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Vol.:(0123456789) Sports Medicine (2020) 50:1785–1812 https://doi.org/10.1007/s40279-020-01317-5 SYSTEMATIC REVIEW The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta‑analysis Kirsty J. Elliott‑Sale 1  · Kelly L. McNulty 2  · Paul Ansdell 2  · Stuart Goodall 2  · Kirsty M. Hicks 2  · Kevin Thomas 2  · Paul A. Swinton 3  · Eimear Dolan 4 Published online: 14 July 2020 © The Author(s) 2020 Abstract Background Oral contraceptive pills (OCPs) are double agents, which downregulate endogenous concentrations of oestradiol and progesterone whilst simultaneously providing daily supplementation of exogenous oestrogen and progestin during the OCP-taking days. This altered hormonal milieu differs significantly from that of eumenorrheic women and might impact exercise performance, due to changes in ovarian hormone-mediated physiological processes. Objective To explore the effects of OCPs on exercise performance in women and to provide evidence-based performance recommendations to users. Methods This review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A between-group analysis was performed, wherein performance of OCP users was compared with naturally menstruating women, and a within-group analysis was conducted, wherein performance during OCP consumption was compared with OCP withdrawal. For the between-group analysis, women were phase matched in two ways: (1) OCP withdrawal versus the early follicular phase of the menstrual cycle and (2) OCP consumption versus all phases of the menstrual cycle except for the early follicular phase. Study quality was assessed using a modified Downs and Black Checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation working group. All meta-analyses were conducted within a Bayesian framework to facilitate probabilistic interpretations. Results 42 studies and 590 participants were included. Most studies (83%) were graded as moderate, low or very low quality, with 17% achieving high quality. For the between-group meta-analysis comparing OCP users with naturally menstruating women, posterior estimates of the pooled effect were used to calculate the probability of at least a small effect (d ≥ 0.2). Across the two between-group comparison methods, the probability of a small effect on performance favouring habitual OCP users was effectually zero (p < 0.001). In contrast, the probability of a small effect on performance favouring naturally menstruating women was moderate under comparison method (1) (d ≥ 0.2; p = 0.40) and small under comparison method (2) (d ≥ 0.2; p = 0.19). Relatively large between-study variance was identified for both between-group comparisons ( 0.5 = 0.16 [95% credible interval (CrI) 0.01–0.44] and 0.5 = 0.22 [95% CrI 0.06–0.45]). For the within-group analysis comparing OCP consumption with withdrawal, posterior estimates of the pooled effect size identified almost zero probability of a small effect on performance in either direction (d ≥ 0.2; p ≤ 0.001). Conclusions OCP use might result in slightly inferior exercise performance on average when compared to naturally menstru- ating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and vari- able across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle. Joint first authors: Kirsty J. Elliott-Sale and Kelly L. McNulty. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s40279-020-01317-5) contains supplementary material, which is available to authorized users. Extended author information available on the last page of the article 1 Introduction Sex hormones are one of the main determinants of biological sex [1]. During adulthood, levels of testosterone, the pre- dominant male sex hormone, remain consistent in men [2], whilst concentrations of oestrogen and progesterone, the pre- vailing female sex hormones, undergo circamensal changes
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  • Vol.:(0123456789)

    Sports Medicine (2020) 50:1785–1812 https://doi.org/10.1007/s40279-020-01317-5

    SYSTEMATIC REVIEW

    The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta‑analysis

    Kirsty J. Elliott‑Sale1  · Kelly L. McNulty2  · Paul Ansdell2  · Stuart Goodall2  · Kirsty M. Hicks2  · Kevin Thomas2  · Paul A. Swinton3  · Eimear Dolan4

    Published online: 14 July 2020 © The Author(s) 2020

    AbstractBackground Oral contraceptive pills (OCPs) are double agents, which downregulate endogenous concentrations of oestradiol and progesterone whilst simultaneously providing daily supplementation of exogenous oestrogen and progestin during the OCP-taking days. This altered hormonal milieu differs significantly from that of eumenorrheic women and might impact exercise performance, due to changes in ovarian hormone-mediated physiological processes.Objective To explore the effects of OCPs on exercise performance in women and to provide evidence-based performance recommendations to users.Methods This review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A between-group analysis was performed, wherein performance of OCP users was compared with naturally menstruating women, and a within-group analysis was conducted, wherein performance during OCP consumption was compared with OCP withdrawal. For the between-group analysis, women were phase matched in two ways: (1) OCP withdrawal versus the early follicular phase of the menstrual cycle and (2) OCP consumption versus all phases of the menstrual cycle except for the early follicular phase. Study quality was assessed using a modified Downs and Black Checklist and a strategy based on the recommendations of the Grading of Recommendations Assessment Development and Evaluation working group. All meta-analyses were conducted within a Bayesian framework to facilitate probabilistic interpretations.Results 42 studies and 590 participants were included. Most studies (83%) were graded as moderate, low or very low quality, with 17% achieving high quality. For the between-group meta-analysis comparing OCP users with naturally menstruating women, posterior estimates of the pooled effect were used to calculate the probability of at least a small effect (d ≥ 0.2). Across the two between-group comparison methods, the probability of a small effect on performance favouring habitual OCP users was effectually zero (p < 0.001). In contrast, the probability of a small effect on performance favouring naturally menstruating women was moderate under comparison method (1) (d ≥ 0.2; p = 0.40) and small under comparison method (2) (d ≥ 0.2; p = 0.19). Relatively large between-study variance was identified for both between-group comparisons ( �0.5 = 0.16 [95% credible interval (CrI) 0.01–0.44] and �0.5 = 0.22 [95% CrI 0.06–0.45]). For the within-group analysis comparing OCP consumption with withdrawal, posterior estimates of the pooled effect size identified almost zero probability of a small effect on performance in either direction (d ≥ 0.2; p ≤ 0.001).Conclusions OCP use might result in slightly inferior exercise performance on average when compared to naturally menstru-ating women, although any group-level effect is most likely to be trivial. Practically, as effects tended to be trivial and vari-able across studies, the current evidence does not warrant general guidance on OCP use compared with non-use. Therefore, when exercise performance is a priority, an individualised approach might be more appropriate. The analysis also indicated that exercise performance was consistent across the OCP cycle.

    Joint first authors: Kirsty J. Elliott-Sale and Kelly L. McNulty.

    Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s4027 9-020-01317 -5) contains supplementary material, which is available to authorized users.

    Extended author information available on the last page of the article

    1 IntroductionSex hormones are one of the main determinants of biological sex [1]. During adulthood, levels of testosterone, the pre-dominant male sex hormone, remain consistent in men [2], whilst concentrations of oestrogen and progesterone, the pre-vailing female sex hormones, undergo circamensal changes

    http://orcid.org/0000-0003-1122-5099http://orcid.org/0000-0001-6176-7983http://orcid.org/0000-0001-7542-1107http://orcid.org/0000-0001-9029-2171http://orcid.org/0000-0002-5057-9191http://orcid.org/0000-0003-2973-5337http://orcid.org/0000-0001-9663-0696http://orcid.org/0000-0002-1018-7601http://crossmark.crossref.org/dialog/?doi=10.1007/s40279-020-01317-5&domain=pdfhttps://doi.org/10.1007/s40279-020-01317-5

  • 1786 K. J. Elliott-Sale et al.

    Key Points

    When compared with a natural menstrual cycle, oral contraceptive pill (OCP) use might result in slightly inferior exercise performance, although any group level effect is most likely to be trivial, and as such from a practical perspective, the current evidence does not warrant general guidance on OCP use compared with non-use.

    Exercise performance appeared relatively consistent across the OCP cycle, suggesting that different guidance is not warranted for OCP-taking days versus non-OCP taking days.

    In the case of sportswomen who are focussing on performance, it is recommended that an individualised approach is sought, based on each athlete’s response to OCP use.

    in women [3], marking one of the major differences between sexes. Moreover, the eumenorrheic menstrual cycle is sus-ceptible to internal (e.g., amenorrhea, oligomenorrhea and menorrhagia) and external (e.g., hormonal contraceptives) perturbations, highlighting the diversity in ovarian hormone profiles between women. In a recent audit of 430 elite female athletes, Martin et al. [4] showed that 213 athletes were hor-monal contraceptive users, meaning that almost half of the population surveyed did not have a eumenorrheic menstrual cycle. Of these, 145 (68%) athletes reported taking oral con-traceptive pills (OCPs), making them the most common type of hormonal contraceptive used and the second most com-mon hormonal profile, after non-hormonal contraceptive users. These differences in endocrine profiles, between men and women, and amongst women (i.e., hormonal contracep-tive users and non-users), highlight the need for sex-specific consideration within sport and exercise science.

    Combined OCPs significantly reduce endogenous con-centrations of 17 beta oestradiol and progesterone [5], when compared to the mid-luteal phase of the menstrual cycle, a stage when endogenous oestradiol and progesterone are relatively high. The exogenous oestrogens and progestins act via negative feedback on the gonadotrophic hormones, resulting in the chronic downregulation of the hypothalamic-pituitary-ovarian axis. Most combined, monophasic OCPs are second generation OCPs, containing low to standard doses of ethinyl oestradiol and either levonorgestrel, nore-thisterone, desogestrel or gestodene, delivered in a fixed amount every day for 21 OCP taking days (i.e., consump-tion phase), followed by 7 OCP free days (i.e., withdrawal phase) [6]. In some countries, rather than a consumption

    and withdrawal approach, there are 21 active OCP days and 7 inactive OCP days. There are many types of OCPs with different compositions and potencies; for a comprehensive overview of hormonal contraceptives and OCPs please see Elliott-Sale and Hicks [6]. Overall, OCP use results in four distinct hormonal environments: (1) a downregulated endog-enous oestradiol profile of ≈ 60 pmol·L−1 for 21 days that rises during the 7 OCP free days to ≈ 140 pmol·L−1; (2) a chronically downregulated endogenous progesterone profile of ≈ 5 nmol·L−1; (3) a daily surge of synthetic oestrogen and progestin that peaks within 1 h after ingestion [from ≈ 2 to ≈ 6 pg·mL−1], with baseline values accumulating slightly from ≈ 2 to ≈ 3 pg·mL−1 over the 21 OCP-taking days; (4) 7 exogenous hormone-free days [7]. These profiles, reflecting OCP consumption and withdrawal, are referred to as pseudo-phases, as they are “artificial” phases in comparison with the phases of the physiological menstrual cycle.

    Aside from fertility control, OCPs are also used to alle-viate the symptoms of dysmenorrhoea and menorrhagia; reduce the occurrence of premenstrual tension, symptomatic fibroids, functional ovarian cysts and benign breast disease; and decrease the risk of ovarian and endometrial cancer and pelvic inflammatory disease [8]. Furthermore, athletic popu-lations have reported strategically using OCPs to manipulate the timing of, or omit entirely, the often-perceived incon-venient withdrawal bleed that occurs during the 7 OCP free days, using back-to-back OCP cycles [4, 9, 10]. Reliable and reversible contraception, along with the means to alleviate the side-effects associated with the eumenorrheic menstrual cycle, such as cramps/pain, bloating and headaches, and the ability to eliminate unpredictable menstruation, make OCPs a desirable option for many athletes.

    Despite the prevalence of OCP use in athletic popula-tions [4], the effects of OCPs on exercise performance are poorly understood. Although many experimental studies [11–13], numerous narrative and systematic reviews [14, 15] and books [16, 17] have addressed this topic, few in the area of sport and exercise science (e.g., athletes, coaches, practitioners or researchers) truly understand the implications of OCP use on exercise performance, as previous research has shown conflicting findings on the directional effects of OCPs on outcomes such as muscle function [18, 19], aerobic and anaerobic [20–22] capacity and performance-based tests [23, 24]. As such, it is not possible to provide useful guidance to either the sport-ing or research community on how to work with athletes or participants using OCPs. Accordingly, the aim of this review was to investigate the effects of OCP use on exer-cise performance in women by making a between group comparison of OCP users and non-users (i.e., naturally menstruating counterparts) and a within group compar-ison of OCP consumption and withdrawal. This is the first meta-analysis on the effects of OCPs on exercise

  • 1787Oral Contraceptives and Exercise Performance

    performance. Additionally, this review is the first of its kind to appraise the quality of previous studies using robust assurance tools.

    2 Methods

    2.1 Design

    The review was designed in accordance with the Pre-ferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Electronic Supplementary Material Appendix S1) guidelines [25], and consideration of the Population, Intervention, Comparator, Outcomes and Study design (PICOS, Table 1) was used to determine the parameters within which the review was conducted.

    2.2 Study Search and Selection

    PubMed, The Cochrane Central Register of Controlled Tri-als (CENTRAL), ProQuest and SPORTDiscus were system-atically searched using the search terms “oral contracep-tives” AND “athletic performance”; “sports performance”; “muscle”; “skeletal muscle”; “strength”; “force”; “mus-cular strength”; “muscular force”; “power”; “anaerobic”; “anaerobic power”; “anaerobic performance”; “anaerobic capacity”; “aerobic”; “aerobic capacity”; “aerobic power”; “aerobic performance”; “endurance”; “endurance capacity”; “endurance power”; “endurance performance”; “fatigue”; “recovery”. Searches were limited to humans, English, and

    females and no date restriction was applied. Only original research articles were considered for inclusion and review articles or conference abstracts were excluded. An example electronic search strategy for PubMed, including limits, can be found in Electronic Supplementary Material Appendix S2. All searches were conducted in January 2019 by KES. Three independent reviewers (KES, KLM and KMH) under-took a three-phase screening strategy: title and abstract, full-text screen and full-text appraisal. The search was updated in April 2020 using the same search criteria and screening strategy. These papers were subsequently included within the review and the meta-analysis was updated.

    2.3 Data Extraction and Quality Appraisal

    Data were extracted by ED using a pre-piloted extraction sheet. When data were presented in graphical, and not in numerical format, DigitizeIt software (Version 2.3, Digi-tizeIt, Germany) was used to convert the data. The quality of each review outcome (defined as each of the statistical models undertaken) was assigned using a strategy based on the recommendations of the Grading of Recommenda-tions Assessment Development and Evaluation (GRADE) working group [26]. This approach considers the quality of research outcomes in a systematic review according to five domains, namely risk of bias, directness, consistency, precision and evidence of publication bias. Risk of bias and directness were assessed at the individual study level with mode ratings used to categorise whole outcomes. The meta-analysis results were subsequently used to ascertain the consistency, precision and risk of publication bias for

    Table 1 Population, intervention, comparator, outcomes and study design (PICOS) criteria

    OCP oral contraceptive pill

    Population Healthy women aged 18–40 years were considered for inclusion in this study. No restrictions on activity level or training status were placed

    Intervention All participants were required to take an OCP, either habitually or experimentally. “Habitual” was defined as OCP use prior to the commencement of the study and not for the purposes of the study. “Experimentally” was defined as starting OCP use for the purposes of the study. All forms of OCPs were considered for use within this review

    Comparator Four broad types of comparisons were considered: (1) Between group comparison of habitual OCP users to naturally menstruat-ing women. Women were phase matched in two ways for this comparison: (i) OCP withdrawal versus the early follicular phase of the menstrual cycle and (ii) OCP consumption versus all other phases of the menstrual cycle except for the early follicular phase; (2) within group comparison of OCP consumption with the hormone-free withdrawal phase; (3) comparison of active OCP use with non-use (e.g ., within-group comparison of women who were habitual users or non-users who stopped/started taking OCP for the purpose of the study); (4) randomised controlled trials of OCPs versus placebo intake ( e.g ., between group comparison of naturally menstruating women who were randomly assigned to either an OCP or placebo pill)

    Outcomes The primary outcome was to determine any differences in exercise performance, based on the comparisons described above. ‘Exercise performance’ referred to outcomes stemming from: workload, time to completion and exhaustion, mean, peak out-puts, rate of production and decline and maximum oxygen uptake (a full list of considered outcomes can be found in Table 2). Although maximum oxygen uptake is not a performance test, this physiology-based outcome was included as it is widely used as an indicator of performance and is often used to describe the fitness of participants. Different exercise outcomes, broadly categorised as endurance and strength were considered. All exercise outcomes were extracted, and effect size duplication of multiple outcomes from the same test accounted for within the statistical analysis, as described in Sect. 2.4

    Study design Any study design that included the information described above was considered for inclusion

  • 1788 K. J. Elliott-Sale et al.

    each outcome. Each individual study was initially appraised using a modified version of the Downs and Black Checklist [27], which was specifically tailored for use in this review (see Electronic Supplementary Material Appendix S3). The modified quality appraisal checklist comprised 15 out-comes, and had a maximum attainable score of 16, with all studies classified as being of high (H; 14–16), moder-ate (M; 10–13), low (L; 6–9) or very low (VL; 0–5) qual-ity. The results of this assessment were used to assign an a priori quality rating to each outcome. This a priori rating was either maintained, or downgraded a level, based on the response to two questions that were considered key to the directness of the research design, i.e., Question 1: was the natural menstrual cycle phase confirmed using appropriate biochemical outcomes? Question 2: was the type of OCP described to the level of detail required for categorisation or replication? With regards to Question 1, for studies with OCP groups only, biochemical confirmation was not deemed necessary, as OCP users do not have cyclical fluctuations in endogenous sex hormones, in which case the a priori score was maintained rather than downgraded. This rating was then either maintained, or downgraded another level based on whether the results obtained were consistent (determined by visual inspection of effect size estimates and the degree of credible intervals [CrI] overlap); precise (with outcomes downgraded if they were based on < 5 data points) and whether or not publication bias was evidence (determined using Egger’s test along with visual inspection of funnel plots as described in Sect. 2.4). The proportion of studies in each category was reported, with the mode considered to represent the overall quality rating for each individual review outcome. Two independent reviewers (KES and KMH) veri-fied the data extraction and quality appraisal.

    2.4 Data Analysis

    Data were extracted from studies comprising both between group and within group designs. Pairwise effect sizes were calculated by dividing mean differences by pooled standard deviations. At the study level, variance of effect sizes were calculated according to standard distributional assumptions [28]. All meta-analyses were conducted within a Bayes-ian framework enabling the results to be interpreted more intuitively compared to a standard frequentist approach through use of subjective probabilities [29]. With a Bayes-ian framework, dichotomous interpretations of the results of a meta-analysis with regards to the presence or absence of an effect (e.g., with p values) can be avoided, and greater emphasis placed on describing the most likely values for the average effect and addressing practical questions such as the probability the average effect is beyond a certain threshold [29]. The Bayesian framework is also particularly suited to hierarchical models and sharing information within and

    across studies to improve estimates [29]. In the present meta-analysis, three-level hierarchical models were conducted to account for covariance in multiple outcomes presented in the same study [30]. Initial models were conducted includ-ing both strength and endurance outcomes with a regression coefficient assessing difference in the average effects. Where no evidence of a difference was identified, the model was re-run combining both categories of outcomes to increase data to better estimate model parameters. Given the expec-tation of relatively small effect sizes, an a priori threshold of ± 2 was identified for outliers. Primary analyses were completed with outliers removed but results also presented from the full complement of studies as sensitivity analyses. Additionally, sensitivity analyses were conducted on data obtained from studies categorised as “high” or “moderate” in quality. Inferences from all analyses were performed on posterior samples generated by Hamiltonian Markov Chain Monte Carlo with Bayesian 95% CrIs constructed to enable probabilistic interpretations of parameter values [29]. Inter-pretations were based on visual inspection of the posterior sample, the median value (ES0.5: 0.5-quantile) and 95% CrIs. Cohen’s [31] standard threshold value of 0.2 was used to describe effect size as small, and values between 0 and 0.2 were described as trivial. Analyses were performed using the R wrapper package brms, which was interfaced with Stan to perform sampling [32]. Convergence of parameter esti-mates was obtained for all models with Gelman–Rubin R-hat values below 1.1 [33]. Additional sensitivity analyses were conducted by restricting the analysis to studies that included exercise performance as the primary study outcome. Assess-ment of publication bias using Egger’s multilevel test with effect sizes regressed on inverse standard errors [34] identi-fied no evidence of publication bias with median absolute intercept values less than 0.1 across all analyses.

    2.5 Rationale for Between Group Comparisons

    For the between group analyses of habitual OCP users to naturally menstruating women, the OCP withdrawal phase [days 1–7] was compared with the early follicular phase [days 1–5] of the menstrual cycle and the OCP consump-tion phase [days 8–28] was compared with all phases of the menstrual cycle [days 6–28] except the early follicular phase [days 1–5]. The OCP withdrawal phase was com-pared with the early follicular phase as during the with-drawal phase OCP users experience a withdrawal bleed and during the early follicular phase of the menstrual cycle women experience menstruation. In addition, dur-ing both phases endogenous concentrations of oestrogen and progesterone are comparably low. During the remain-der of the menstrual cycle, endogenous concentrations of oestrogen and progesterone change over time (e.g., the mid-cycle peak in oestrogen and the mid-luteal rise in

  • 1789Oral Contraceptives and Exercise Performance

    progesterone and oestrogen) and there is large variation in endogenous concentrations of oestrogen and progesterone as a result of different OCP formulations. As such, it is difficult to make meaningful comparisons during these phases and this could be considered a limiting factor of any meta-analysis making between group comparisons of naturally menstruating women and OCP users. To reduce the impact of this limitation, a sensitivity analy-sis was completed on the between group design data to better match the physiological menstrual cycle and OCP pseudo-phases. This was achieved by mapping days 1–5, 12–16 and 19–23 from both cycles, which correspond with the early follicular, ovulatory and mid-luteal phases in a natural menstrual cycle and represents the following hormonal profiles: low oestrogen and progesterone, high oestrogen and low progesterone and high progesterone and medium oestrogen. As such, this meta-analysis (1) compared the two most stable phases of the OCP and menstrual cycles in the first between group analyses; (2) compared the two least stable phases of the OCP and menstrual cycles in the second between group analysis; and (3) performed an additional sensitivity analysis to better match the OCP and menstrual phases.

    3 Results

    3.1 Study Characteristics

    Figure 1 shows the studies identified and selected by the search strategy. Details of the included studies are shown in Table 2. In total 42 studies [5, 13, 18–20, 22–24, 35–68] and 590 participants were included.

    Methodological quality at the level of the individual study is shown in Fig. 2; 83% of the studies were graded as M, L or very low VL, with 17% achieving H quality. Specifically, 4 studies were graded as VL, 10 as L, 21 as M and 7 as H quality.

    3.2 Between Group Analyses of Habitual Oral Contraceptive Users Compared to Naturally Menstruating Women

    Thirty of the included studies (combined quality rating = M; specifically 20% H; 37% M; 30% L; 13% VL) generated 151 effects sizes from research designs comparing habitual OCP users with naturally menstruating women. The data were collected from 597 participants (habitual OCP n = 303, naturally menstruating n = 294) with studies comprising a mean group size of 10 (range n = 5–25).

    3.2.1 Oral Contraceptive Pill Withdrawal [Days 1–7] Versus the Early Follicular Phase [Days 1–5] of the Menstrual Cycle

    Three outliers were identified with effect sizes greater than + 2, and were removed from the analysis, leaving a total of 49 effect sizes (26 endurance, 23 strength) from 18 studies (combined quality rating = M; specifically 17% H; 33% M; 28% L; 22% VL; habitual OCP n = 176, naturally menstruating n = 169). The three-level hierarchical model indicated a trivial effect with the median value associating greater performances with naturally menstruating women (ES0.5 = 0.18 [95% CrI − 0.02 to 0.37]; Fig. 3). Relatively large between-study standard deviation was identified ( �0.5 = 0.16 [95% CrI 0.01–0.44]) with estimates indicating moderate intraclass correlation (ICC0.5 = 0.42 [95% CrI 0.00–0.80]) due to analysis of multiple outcomes reported within studies. Pooling of strength and endurance outcomes was conducted as no evidence was obtained that indicated a differential effect between the performance categories (ES0.5/Endurance-Strength = 0.04 [95% CrI − 0.41 to 0.43]). Poste-rior estimates of the pooled effect size identified a moderate probability of a small effect favouring naturally menstruating women in the early follicular phase of the menstrual cycle (d ≥ 0.2; p = 0.404) and effectually a zero probability favour-ing habitual OCP women (d ≤ − 0.2; p = 0.001). Inclusion of outliers within the model substantially increased the aver-age effect size (ES0.5 = 0.34 [95% CrI − 0.04 to 0.72]) and between study variance ( �0.5 = 0.70 [95% CrI 0.24–1.23]).

    3.2.2 Oral Contraceptive Pill Consumption [Days 8–28] Versus all Phases of the Menstrual Cycle [Days 6–28] Except the Early Follicular Phase [Days 1–5]

    Eleven outliers were identified with effect sizes greater than + 2, and were removed from the analysis, leaving a total of 88 effect sizes (53 endurance, 35 strength) from 24 stud-ies (combined quality rating = M; specifically 21% H; 42% M; 25% L; 13% VL; habitual OCP n = 244 habitual OCP, naturally menstruating n = 230). The three-level hierarchi-cal model indicated a trivial effect with the median value associating greater performances obtained in the naturally menstruating women (ES0.5 = 0.13 [95% CrI − 0.05 to 0.28]; Fig. 4). Relatively large between study variance was identi-fied �0.5 = 0.22 [95% CrI 0.06–0.45] with central estimates indicating very low intraclass correlation ICC0.5 = 0.08 [95% CrI 0.0–0.61] due to analysis of multiple outcomes reported within studies. Pooling of strength and endurance outcomes was conducted as no evidence was obtained that indicated a differential effect between the performance categories (ES0.5/Endurance-Strength = 0.02 [95% CrI − 0.25 to

  • 1790 K. J. Elliott-Sale et al.

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    or

    (N)—

    S

    Low

    Arm

    stron

    g et

     al.

    [36]

    To m

    easu

    re th

    e in

    flu-

    ence

    of d

    iffer

    ent

    met

    hods

    of e

    xog-

    enou

    s hor

    mon

    al

    cont

    race

    ptiv

    e (O

    CP,

    in

    ject

    able

    ster

    oid

    cont

    race

    ptiv

    e, o

    r no

    cont

    race

    ptiv

    e) o

    n th

    erm

    al, m

    etab

    olic

    , ca

    rdio

    resp

    irato

    ry,

    perfo

    rman

    ce, b

    ody

    com

    posi

    tion

    and

    per-

    cept

    ual r

    espo

    nse

    of

    heal

    thy

    youn

    g w

    omen

    (c

    ontra

    cept

    ive)

    to a

    7–

    8 w

    eek

    prog

    ram

    of

    heat

    acc

    limat

    ion

    and

    phys

    ical

    trai

    ning

    Hea

    lthy

    wom

    en (2

    1 ± 3

    year

    s) w

    ho w

    ere

    not

    unde

    rtaki

    ng fr

    eque

    nt

    phys

    ical

    trai

    ning

    Para

    llel g

    roup

    , int

    er-

    vent

    ion,

    repe

    ated

    m

    easu

    res

    Ora

    l eth

    inyl

    oes

    tra-

    diol

    and

    pro

    gesti

    n co

    ntra

    cept

    ives

    (O

    rtho-

    Nov

    um,

    Orth

    o-C

    ycle

    n,

    Nor

    thi-T

    riCyc

    len,

    M

    arve

    lon

    or F

    emo-

    dene

    )

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    , tes

    ted

    at th

    e EF

    pha

    se, v

    eri-

    fied

    by se

    rum

    oes

    tro-

    gen

    and

    prog

    este

    rone

    le

    vels

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l run

    to

    volit

    iona

    l fat

    igue

    —E

    Low

    Bel

    l et a

    l. [3

    7]To

    mea

    sure

    the

    influ

    -en

    ce o

    f OC

    P on

    ham

    -str

    ing

    neur

    omec

    han-

    ics a

    nd le

    g sti

    ffnes

    s ac

    ross

    the

    MC

    Hea

    lthy

    wom

    en

    (20.

    2 ± 1.

    4 ye

    ars)

    w

    ho w

    ere

    phys

    ical

    ly

    activ

    e (d

    efine

    d as

    a

    min

    imum

    of 2

    0 m

    in

    of a

    ctiv

    ity th

    ree

    times

    pe

    r wee

    k)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Mon

    opha

    sic

    OC

    PW

    omen

    with

    a se

    lf-re

    porte

    d na

    tura

    l m

    onth

    ly M

    C fo

    r the

    pr

    evio

    us 6

     mon

    ths,

    teste

    d at

    the

    EF a

    nd

    ovul

    atio

    n ph

    ase,

    ve

    rified

    usi

    ng u

    rinar

    y ov

    ulat

    ion

    dete

    ctio

    n an

    d se

    rum

    oes

    troge

    n an

    d pr

    oges

    tero

    ne

    leve

    ls

    Rat

    e of

    forc

    e pr

    oduc

    -tio

    n (N

    ·s−1 )

    , and

    tim

    e to

    reac

    h 50

    %

    peak

    (ms)

    mea

    sure

    d du

    ring

    a m

    axim

    al

    volu

    ntar

    y is

    omet

    ric

    ham

    strin

    g co

    ntra

    c-tio

    n—S

    Mod

    erat

    e

  • 1791Oral Contraceptives and Exercise Performance

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Bem

    ben

    et a

    l. [3

    8]To

    mea

    sure

    the

    influ

    -en

    ce o

    f OC

    P on

    gr

    owth

    hor

    mon

    e an

    d pr

    olac

    tin re

    spon

    ses

    and

    on e

    nerg

    y su

    bstra

    te u

    tiliz

    atio

    n du

    ring

    prol

    onge

    d su

    bmax

    imal

    exe

    rcis

    e

    Hea

    lthy,

    mod

    erat

    ely

    activ

    e w

    omen

    (2

    5.1 ±

    1.4

    year

    s)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    sing

    le-

    mea

    sure

    Mul

    ti or

    mon

    opha

    sic

    OC

    Ps c

    onta

    inin

    g 35

     µg

    of o

    estro

    gen

    (Orth

    o N

    ovum

    10/

    11,

    7–7–

    7, 1

    /35

    and

    Dem

    ulen

    )

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    (cyc

    les

    rang

    ing

    from

    28

    to

    35 d

    ays i

    n le

    ngth

    ), fo

    r one

    yea

    r prio

    r to

    the

    study

    , tes

    ted

    at th

    e EL

    , ML

    and

    LL p

    hase

    s, ve

    rified

    by

    BB

    T an

    d se

    rum

    pr

    oges

    tero

    ne

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    and

    ab

    solu

    te w

    orkl

    oad

    (m·m

    in−

    1 ) m

    easu

    red

    durin

    g an

    incr

    emen

    -ta

    l run

    to v

    oliti

    onal

    fa

    tigue

    —E

    Low

    Bus

    hman

    et a

    l. [3

    9]To

    mea

    sure

    the

    effec

    t of

    men

    strua

    tion

    and

    OC

    P on

    pow

    er

    perfo

    rman

    ce

    Hea

    lthy,

    mod

    erat

    ely

    activ

    e w

    omen

    (2

    1.6 ±

    2.6

    year

    s)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    2 pa

    rtici

    pant

    s too

    k a

    mon

    opha

    sic

    and

    15 a

    m

    ultip

    hasi

    c O

    CP

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    teste

    d at

    the

    EF a

    nd E

    L ph

    ases

    , ver

    ified

    by

    BB

    T an

    d ur

    inar

    y ov

    ulat

    ion

    dete

    ctio

    n te

    st

    Estim

    ated

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    m

    easu

    red

    from

    th

    e Fo

    restr

    y St

    ep

    Test—

    E; p

    eak

    pow

    er

    (W o

    r W·k

    g−1 )

    , an

    aero

    bic

    capa

    city

    (W

    or W

    ·kg−

    1 ) a

    nd

    pow

    er d

    eclin

    e (W

    or

    W·k

    g−1 )

    mea

    sure

    d by

    th

    e W

    inga

    te te

    st—E

    and

    anae

    robi

    c po

    wer

    (k

    gm·s−

    1 ) m

    easu

    red

    in th

    e M

    arga

    ria K

    ala-

    men

    test—

    E

    Low

    /ver

    y lo

    w

    Cas

    azza

    et a

    l. [2

    0]To

    mea

    sure

    the

    effec

    ts

    of M

    C p

    hase

    and

    tri

    phas

    ic O

    CP

    use

    on p

    eak

    exer

    cise

    ca

    paci

    ty

    Hea

    lthy,

    hab

    itual

    ly

    activ

    e w

    omen

    who

    w

    ere

    not c

    ompe

    titiv

    e at

    hlet

    es (2

    5.5 ±

    1.5

    year

    s)

    With

    in g

    roup

    , int

    er-

    vent

    ion

    (OC

    P),

    repe

    ated

    mea

    sure

    s

    Stan

    dard

    ized

    trip

    hasi

    c O

    CP

    (day

    s 1–7

    : 0.

    035 

    mg

    ethi

    nyle

    -str

    adio

    l and

    0.1

    8 m

    g no

    rges

    timat

    e; d

    ays

    8–14

    : 0.0

    35 e

    thin

    yle-

    strad

    iol a

    nd 0

    .215

    no

    rges

    timat

    e; d

    ays

    15–2

    1: 0

    .035

     mg

    ethi

    nyle

    strad

    iol a

    nd

    0.25

     mg

    norg

    esti-

    mat

    e, d

    ays 2

    2–28

    : pl

    aceb

    o pi

    ll)

    Wom

    en w

    ith a

    se

    lf-re

    porte

    d na

    tura

    l mon

    thly

    M

    C (2

    2–32

     day

    s in

    leng

    th) f

    or a

    t lea

    st 6 

    mon

    ths,

    teste

    d du

    r-in

    g th

    e LF

    and

    ML

    phas

    es, v

    erifi

    ed b

    y a

    urin

    ary

    ovul

    atio

    n de

    tect

    ion

    test

    and

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    Peak

    ̇ VO

    2 (L·

    min

    −1 )

    , po

    wer

    (W) a

    nd ti

    me

    to e

    xhau

    stion

    (min

    ) m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l cyc

    le to

    vo

    litio

    nal f

    atig

    ue—

    E

    Mod

    erat

    e

  • 1792 K. J. Elliott-Sale et al.

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    de B

    ruyn

    -Pre

    vost

    et a

    l. [4

    0]To

    mea

    sure

    the

    effec

    ts o

    f OC

    P an

    d eu

    men

    orrh

    eic

    MC

    on

    the

    phys

    iolo

    gica

    l re

    spon

    se to

    aer

    obic

    an

    d an

    aero

    bic

    endu

    r-an

    ce te

    sts

    Wom

    en (2

    2 ± 2.

    2 ye

    ars)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    No

    info

    rmat

    ion

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    , tes

    ted

    durin

    g th

    e EF

    , ovu

    la-

    tory

    and

    LL

    phas

    es,

    verifi

    ed b

    y B

    BT

    ̇ VO

    2 pea

    k (L

    ·min

    −1 )

    an

    d w

    orki

    ng c

    apac

    -ity

    at a

    hea

    rt ra

    te

    of 1

    70 b

    pm (W

    ) m

    easu

    red

    usin

    g an

    in

    crem

    enta

    l cyc

    le to

    vo

    litio

    nal f

    atig

    ue—

    E,

    and

    max

    imal

    ped

    al

    time

    (s) d

    urin

    g a

    fixed

    load

    (350

     W)

    anae

    robi

    c en

    dura

    nce

    test—

    E

    Very

    low

    Dra

    ke e

    t al.

    [41]

    To m

    easu

    re th

    e eff

    ect o

    f OC

    P an

    d eu

    men

    orrh

    eic

    MC

    on

    ele

    ctro

    myo

    grap

    hy

    and

    mec

    hano

    myo

    gra-

    phy

    durin

    g is

    omet

    ric

    mus

    cle

    cont

    ract

    ions

    Hea

    lthy

    wom

    en (2

    4 ± 1

    year

    s) w

    ho w

    ere

    not

    invo

    lved

    in a

    n ex

    er-

    cise

    pro

    gram

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    No

    info

    rmat

    ion

    Wom

    en w

    ith a

    se

    lf-re

    porte

    d na

    tura

    l mon

    thly

    M

    C (2

    6–32

     day

    s in

    leng

    th) t

    este

    d at

    the

    EF, L

    F, o

    vula

    tion

    and

    EL, v

    erifi

    ed u

    sing

    ur

    inar

    y ov

    ulat

    ion

    dete

    ctio

    n te

    st

    Max

    imal

    and

    sub-

    max

    imal

    isom

    etric

    ex

    tens

    or a

    nd fl

    exor

    co

    ntra

    ctio

    n at

    100

    , 75

    , 50

    and

    25%

    of

    max

    imal

    torq

    ue

    (N m

    )—S

    Very

    low

    Eken

    ros e

    t al.

    [42]

    To m

    easu

    re th

    e eff

    ect

    of O

    CP

    and

    eum

    enor

    -rh

    eic

    MC

    on

    mus

    cle

    stren

    gth

    and

    hop

    perfo

    rman

    ce

    Hea

    lthy

    wom

    en

    (26.

    7 ± 3.

    8 ye

    ars)

    w

    ho w

    ere

    enga

    ged

    in m

    oder

    ate

    to h

    igh

    leve

    ls o

    f rec

    reat

    iona

    l ac

    tivity

    With

    in-g

    roup

    , int

    er-

    vent

    ion,

    repe

    ated

    m

    easu

    res

    Low

    dos

    e m

    onop

    hasi

    c O

    CPs

    con

    tain

    ing

    ethi

    nyl o

    estra

    diol

    (2

    0–35

     μg)

    com

    bine

    d w

    ith d

    iffer

    ent p

    ro-

    gesto

    gen

    (Lev

    onor

    g-es

    trel,

    Nor

    gesti

    mat

    e,

    Dro

    spire

    none

    , Des

    -og

    estre

    l, N

    oret

    ister

    -on

    e an

    d Ly

    nestr

    enol

    )

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    who

    ha

    d no

    t bee

    n ta

    king

    an

    y ho

    rmon

    e-co

    n-ta

    inin

    g co

    ntra

    cept

    ive

    for a

    t lea

    st th

    ree

    mon

    ths p

    rior t

    o th

    e stu

    dy, t

    este

    d du

    ring

    the

    EF, o

    vula

    tory

    and

    M

    L ph

    ases

    , ver

    ified

    us

    ing

    urin

    ary

    ovul

    a-tio

    n de

    tect

    ion

    test

    and

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    Peak

    isok

    inet

    ic k

    nee

    exte

    nsor

    stre

    ngth

    (N

    m)—

    S, h

    andg

    rip

    stren

    gth

    (kg)

    —S

    and

    jum

    p he

    ight

    dur

    ing

    the

    one

    leg

    hop

    test

    (cm

    )—S

    Mod

    erat

    e

  • 1793Oral Contraceptives and Exercise Performance

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Ellio

    tt et

     al.

    [5]

    To m

    easu

    re th

    e eff

    ect

    of O

    CP

    and

    MC

    on

    max

    imum

    forc

    e pr

    oduc

    tion

    Hea

    lthy

    wom

    en (2

    2 ± 4

    year

    s) w

    ho w

    ere

    sede

    ntar

    y (d

    efine

    d as

    no

    t bei

    ng in

    volv

    ed in

    a

    stren

    gth

    or a

    erob

    ic

    train

    ing

    prog

    ram

    fo

    r the

    pre

    viou

    s 6 

    mon

    ths)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Com

    bine

    d m

    onop

    hasi

    c O

    CPs

    (Mic

    rogy

    non,

    B

    revi

    nor,

    Ova

    rnet

    te,

    Mar

    valo

    n, C

    ilest)

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    (mea

    n cy

    cle

    leng

    th o

    f 29

     day

    s) w

    ho w

    ere

    not t

    akin

    g an

    y ho

    rmon

    al b

    ased

    con

    -tra

    ctio

    n fo

    r 6 m

    onth

    s pr

    ior t

    o th

    e stu

    dy,

    teste

    d du

    ring

    the

    EF a

    nd M

    L ph

    ases

    , ve

    rified

    by

    BB

    T,

    urin

    ary

    ovul

    atio

    n de

    tect

    ion

    test

    and

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    Max

    imal

    vol

    unta

    ry

    isom

    etric

    forc

    e of

    the

    first

    dors

    al in

    tero

    s-se

    us m

    uscl

    e (N

    )—S,

    is

    okin

    etic

    ext

    en-

    sion

    and

    flex

    ion

    of

    the

    quad

    ricep

    s and

    ha

    mstr

    ing

    mus

    cles

    at

    1.0

    4. 2

    .09

    and

    4.19

     rad/

    S (N

     m)—

    S,

    and

    isom

    etric

    ext

    en-

    sion

    and

    flex

    ion

    (N m

    )—S

    Mod

    erat

    e

    Gia

    com

    oni a

    nd F

    al-

    gaire

    tte [4

    3]To

    mea

    sure

    the

    effec

    t of

    tim

    e of

    day

    an

    d O

    CP

    use

    on

    max

    imum

    ana

    erob

    ic

    pow

    er

    Phys

    ical

    edu

    catio

    n stu

    dent

    s (22

    .8 ±

    2.8

    year

    s)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Com

    bine

    d m

    onop

    hasi

    c O

    CP

    (0.0

    2–0.

    03 m

    g et

    hiny

    lestr

    adio

    l and

    0.

    150 

    mg

    des-

    oges

    trel o

    r 0.0

    75 m

    g ge

    stode

    ne)

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    lasti

    ng

    25–3

    1 da

    ys in

    leng

    th,

    who

    had

    not

    use

    d an

    y O

    CP

    for a

    t lea

    st 4 

    mon

    ths b

    efor

    e en

    terin

    g th

    e stu

    dy,

    teste

    d du

    ring

    the

    LF

    and

    ML,

    ver

    ified

    by

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    leve

    ls

    Peak

    vel

    ocity

    (rpm

    )—E,

    pea

    k fo

    rce

    (kg)

    —S

    and

    peak

    pow

    er

    (W)—

    E, m

    easu

    red

    durin

    g a

    forc

    e ve

    loc-

    ity te

    st

    Mod

    erat

    e

    Gia

    com

    oni e

    t al.

    [22]

    To m

    easu

    re th

    e eff

    ect

    of O

    CP

    and

    eum

    enor

    -rh

    eic

    MC

    on

    anae

    ro-

    bic

    perfo

    rman

    ce

    Phys

    ical

    edu

    catio

    n stu

    -de

    nts (

    23 ±

    3 ye

    ars)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Com

    bine

    d m

    ono-

    phas

    ic O

    CP

    with

    co

    nsta

    nt o

    estro

    gen

    and

    prog

    este

    rone

    le

    vels

    (0.0

    2–0.

    03 m

    g et

    hiny

    lestr

    adio

    l and

    0.

    150 

    mg

    des-

    oges

    trel o

    r 0.0

    75 m

    g ge

    stode

    ne)

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    lasti

    ng

    25–3

    1 da

    ys in

    leng

    th,

    who

    had

    not

    use

    d an

    y O

    CP

    for a

    t lea

    st 4 

    mon

    ths b

    efor

    e en

    terin

    g th

    e stu

    dy,

    teste

    d du

    ring

    the

    LF

    and

    ML,

    ver

    ified

    by

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    leve

    ls

    Peak

    vel

    ocity

    (rpm

    )—E,

    pea

    k fo

    rce

    (kg)

    —S

    and

    peak

    pow

    er

    (W)—

    E, m

    easu

    red

    durin

    g a

    forc

    e ve

    loc-

    ity te

    st an

    d ju

    mp

    heig

    ht (c

    m) m

    easu

    red

    usin

    g m

    ulti

    and

    squa

    t ju

    mp

    tests

    —S

    Mod

    erat

    e

  • 1794 K. J. Elliott-Sale et al.

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Gor

    don

    et a

    l. [4

    4]To

    mea

    sure

    the

    effec

    t of

    OC

    P an

    d M

    C o

    n pe

    ak is

    okin

    etic

    torq

    ue

    Hea

    lthy,

    wel

    l-tra

    ined

    w

    omen

    (20.

    6 ± 1.

    2 ye

    ars)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Mon

    opha

    sic

    OC

    PW

    omen

    with

    a se

    lf-re

    porte

    d na

    tura

    l m

    onth

    ly M

    C (m

    ean

    cycl

    e le

    ngth

    of

    28 d

    ays)

    teste

    d du

    ring

    the

    EF, L

    F,

    ML

    and

    LL p

    hase

    s, ve

    rified

    by

    saliv

    ary

    oestr

    ogen

    and

    pro

    -ge

    stero

    ne le

    vels

    Peak

    con

    cent

    ric k

    nee

    flexo

    r and

    ext

    enso

    r to

    rque

    at 6

    0, 1

    20, 1

    8-

    and

    240°

    (N m

    )—S

    Very

    low

    Gor

    don

    et a

    l. [4

    5]To

    mea

    sure

    the

    effec

    t of O

    CP

    and

    eum

    enor

    rhei

    c M

    C o

    n in

    cide

    nce

    of ̇ V

    O2 m

    ax

    plat

    eau

    and

    asso

    ci-

    ated

    car

    dior

    espi

    rato

    ry

    dyna

    mic

    s

    Hea

    lthy,

    phy

    sica

    lly

    activ

    e w

    omen

    (2

    1 ± 1.

    8 ye

    ars)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Mon

    opha

    sic

    OC

    P co

    n-ta

    inin

    g 30

     µg

    ethi

    nyl

    oestr

    adio

    l and

    150

     µg

    levo

    norg

    estre

    l

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    teste

    d du

    ring

    the

    EF, L

    F,

    ML

    and

    LL, v

    erifi

    ed

    by M

    C h

    istor

    y an

    d sa

    livar

    y oe

    strog

    en

    and

    prog

    este

    rone

    le

    vels

    Peak

    ̇ VO

    2 (L·

    min

    −1 )

    an

    d po

    wer

    (W)

    mea

    sure

    d du

    ring

    an

    incr

    emen

    tal r

    un to

    vo

    litio

    nal f

    atig

    ue—

    E

    Mod

    erat

    e

    Gru

    cza

    et a

    l. [4

    6]To

    mea

    sure

    the

    effec

    t of O

    CP

    and

    eum

    enor

    rhei

    c M

    C o

    n th

    erm

    osen

    sitiv

    ity

    Hea

    lthy

    wom

    en

    (21.

    3 ± 1.

    8 ye

    ars)

    w

    ho w

    ere

    unde

    rtak-

    ing

    appr

    oxim

    atel

    y 2–

    3 h

    of v

    ario

    us

    activ

    ity ty

    pes p

    er

    wee

    k

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Mon

    opha

    sic

    OC

    P (T

    rikvi

    lar o

    r Neo

    -G

    entro

    l 150

    /30)

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    for

    one

    year

    pre

    ced-

    ing

    the

    expe

    rimen

    t an

    d w

    ho h

    ad n

    ever

    ta

    ken

    OC

    Ps, t

    este

    d du

    ring

    the

    LF a

    nd

    ML

    phas

    e, v

    erifi

    ed

    by B

    BT

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1)

    m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l cyc

    le to

    vo

    litio

    nal f

    atig

    ue—

    E

    Low

    Gru

    cza

    et a

    l. [4

    7]To

    mea

    sure

    the

    effec

    t of O

    CP

    and

    eum

    enor

    rhei

    c M

    C

    on c

    ardi

    ores

    pira

    tory

    re

    spon

    ses t

    o ex

    erci

    se

    Hea

    lthy

    univ

    ersi

    ty

    stude

    nts (

    21.3

    ± 1.

    8 ye

    ars)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Mon

    opha

    sic

    OC

    P (T

    rikvi

    lar o

    r Neo

    -G

    entro

    l)

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    for

    1 ye

    ar p

    rece

    ding

    th

    e ex

    perim

    ent a

    nd

    who

    had

    nev

    er ta

    ken

    OC

    Ps, t

    este

    d du

    r-in

    g th

    e LF

    and

    ML

    phas

    e, v

    erifi

    ed b

    y B

    BT

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l cyc

    le to

    vo

    litio

    nal f

    atig

    ue—

    E

    Low

  • 1795Oral Contraceptives and Exercise Performance

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Hic

    ks e

    t al.

    [48]

    To m

    easu

    re th

    e eff

    ect

    of O

    CP

    and

    eum

    enor

    -rh

    eic

    MC

    on

    exer

    cise

    in

    duce

    d m

    uscl

    e da

    mag

    e, a

    nd te

    ndon

    pr

    oper

    ties

    Hea

    lthy,

    recr

    eatio

    n-al

    ly a

    ctiv

    e w

    omen

    (2

    2.3 ±

    2.3

    year

    s)

    Para

    llel g

    roup

    , int

    er-

    vent

    ion,

    repe

    ated

    m

    easu

    res

    Com

    bine

    d m

    onop

    hasi

    c O

    CP

    with

    eth

    inyl

    oe

    strad

    iol d

    osag

    e be

    twee

    n 20

    and

    30

     µg

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    (ave

    r-ag

    e cy

    cle

    leng

    th o

    f 28

     day

    s) a

    nd w

    ho

    had

    neve

    r tak

    en th

    e O

    CP,

    teste

    d du

    ring

    the

    ovul

    ator

    y ph

    ase,

    ve

    rified

    by

    seru

    m

    oestr

    ogen

    Peak

    vol

    unta

    ry is

    omet

    -ric

    torq

    ue (N

     m)—

    SM

    oder

    ate

    Isac

    co e

    t al.

    [49]

    To m

    easu

    re th

    e eff

    ect o

    f OC

    P an

    d eu

    men

    orrh

    eic

    MC

    on

    lipi

    d ox

    idat

    ion

    and

    card

    iore

    spira

    tory

    pa

    ram

    eter

    s at t

    he

    anae

    robi

    c th

    resh

    -ol

    d an

    d m

    axim

    um

    capa

    city

    Wei

    ght s

    tabl

    e, h

    ealth

    y w

    omen

    (22 ±

    2.9

    year

    s) w

    ho w

    ere

    recr

    eatio

    nally

    act

    ive

    (defi

    ned

    as th

    ose

    not

    invo

    lved

    in a

    ny re

    gu-

    lar e

    xerc

    ise

    train

    ing)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Low

    -dos

    e m

    onop

    hasi

    c O

    CP

    cont

    aine

    d 20

    ( n =

    8) o

    r 30

    ( n =

    3)

    µg o

    f eth

    inyl

    estra

    diol

    an

    d ge

    stode

    ne o

    r le

    vono

    rges

    trel

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    (ave

    r-ag

    e cy

    cle

    leng

    th o

    f 28

     day

    s for

    at l

    east

    1 ye

    ar) a

    nd h

    ad n

    ot

    take

    n an

    y O

    CP

    for

    mor

    e th

    an 1

     yea

    r pr

    ior t

    o th

    e stu

    dy

    begi

    nnin

    g, te

    sted

    durin

    g th

    e M

    L ph

    ase,

    ve

    rified

    by

    coun

    ting

    of d

    ays a

    nd se

    rum

    oe

    strog

    en a

    nd p

    ro-

    geste

    rone

    leve

    ls

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l cyc

    le to

    vo

    litio

    nal f

    atig

    ue—

    E

    Mod

    erat

    e

    Joyc

    e et

     al.

    [13]

    To m

    easu

    re th

    e eff

    ect

    of lo

    ng-te

    rm O

    CP

    use

    on e

    ndur

    ance

    pe

    rform

    ance

    Hea

    lthy

    wom

    en

    (21 ±

    2.7

    year

    s) w

    ho

    wer

    e re

    crea

    tiona

    lly

    activ

    e (d

    efine

    d as

    ex

    erci

    sing

    > 3 

    days

    pe

    r wee

    k fo

    r at l

    east

    30 m

    in p

    er se

    ssio

    n)

    Para

    llel g

    roup

    , ob

    serv

    atio

    nal,

    sing

    le

    mea

    sure

    Com

    bine

    d m

    onop

    hasi

    c O

    CP

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    lasti

    ng

    betw

    een

    28 a

    nd

    30 d

    ays f

    or a

    t lea

    st 12

     mon

    ths b

    efor

    e th

    e stu

    dy, t

    este

    d du

    ring

    the

    EF p

    hase

    , ver

    ified

    by

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    le

    vels

    Peak

    ̇ VO

    2 (L·

    min

    −1 )

    an

    d po

    wer

    (W)

    mea

    sure

    d du

    ring

    an in

    crem

    enta

    l cy

    cle

    to v

    oliti

    onal

    fa

    tigue

    —E,

    and

    tim

    e to

    exh

    austi

    on (s

    ) on

    a su

    bmax

    imal

    cyc

    ling

    test—

    E

    Mod

    erat

    e

  • 1796 K. J. Elliott-Sale et al.

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Joyc

    e et

     al.

    [50]

    To m

    easu

    re th

    e eff

    ect

    of se

    x an

    d O

    CP

    on

    subm

    axim

    al c

    yclin

    g pe

    rform

    ance

    fol-

    low

    ing

    an e

    ccen

    tric

    exer

    cise

    pro

    toco

    l

    Hea

    lthy

    wom

    en

    (20.

    8 ± 2.

    4 ye

    ars)

    w

    ho w

    ere

    regu

    larly

    ph

    ysic

    ally

    act

    ive,

    bu

    t not

    par

    ticip

    at-

    ing

    in a

    ny re

    gula

    r re

    sist

    ance

    -exe

    rcis

    e tra

    inin

    g

    Para

    llel g

    roup

    , int

    er-

    vent

    ion,

    repe

    ated

    m

    easu

    res

    Com

    bine

    d m

    onop

    hasi

    c O

    CP

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    lasti

    ng

    betw

    een

    28 a

    nd

    30 d

    ays f

    or a

    t lea

    st 12

     mon

    ths b

    efor

    e th

    e stu

    dy, t

    este

    d du

    ring

    the

    EF p

    hase

    and

    ve

    rified

    seru

    m o

    es-

    troge

    n an

    d pr

    oges

    ter-

    one

    leve

    ls

    Peak

    ̇ VO

    2 (m

    l·kg·

    min

    −1 )

    and

    po

    wer

    (W) m

    easu

    red

    durin

    g an

    incr

    emen

    -ta

    l cyc

    le to

    vol

    ition

    al

    fatig

    ue—

    E, a

    nd m

    ean

    torq

    ue (N

     m·k

    g−1 )

    an

    d to

    rque

    dec

    line

    (N m

    ) mea

    sure

    d ac

    ross

    240

    max

    imal

    ec

    cent

    ric q

    uadr

    icep

    s co

    ntra

    ctio

    ns—

    S

    Low

    Lebr

    un e

    t al.

    [23]

    To m

    easu

    re th

    e eff

    ect

    of O

    CP

    and

    eum

    enor

    -rh

    eic

    MC

    on

    exer

    cise

    pe

    rform

    ance

    in

    high

    ly a

    ctiv

    e w

    omen

    Hea

    lthy,

    ath

    letic

    w

    omen

    (18–

    40

    year

    s), b

    ut n

    one

    that

    co

    mpe

    ted

    in a

    erob

    ic

    activ

    ities

    (cyc

    ling,

    tri

    athl

    on, r

    owin

    g,

    cros

    s-co

    untry

    skiin

    g)

    Ran

    dom

    ised

    con

    trolle

    d tri

    alTr

    ipha

    sic

    OC

    P (S

    yn-

    phas

    ic, 0

    .035

     mg

    ethi

    nyle

    strad

    iol a

    nd

    0.5–

    1.0 

    mg

    nore

    thin

    -dr

    one)

    Wom

    en w

    ith a

    se

    lf-re

    porte

    d na

    tura

    l mon

    thly

    M

    C (2

    4–35

     day

    s in

    leng

    th) a

    nd n

    o O

    CP

    use

    in th

    e 3 

    mon

    ths

    befo

    re e

    nter

    ing

    the

    study

    , tes

    ted

    durin

    g th

    e EF

    and

    ML

    phas

    es, v

    erifi

    ed b

    y se

    rum

    oes

    troge

    n an

    d pr

    oges

    tero

    ne le

    vels

    ̇ VO

    2 pea

    k (L

    ·min

    −1 )

    m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l cyc

    le to

    vo

    litio

    nal f

    atig

    ue—

    E,

    time

    to e

    xhau

    stion

    (s

    ) in

    a su

    bmax

    imal

    en

    dura

    nce

    test—

    E,

    time

    to e

    xhau

    stion

    (s

    ) in

    an a

    naer

    obic

    sp

    eed

    test—

    E an

    d pe

    ak q

    uadr

    icep

    s and

    ha

    mstr

    ing

    torq

    ue

    (N m

    )—S

    Mod

    erat

    e

    Lee

    et a

    l. [5

    1]To

    mea

    sure

    the

    effec

    t of

    OC

    P an

    d eu

    men

    or-

    rhei

    c M

    C o

    n an

    terio

    r cr

    ucia

    te li

    gam

    ent

    elas

    ticity

    , for

    ce to

    flex

    th

    e kn

    ee a

    nd k

    nee

    flexi

    on–e

    xten

    sion

    hy

    stere

    sis

    Hea

    lthy,

    non

    -ath

    letic

    w

    omen

    (24.

    7 ± 2

    year

    s)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Low

    dos

    e O

    CP

    cont

    aini

    ng <

    50 µ

    g et

    hiny

    l-estr

    adio

    l

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    for a

    t le

    ast 6

     mon

    ths,

    with

    an

    aver

    age

    cycl

    e le

    ngth

    of 2

    9 da

    ys,

    teste

    d du

    ring

    the

    EF,

    LF, o

    vula

    tory

    and

    M

    L ph

    ases

    , ver

    ified

    by

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    le

    vels

    Kne

    e fle

    xion

    forc

    e (N

    )—S

    Mod

    erat

    e

  • 1797Oral Contraceptives and Exercise Performance

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Lync

    h an

    d N

    imm

    o [5

    2]To

    mea

    sure

    the

    effec

    t of O

    CP

    and

    eum

    enor

    rhei

    c M

    C o

    n in

    term

    itten

    t exe

    rcis

    e pe

    rform

    ance

    Hea

    lthy

    wom

    en

    (25.

    3 ± 6

    year

    s) w

    ho

    wer

    e re

    crea

    tiona

    lly

    activ

    e bu

    t not

    trai

    ning

    fo

    r any

    one

    spor

    t ex

    clus

    ivel

    y

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Low

    -dos

    e m

    onop

    hasi

    c O

    CP

    (Fem

    oden

    e,

    Cile

    st, O

    vran

    ette

    , M

    icro

    gyno

    n)

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    ovu

    lato

    ry

    MC

    s with

    an

    aver

    -ag

    e cy

    cle

    leng

    th o

    f 29

     day

    s, an

    d w

    ho h

    ad

    eith

    er n

    ever

    take

    n O

    CPs

    or h

    ad n

    ot

    take

    n an

    OC

    P in

    the

    last

    4 m

    onth

    s, te

    sted

    durin

    g th

    e LF

    and

    LL

    phas

    es, v

    erifi

    ed b

    y se

    rum

    pro

    geste

    rone

    le

    vels

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l run

    to

    volit

    iona

    l fat

    igue

    —E,

    and

    tim

    e to

    ex

    haus

    tion

    (s) i

    n an

    in

    term

    itten

    t spr

    int

    test—

    E

    Mod

    erat

    e/ lo

    w

    Lync

    h et

     al.

    [53]

    To m

    easu

    re th

    e eff

    ect

    of O

    CP

    on p

    erfo

    r-m

    ance

    and

    met

    abol

    ic

    resp

    onse

    s to,

    inte

    r-m

    itten

    t exe

    rcis

    e du

    r-in

    g th

    e 1s

    t or 3

    rd w

    eek

    of th

    e O

    CP

    cycl

    e

    Hea

    lthy,

    unt

    rain

    ed

    wom

    en (2

    3.1 ±

    4 ye

    ars)

    Sing

    le g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Low

    dos

    e m

    onop

    hasi

    c O

    CP

    (Ovr

    anet

    te,

    Fem

    oden

    e, M

    er-

    cilo

    n, M

    icro

    gyno

    n,

    Bre

    vino

    r)

    N/A

    Tim

    e to

    exh

    austi

    on (s

    ) in

    the

    final

    sprin

    t of

    an in

    term

    itten

    t spr

    int

    prot

    ocol

    —E

    Mod

    erat

    e

    Mac

    kay

    et a

    l. [6

    7]To

    mea

    sure

    the

    effec

    t of

    OC

    P us

    e on

    indi

    -re

    ct m

    arke

    rs o

    f mus

    -cl

    e da

    mag

    e fo

    llow

    ing

    ecce

    ntric

    cyc

    ling

    in

    wom

    en

    Hea

    lthy

    wom

    en

    (27.

    7 ± 4.

    5 ye

    ars)

    w

    ho w

    ere

    not a

    ctiv

    ely

    parti

    cipa

    ting

    in a

    ny

    resi

    stan

    ce o

    r flex

    -ib

    ility

    trai

    ning

    in th

    e 6 

    mon

    ths p

    rior t

    o th

    e stu

    dy

    Para

    llel g

    roup

    , acu

    te

    inte

    rven

    tion,

    sing

    le

    mea

    sure

    Third

    and

    four

    th

    gene

    ratio

    n m

    ono-

    phas

    ic O

    CP

    (eth

    inyl

    es

    tradi

    ol 0

    .02 

    µg;

    dros

    pire

    none

    3 µ

    g)

    Wom

    en w

    ith a

    se

    lf-re

    porte

    d na

    tura

    l mon

    thly

    MC

    (b

    etw

    een

    24 a

    nd

    35 d

    ays)

    and

    who

    w

    ere

    not u

    sing

    any

    fo

    rm o

    f hor

    mon

    e-ba

    sed

    cont

    race

    ptiv

    e m

    etho

    ds fo

    r 6 m

    onth

    s pr

    ior t

    o th

    e stu

    dy,

    teste

    d du

    ring

    the

    ovu-

    lato

    ry p

    hase

    , ver

    ified

    by

    urin

    ary

    ovul

    atio

    n de

    tect

    ion

    kit a

    nd sa

    li-va

    ry o

    estro

    gen

    and

    prog

    este

    rone

    leve

    ls

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    mea

    s-ur

    ed d

    urin

    g an

    incr

    e-m

    enta

    l cyc

    ling

    test

    to

    volit

    iona

    l fat

    igue

    —E,

    m

    axim

    al v

    olun

    -ta

    ry k

    nee

    exte

    nsor

    co

    ntra

    ctio

    n at

    90%

    kn

    ee fl

    exio

    n (N

    )—S,

    an

    d m

    ean

    pow

    er (W

    ) du

    ring

    an e

    ccen

    tric

    cycl

    ing

    test—

    E

    Hig

    h/ m

    oder

    ate

  • 1798 K. J. Elliott-Sale et al.

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Mat

    tu e

    t al.

    [68]

    To m

    easu

    re m

    axim

    al

    and

    subm

    axim

    al

    exer

    cise

    out

    com

    es

    at d

    iffer

    ent p

    hase

    s of

    the

    men

    strua

    l and

    O

    CP

    cycl

    e

    Hea

    lthy,

    trai

    ned,

    w

    omen

    (25.

    5 ± 5.

    2 ye

    ars)

    who

    per

    form

    ed

    mod

    erat

    e to

    vig

    orou

    s ph

    ysic

    al a

    ctiv

    ity

    at le

    ast 4

    tim

    es p

    er

    wee

    k, a

    nd fo

    r at l

    east

    30 m

    in p

    er b

    out

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Seco

    nd o

    r thi

    rd g

    en-

    erat

    ion

    mon

    opha

    sic

    OC

    P co

    ntai

    ning

    be

    twee

    n 20

    and

    35 

    µg

    of e

    thin

    yl o

    estra

    diol

    an

    d 10

    0–20

    0 µg

    of

    prog

    estin

    )

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    (cyc

    le

    betw

    een

    21 a

    nd

    35 d

    ays i

    n le

    ngth

    ) w

    ho w

    ere

    non

    horm

    onal

    con

    trace

    p-tiv

    e us

    ers f

    or a

    t lea

    st 12

     mon

    ths p

    rior t

    o th

    e stu

    dy, t

    este

    d du

    r-in

    g th

    e LF

    and

    ML

    phas

    es, t

    este

    d us

    ing

    urin

    ary

    ovul

    atio

    n de

    tect

    ion

    test

    ̇ VO

    2 pea

    k (L

    ·min

    −1 o

    r m

    l·kg·

    min

    −1 )

    dur

    ing

    an in

    crem

    enta

    l ram

    p te

    st to

    vol

    ition

    al

    fatig

    ue—

    E, a

    nd ti

    me

    to e

    xhau

    stion

    (s)

    durin

    g a

    cons

    tant

    lo

    ad te

    st at

    85%

    pea

    k po

    wer

    —E

    Hig

    h

    Min

    ahan

    et a

    l. [5

    4]To

    mea

    sure

    the

    effec

    t of

    sex

    and

    OC

    P in

    the

    resp

    onse

    to m

    uscl

    e da

    mag

    e af

    ter i

    nten

    se

    ecce

    ntric

    exe

    rcis

    e

    Hea

    lthy

    wom

    en

    (21 ±

    2.7

    year

    s) w

    ho

    wer

    e ha

    bitu

    ally

    act

    ive

    (prim

    arily

    mod

    erat

    e in

    tens

    ity e

    ndur

    ance

    -ba

    sed

    activ

    ities

    ), bu

    t w

    ho w

    ere

    not u

    nder

    -ta

    king

    a re

    sist

    ance

    tra

    inin

    g pr

    ogra

    m

    Para

    llel g

    roup

    , int

    er-

    vent

    ion,

    repe

    ated

    m

    easu

    res

    Com

    bine

    d m

    onop

    hasi

    c O

    CP

    Wom

    en w

    ith a

    self-

    repo

    rted

    natu

    ral

    mon

    thly

    MC

    that

    oc

    curr

    ed e

    very

    28

    –30 

    days

    , tes

    ted

    durin

    g th

    e EF

    pha

    se,

    verifi

    ed b

    y se

    rum

    oe

    strog

    en le

    vels

    Peak

    and

    mea

    n is

    omet

    -ric

    torq

    ue (N

     m a

    nd

    N m

    ·kg−

    1 ) a

    cros

    s 240

    ec

    cent

    ric c

    ontra

    c-tio

    ns—

    S

    Low

    Min

    ahan

    et a

    l. [5

    5]To

    mea

    sure

    the

    effec

    t of O

    CP

    and

    the

    eum

    enor

    rhei

    c M

    C o

    n co

    re b

    ody

    tem

    pera

    ture

    and

    skin

    bl

    ood

    flow

    at r

    est

    and

    durin

    g ex

    erci

    se

    (tem

    pera

    te a

    nd h

    ot

    envi

    ronm

    ents

    )

    Hea

    lthy

    wom

    en

    (22 ±

    3.4

    year

    s) w

    ho

    wer

    e re

    crea

    tiona

    lly

    activ

    e (3

    00–5

    00 m

    in

    per w

    eek

    of m

    oder

    ate

    inte

    nsity

    exe

    rcis

    e)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Low

    dos

    e co

    mbi

    ned

    mon

    opha

    sic

    OC

    PW

    omen

    with

    a se

    lf-re

    porte

    d na

    tura

    l m

    onth

    ly M

    C (e

    very

    25

    –32 

    days

    ) for

    m

    ore

    than

    12 

    mon

    ths

    and

    who

    had

    nev

    er

    take

    n an

    y fo

    rm o

    f sy

    nthe

    tic h

    orm

    ones

    , te

    sted

    durin

    g th

    e EF

    ph

    ase,

    ver

    ified

    by

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    leve

    ls

    Peak

    ̇ VO

    2 (m

    l·kg·

    min

    −1 )

    and

    po

    wer

    (W) m

    easu

    red

    durin

    g an

    incr

    emen

    -ta

    l cyc

    le to

    vol

    ition

    al

    fatig

    ue—

    E, a

    nd

    mea

    n po

    wer

    out

    put

    (W) d

    urin

    g a

    3-st

    age

    subm

    axim

    al te

    st—E

    Mod

    erat

    e

    Orte

    ga-S

    anto

    s et a

    l. [5

    6]To

    mea

    sure

    the

    effec

    t of O

    CP

    and

    eum

    enor

    rhei

    c M

    C o

    n su

    bstra

    te o

    xida

    tion

    durin

    g ste

    ady-

    stat

    e ex

    erci

    se

    Hea

    lthy

    train

    ed w

    omen

    (3

    5.6 ±

    4.2

    year

    s)

    who

    wer

    e tra

    inin

    g in

    ei

    ther

    end

    uran

    ce o

    r str

    engt

    h ac

    tiviti

    es fo

    r 5–

    12 h

    per

    wee

    k

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Stab

    le m

    onop

    hasi

    cW

    omen

    with

    a se

    lf-re

    porte

    d na

    tura

    l m

    onth

    ly M

    C te

    sted

    durin

    g th

    e EF

    , LF

    and

    ML

    phas

    e, v

    eri-

    fied

    by M

    C h

    istor

    y an

    d se

    rum

    oes

    troge

    n an

    d pr

    oges

    tero

    ne

    ̇ VO

    2 pea

    k (m

    l·kg·

    min

    −1 )

    m

    easu

    red

    durin

    g an

    in

    crem

    enta

    l run

    to

    volit

    iona

    l fat

    igue

    —E

    Low

  • 1799Oral Contraceptives and Exercise Performance

    Tabl

    e 2

    (con

    tinue

    d)

    Stud

    yA

    imPa

    rtici

    pant

    hea

    lth a

    nd

    train

    ing

    stat

    usSt

    udy

    desi

    gnO

    ral c

    ontra

    cept

    ive

    pill

    type

    Eum

    enor

    rhei

    c gr

    oup

    desc

    riptio

    nEx

    erci

    se o

    utco

    mes

    Qua

    lity

    ratin

    g

    Pete

    rs a

    nd B

    urro

    ws

    [57]

    To m

    easu

    re th

    e eff

    ect

    of th

    e an

    drog

    enic

    ity

    of p

    roge

    stins

    in O

    CP

    on le

    g str

    engt

    h

    Uni

    vers

    ity a

    thle

    tes

    (20.

    2 ± 0.

    5 ye

    ars)

    fro

    m a

    var

    iety

    of

    spor

    ts (c

    ricke

    t, fo

    otba

    ll, e

    ndur

    ance

    ru

    nnin

    g an

    d sw

    im-

    min

    g)

    Para

    llel g

    roup

    , obs

    er-

    vatio

    nal,

    repe

    ated

    m

    easu

    res

    Mon

    opha

    sic

    OC

    P co

    ntai

    ning

    30 

    µg

    ethi

    nyle

    strad

    iol w

    ith

    120 

    µg le

    vono

    rg-

    este

    rel o

    r 250

     µg

    norg

    estim

    ate

    N/A

    Peak

    leg

    exte

    nsio

    n an

    d fle

    xion

    torq

    ue

    (N m

    )—S

    Mod

    erat

    e

    Qui

    nn e

    t al.

    [58]

    To m

    easu

    re th

    e eff

    ect

    of lo

    ng-te

    rm O

    CP

    use

    on c

    ereb

    ral

    oxyg

    enat

    ion

    durin

    g in

    crem

    enta

    l cyc

    ling

    to e

    xhau

    stion

    Hea

    lthy

    wom

    en (2

    1 ± 3

    year

    s) w

    ho w

    ere

    recr

    eatio

    nally

    -act

    ive

    (defi

    ned

    as 1

    50–

    300 

    min

    per

    wee

    k of

    m

    oder

    ate

    inte

    nsity

    ex

    erci

    se)

    Para

    llel g

    roup

    , ob

    serv

    atio

    nal,

    sing

    le

    mea

    sure

    28-d

    ay c

    ombi

    ned

    mon

    opha

    sic

    OC

    PW

    omen

    with

    a

    self-

    repo

    rted

    natu

    ral m

    onth

    ly

    MC

    (28–

    30 d

    ays i

    n le

    ngth

    ) and

    had

    not

    ta

    ken

    any

    form

    of

    horm

    onal

    con

    trace

    p-tio

    n fo

    r 12 

    mon

    ths

    prio

    r to

    the

    study

    , te

    sted

    durin

    g th

    e EF

    ph

    ase,

    ver

    ified

    by

    seru

    m o

    estro

    gen

    and

    prog

    este

    rone

    leve

    ls

    Peak

    ̇ VO

    2 (m

    l·kg·

    min

    −1 )

    and

    po

    wer

    (W) d

    urin

    g an

    in

    crem

    enta

    l cyc

    le to

    vo

    litio

    nal f

    atig

    ue—

    E

    Mod

    erat

    e

    Rebe

    l


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