstances rather than generalised advice.