Birth Control, Trail Running and Performance Impacts

As a female, deciding which birth control is right for your body is hard: what works for one might not work for another, and the side effects of one method may help alleviate certain conditions for one woman while contributing to issues for another. Add running to the mix—and in some cases, large training volumes, hours spent on the trail and races exceeding even 100 miles in distance—and it’s only a matter of time before birth control and trail running collide.

Before we begin, it’s a good idea to understand how hormones affect our body without birth control: the average menstrual cycle lasts 28 days but can range from 21 to 41 days and still be considered normal. The first part of the cycle, days one through 14, are the follicular phase; this phase begins with menstruation. Around day five, ovaries begin to produce more estrogen and, from the rise in follicle-stimulating hormone, ovarian follicles mature eggs for release.

On roughly days 12 to 14, estrogen levels and luteinizing hormone rise, causing an egg to be released and signaling ovulation. From here, estrogen levels begin to drop as the luteal phase begins. Meanwhile, progesterone levels begin to increase. Several days before menstruation, both estrogen and progesterone peak, which is often when premenstrual syndrome, and the symptoms that come along with it, begin.

For many women, birth control can help control PMS, but deciding which type of birth control is best for an individual is almost as, if not more, difficult than finding the perfect pair of running shoes. Some prefer the pill, which requires remembering to take a small, oh-so-easy-to-drop pill every day at the same time; others are happy to choose Intrauterine contraception, also known as an IUD, that can last for years following an uncomfortable insertion; still others opt for the Fertility Awareness Method, where daily waking temperature and cervical fluid are monitored.

Knowing more about the choices we have can make our periods more manageable, allow us to make decisions for our own bodies, and sometimes negate the more uncomfortable side effects that our menstrual cycle can illicit—but how do these options impact our running?

IUD (Intrauterine device)

What is it?

Intrauterine devices are small, T-shaped pieces that fit inside the uterus. IUDs include non-hormonal and hormonal devices. Non-hormonal devices, like the ParaGard, relies on its copper-wrapping as a natural spermicide, while hormonal devices, like the Mirena, use small amounts of the hormone progestin to thicken mucus in the cervix to prevent pregnancy. Additional hormonal IUDs that have been approved in the U.S. include Kyleena, Liletta and Skyla. IUDs are more than 99 percent effective at preventing pregnancies.

It sucks losing 30 minutes to changing a menstrual cup during an ultramarathon, not to mention the cramping, bloating and general pain I experienced.

How long does it last?

The ParaGard reportedly lasts up to 10 years, while the Mirena works for five before needing replacement. The Kyleena, Liletta and Skyla work, on average, between three to five years.

What are the side effects?

The majority of women I spoke with used or have used an IUD, both before and during their running careers. Unfortunately, having an IUD inserted can be a very painful experience. As a 2017 report, from the medical resource, “UpToDate,” on Intrauterine contraception reveals, of those who have it removed within the first six months, 28 to 35 percent cite pain and irregular bleeding as their reason.

Alyssa, 30, from Sioux Falls, South Dakota, started using the ParaGard at the end of 2015. Six months later, she started running and noticed intense cramping and heavy bleeding during the three days surrounding a race. “I waited it out and kept hoping my body would regulate, but this pattern held true, to the point of spotting or fully being on my period three out of four weeks a month.”

Unfortunately, bleeding and spotting are common side effects of the ParaGard, and while a 2013 study from the Journal of Human Reproduction suggests that copper IUDs, like the ParaGard, don’t worsen menstrual cramps, some women may experience much more painful periods.

Unfortunately, Alyssa doesn’t feel that her physicians prepared her for the potential side effects of the ParaGard. “It sucks losing 30 minutes to changing a menstrual cup during an ultramarathon, not to mention the cramping, bloating and general pain I experienced.”

How might it impact running or racing?

Post-insertion bleeding is fairly common, which means that having your IUD inserted several weeks, or at the very least, several days, before a race is likely more comfortable as uterine cramping is possible. In the 2017 report, 86 percent of women reported requiring analgesics for post-insertion cramping, although that number dropped to between 11 and 13 percent after five days.

Madeline, 26, from Bend, Oregon, tried to wait until her season had ended before having the Mirena inserted. Due to a tight schedule, however, she had to have hers put in two days before a 50K, which left her with what felt like contractions during her race. “The pain was running all the way down my legs,” she says. “I think the physical stress of running a 50K just sent my body over the edge.”

While Madeline still experiences cramping, she believes that the Mirena makes sense for many athletes. “There are less negative side effects than other hormonal options. I won’t have to worry about remembering a daily pill, it will last for up to five years, and it will likely reduce my PMS and period issues, whereas ParaGard often worsens cramping,” she explains. “I have had my first period on Mirena, which was lighter, and I had less fatigue and stomach issues, which usually prevent me from training for a day or two when I’m not on birth control.”

When deciding upon any form of birth control, it’s important to consider the recovery time that may be needed. Megan Roche, MD, a runner for HOKA ONE ONE and a coach at Some Work All Play, often sees athletes experience one to two weeks of fatigue after receiving an IUD. “Everyone is different,” she says, “but I often suggest that athletes plan a down week after IUD placement or get IUDs placed in the offseason.”

Pill (Oral contraceptive)

What is it?

The pill is an oral contraceptive that uses progestin and estrogen—or progestin only—to prevent pregnancy, although many women use it to help with acne, polycystic ovarian syndrome (PCOS), endometriosis and irregular periods. There are various kinds of birth control pills delivering similar, or varying, amounts of hormones depending on the week of a cycle.

How long does it last?

The pill has a 99 percent efficacy rate when used correctly; it lasts as long as it is taken.

What are the side effects?

Side effects are dependent on the dosage of each oral contraceptive, with higher estrogen dose combination oral contraceptives (COCs) having side effects like breast tenderness, nausea and bloating. Lower-dose COCs typically result in more breakthrough bleeding and spotting.

There are several positive side effects that oral contraceptives can have, including a reduced risk of ovarian and endometrial cancers (for reasons that aren’t yet understood), but a slight increase in breast cancer risk as a 1996 study from The Lancet demonstrates. Additionally, combined oral contraceptives can significantly increase the risk of deep-vein thrombosis since hormonal birth control introduces different forms of estrogen and progestin into the body.

While Lauren has thought about stopping hormonal birth control, being able to skip her period if it happens to fall during a race is a big of a benefit for her.

These hormones work to increase the production of chemicals that help blood clot and allow blood vessels to widen and blood to pool in veins, respectively. As such, those with blood clotting disorders or who may be obese are typically warned to stay away from the pill.

How might it impact running or racing?

While the pill seems to work well for some women, it can cause issues—or even mask underlying problems—in others.

Lauren, 27, of Boston, Massachusetts, originally started using oral contraceptives as a way to reduce acne during high school. In the past year, however, she has started to feel that the pill is contributing to mood swings and a very low libido. “These mood swings feel out of my control and affect the consistency of my training,” she says. “Some days I’m so incredibly excited to run, and other days it feels like a total chore.”

While Lauren has thought about stopping hormonal birth control, being able to skip her period if it happens to fall during a race is a big of a benefit for her.

Like Lauren, Mandie, 32, from Mountain View, California, takes oral contraceptives to avoid having to deal with her periods, not only during racing but in life. “I’ve done this for 14 years now and have never had any issues,” she says. “As an athlete, especially an endurance athlete, not needing to deal with the mental and physical stresses of the hormonal cycle on top of the stresses of a peak-training block (or a race) has been a godsend. I mean, emotions when you’re in the middle of 100-mile weeks are bad enough.”

Latoya, 33, from Brooklyn, New York, stopped taking the pill after several years of symptoms that ranged from mild to extreme. “I went through nausea, dizziness, headaches and exceptional fatigue,” she says. After several years of trying different oral contraceptives, she was placed on another birth control pill.

“I went from running a 13-minute pace and doing ultramarathons to being stifled by headaches that wouldn’t leave for days,” Latoya says. On days one to five, I tried to work through it and stick to my regular routine but by the sixth day, I was experiencing shortness of breath.” Simply walking up stairs was a struggle and by the eighth day, her headaches grew to the point that she was unable to workout. “Heart palpitations, sharp pains and tingling in my fingers followed—I thought that I was going through a stroke or heart attack.” Latoya’s gynecologist recommended she stop taking her birth control immediately.

Implant

What is it?

The etonogestrel implant is a small progestin-releasing device that is inserted into the inner upper arm. Popular brands include Nexplanon and Implanon, both of which are over 99 percent effective.

The implant works by slowly releasing hormones that prevent pregnancy long term. Within the first few weeks, 60-70 mcg etonogestrel is released per day, gradually declining to 35-45 mcg by the end of the first year. By the third year, this declines to 25-30 mcg per day. Beyond this, pregnancy is possible; thus, it is recommended to have the implant exchanged at the end of three years. Etonogestrel works by preventing the ovaries from releasing an egg and thickening the cervical mucus so that sperm can’t reach the uterus.

While IUDs and the pill, with proper use, have a more than 99 percent efficacy rate, the implant has an even lower failure rate.

How long does it last?

The implant lasts for three years before needing replacement.

What are the side effects?

A 2018 review from”UpToDate” states that unscheduled bleeding is fairly common and 90 percent of women who discontinued using the implant had frequent or prolonged bleeding and spotting. Additional side effects include headaches, weight gain, acne, breast tenderness, emotional liability and abdominal pain.

With any form of contraception, it’s important to pay attention to energy availability,’ says Roche. ‘Oral contraceptives can give you a false sense of security that you are menstruating and IUDs often create “normal” amenorrhea.

How might it impact running or racing?

While the insertion of the implant is typically marketed as being quick and simple, removal can be difficult and the small rod often hard to find. Additionally, while the implant might make the most sense for athletes since it doesn’t involve having to remember to take a daily pill nor deal with cramping following a recent IUD placement, the implant often comes with many side effects. A search of the side effects on the official Nexplanon website reveals a list of nearly two dozen potential symptoms like weight gain and viral infections, both of which can affect running and racing performance.

Candice, 36, of Leavenworth, Washington, used an implant for 10 months but recently had it removed. “For two months I had awful symptoms,” she says. “Emotional instability, spotting and feeling like I had a yeast infection were the three main things I remember.”

Vasectomy

What is it?

Birth control isn’t inherently a woman’s responsibility. For partners or single men who are certain they do not want children (or any more children than they might already have), a vasectomy is a practical option that involves cutting the tubes (vas deferens) to prevent sperm from leaving the testes.

What are the side effects?

Soreness in the days following the procedure.

How might it impact running or racing?

Most doctors recommend taking a week off after having a vasectomy. Ten years ago, Paul, 60, from Seattle, WA, had a vasectomy. “I was sore for maybe a day,” he says. “Otherwise it was pretty painless.”

Not All Birth Control is Hormonal

While this article focuses on how hormonal birth control can affect running and racing performance, not all birth control is hormonal. Fertility awareness method (FAM), also called the Symptothermal Method, uses three combined methods to predict ovulation and prevent pregnancy. This method relies on taking your daily waking temperature, checking your cervical mucus,charting your menstrual cycle on a calendar and, in some cases, checking the position of the cervix.

Many people confuse FAM with the rhythm method, which is essentially a less precise version of FAM that assumes a specific ovulation date each month rather than relying on several of the body’s signals. When used correctly, FAM is 99.5 percent effective according to a 2007 study from the Journal of Human Reproduction.

Additionally, FAM doesn’t impact running or racing since it is non-hormonal. For some, this is a problem since bleeding occurs each cycle (unlike some of the options mentioned above where bleeding can disappear); for others, however, this can be added reassurance that the body is functioning hormonally well and that amenorrhea (the absence of a period) is not an issue.

Samantha, 23, from Denver, Colorado, started using FAM 10 months ago. “It continues to radically shift how I view and appreciate my body,” she says. “Knowing my cycle and my body this intimately has made my running/training-related crises much more infrequent, because I always know exactly what to expect based on where I’m at in my cycle.” After giving ParaGard two tries (“the first time my body outright rejected the IUD and expelled it within 72 hours”) and trying the pill which resulted in depression and anxiety, Samantha decided to attempt FAM. “It took two cycles for me to really get the hang of it, but it’s now a simple, easy, habitual part of my days and weeks,” she says.

While FAM doesn’t allow the user to control her periods, it provides knowledge that can change the perspective of how she views her runs. For Samantha, knowing she’s in her luteal phase means being a little easier on herself. “It’s so powerful to know why I feel like I can’t move the day before my period arrives, rather than yell at the pavement after a particularly tough run. FAM is empowering.”

A Word of Caution

For many women, birth control that diminishes, or entirely eliminates, monthly bleeding is enticing, but it’s important to ensure that hormones are still working as they need to. “With any form of contraception, it’s important to pay attention to energy availability,” says Roche. “Oral contraceptives can give you a false sense of security that you are menstruating and IUDs often create “normal” amenorrhea.” Unfortunately, without the knowledge that you’re menstruating, you could be missing one of the key components of the Female Athlete Triad (the other two include energy availability and bone density) and, even if you are menstruating, hormonal birth control can provide a false sense of security by providing a “pill bleed.” If you’re not sure that your hormones are intact, it’s worth getting a blood test or requesting a DEXA scan to test bone-density.

—Jade de la Rosa is a writer, runner and MFA in Creative Writing living in the Pacific Northwest. Follow Jade’s adventures on Instagram at @jaderebeccar.