Could your PMOS diagnosis actually be RED-S? Before we get to the pill, find out HERE.
There is a conversation I have in my clinic more often than I would like. A woman comes in – usually an athlete, usually someone who has been active for years – and she tells me she went to her GP with irregular or painful periods, was put on the pill, and has been on it ever since. Sometimes for five years. Sometimes for ten. Sometimes longer.
When I ask what was identified as the underlying cause, the answer is almost always the same.
Nobody looked.
This is not a criticism of the clinicians involved. The prescription makes a certain kind of sense: hormonal contraception regulates cycles, reduces pain, lightens bleeds, and generally makes the problem less immediately visible. For many women, it is exactly the right choice. But for athletes presenting with period problems, reaching for contraception before establishing what is actually driving those symptoms is a significant clinical gap – and one that can have serious long-term consequences.
The short answer first
Hormonal contraception does not treat the cause of period problems. It manages their presentation- almost like a plaster. In athletes, where the most common driver of menstrual disruption is an energy deficit rather than a hormonal condition, this distinction matters enormously.
The default pathway and where it falls short
When a woman presents with heavy, painful or irregular periods, the standard clinical response is broadly consistent: a conversation about symptoms, sometimes blood tests, sometimes a scan, and frequently a prescription for hormonal contraception to regulate the cycle and manage the pain.
For a significant number of women and even athletes who want cycle control, this is appropriate and effective. But the pathway has a built-in problem: it treats the symptom and stops there. The question of what is causing the symptom – which is the only question that leads to actually resolving it – often goes unasked.
In athletes, that unasked question is particularly costly.
What might actually be driving the problem
Period problems in active women are rarely straightforward, and they are rarely caused by a single thing. The most common drivers I see in my clinic include:
- Relative Energy Deficiency in Sport (RED-S). When the body is not receiving enough fuel to support both training demands and basic physiological function, the reproductive system is one of the first things it deprioritises. Menstrual disruption (ranging from subtle cycle changes to periods stopping entirely) is usually the earliest and most visible sign. Hormonal contraception will regulate the bleed, but it will not close the energy gap. The underlying deficiency continues, silently, with its consequences accumulating. [Link to RED-S and PMOS blog]
- Endometriosis. One of the most common causes of painful and heavy periods, endometriosis affects an estimated one in ten women and is notoriously underdiagnosed. The pill can reduce pain and manage symptoms, but it does not treat the condition. Women who spend years on contraception without ever receiving an endometriosis diagnosis may eventually find that the disease has progressed in a way that affects their fertility and quality of life.
- Thyroid dysfunction. An under active or overactive thyroid can significantly disrupt menstrual function, and it is often missed when period problems are managed symptomatically rather than investigated. Thyroid function is a straightforward blood test, but it requires someone to ask the question.
- Other hormonal imbalances. The hormonal picture in active women is complex, and changes in training load, recovery, nutrition and stress can all influence cycle regularity in ways that deserve investigation rather than management.
The specific problem for athletes
For athletes in particular, the stakes of missing the underlying cause are higher than they might appear.
If a woman has RED-S and is put on the pill, her cycle will return – artificially. She will look, on the surface, as though the problem has been resolved. But the energy deficit driving her symptoms is still there. Her bone density is still declining. Her hormonal environment is still disrupted in ways the pill does not address. Her fertility may be affected in ways that won’t become apparent until she tries to conceive, potentially years later.
There is also the question of performance. Athletes making decisions about their contraception need accurate information about the potential effects on training adaptation, recovery and energy availability. The evidence on hormonal contraception and athletic performance is evolving, but it deserves to be part of the conversation – not ignored because the prescription was made on the basis of symptom management alone. Then there is the consideration of Anti-Doping regulations and how hormones fit into that (but that is an entire conversation in itself).
What should happen instead
A proper assessment of period problems in an active woman should ask several questions before any prescription is written. How much is she training? What does her nutrition look like around exercise? Has her cycle changed in the context of increased load or reduced energy intake? Is there any family history of endometriosis or other gynaecological conditions? What does her thyroid function look like?
These are not complicated questions. They do not require specialist equipment or lengthy referrals. They require a clinician who understands that active women have a specific hormonal context and that the standard pathway does not always account for it.
A word on what this is not
This is not an argument against hormonal contraception. For many women (athletes included) it is an appropriate, well-tolerated and effective choice, whether for contraception, symptom management, or both.
The issue is not the pill. The issue is using the pill as a first response to period problems without first establishing what is causing those problems. Contraception can be part of the answer. It should not be the whole answer before the question has been properly asked.
If this resonates with you
If you are an athlete with period problems and you have been managing them with hormonal contraception for a significant period of time – particularly if something has never quite felt resolved – it is worth asking whether the underlying cause has actually been explored.
A proper assessment, with someone who understands both the gynaecological and the athletic picture, can tell you a great deal more than a prescription alone.
Book a consultation with me HERE.