Auditing the representation of hormonal contraceptives in studies assessing exercise performance in women

Figures & data

Table 1. Hormonal contraceptives (HCs) considered for inclusion in the audit paper.

Type	Additional information	Example brands (UK)	Example exogenous hormones and concentrations for each brand	Usage
Oral Contraceptives
Monophasic combined pill	Generation 2	Microgynon® Levest®	Ethinylestradiol: 30 µg Levonorgestrel: 150 µg	21 pills per packet (constant hormonal exposure)7-day pill free break
	Generation 3	Millinette 30® Femodene	Ethinylestradiol: 30 µg Gestodene: 75 µg
	Generation 4	Yasmine® Lucette®	Ethinylestradiol: 30 µg Drospirenone: 3.0 µg
Extended monophasic combined pill (28-day preparations)	Generation 2	Microgynon® 30 ED	Ethinylestradiol: 30 µg Levonorgestrel: 150 µg	28 pills per packet (21 active, 7 inactive)
	Generation 3	Femodene® ED	Ethinylestradiol: 30 µgGestodene 75 µg
Phasic combined pill	-	Logynon®, TriRegol®	Pill 1 (6 tablets)- Ethinylestradiol: 30 µg Levonorgestrel: 50 µg Pill 2 (5 tablets)- Ethinylestradiol: 40 µg Levonorgestrel: 75 µg Pill 3 (10 tablets)- Ethinylestradiol: 30 µg Levonorgestrel: 125 µg	21 pills per packet (3 sections with different concentrations of hormones) 7-day pill free break
	-	Synphase®	Pill 1 (7 tablets) - Ethinylestradiol: 35 µg Norethisterone: 500 µg Pill 2 (9 tablets)- Ethinylestradiol: 35 µg Norethisterone: 1 mg Pill 3 (5 tablets)- Ethinylestradiol: 35 µg Norethisterone: 500 µg
Extended phasic combined pill (28-day preparations)	-	Logynon® ED	Pill 1 (6 tablets)- Ethinylestradiol: 30 µg Levonorgestrel: 50 µg Pill 2 (5 tablets)- Ethinylestradiol: 40 µg Levonorgestrel: 75 µg Pill 3 (10 tablets)- Ethinylestradiol: 30 µg Levonorgestrel: 125 µg	28 pills per packet (3 or 4 sections with different concentrations of hormones) Can contain active and inactive pills
	-	Qlaira®	Pill 1 (2 tablets)- Estradiol valerate: 3 mg Pill 2 (5 tablets)- Estradiol valerate: 2 mg Dienogest: 2 mg Pill 3 (17 tablets)- Estradiol valerate 2 mg Dienogest 3 mg Pill 4 (2 tablets)- Estradiol valerate 1 mg Pill 5 (2 tablets)- No ingredient
Progestogen only pill	-	Norgeston	Levonorgestrel: 30 µg	28 pills per packet, no break between pill packets
	-	Cerazette Cerelle	Desogestrel: 75 µg
	-	Noriday	Norethisterone: 350 µg
Cyclic Contraceptives
Vaginal ring	-	NovaRing	Ethinylestradiol: 2.7 mg (0.015 mg per 24-h) Etonogestral: 11.7 mg (0.120 mg per 24-h)	Each ring lasts 21 days 7-day break
Patch	-	Evra	Ethinylestradiol: 600 µg (33.9 µg per 24-h) Norelgestromin: 6 mg (203 µg per 24-h)	Each patch lasts 7 days (use for 21 days) 7-day break
Long Acting Reversible Contraceptives
Implant	-	Nexplanon	Etonogestrel: 60–70 µg/day for first 6 weeks. 35–45 µg/day at the end of year 1 30–40 µg/day at the end of year 2 25–30 µg/day at the end of year 3	3 years
Injection	-	Depo-Provera	Medroxyprogesterone acetate: 150 µg	13 weeks
	-	Sayana Press	Medroxyprogesterone acetate: 104 µg	13 weeks
	-	Noristerat	Medroxyprogesterone acetate: 200 µg	8 weeks
Intrauterine system	-	Mirena	Levonorgestrel (52 mg): 20 µg/day initially 18 µg/day after 1 year 12 µg/day after 4 years	3–6 years
	-	Levosert	Levonorgestrel (52 mg): 20 µg/day initially Declines progressively ~60% over 6 years
		Kyleena	Levonorgestrel (19.5 mg)
	-	Jaydess	Levonorgestrel (13.5 mg)

Table 2. Inclusion criteria based on population, intervention, study outcomes, and study design.

Population	Healthy cis-gendered women aged 18–40 years were considered for inclusion.No restrictions were put on activity level or training status.
Intervention	All participants were required to be taking a HC. All forms of HCs as listed in Table 1 were accepted. Participants could be taking the HC habitually or experimentally. Habitual and experimental were defined as per Elliott-Sale et al. (2020).
Study Outcomes	The primary outcome of each study was exercise performance. Studies were included if they met any of the following categories: Athletic or sports performance (e.g., a mix of performance tests) Strength or resistance training (strength training with strength testing e.g., 1 repetition maximum) Muscular strength (isolated strength testing, e.g., maximum voluntary contraction) Anaerobic power, or performance (e.g., maximum power) Aerobic performance, or capacity (e.g., VO2max) Endurance performance, or capacity (e.g., time trial) Fatigue/Recovery (e.g., muscle damage protocols)
Study Design	Any study design that included the above information was considered for inclusion.

Table 3. Criteria for each tier system for quality of methodological control adapted from Smith et al., 2022 based on Elliott-Sale et al., 2021.

Tier	Oral contraceptive pill (OCP) criteria	Hormonal contraceptives (HC) criteria
Gold	Three of three stated: OCP use ≥3 months prior to recruitment (i.e., length of usage),with the type (e.g., mono, bi, or triphasic; combined or progesterone only and formulation [name and concentration of exogenous hormones]) stated. Stipulate and consider OCP taking (i.e., active OCP) days and OCP free (i.e., inactive/placebo OCP) days. One brand/type/generation of OCP per group of participants	Three of three stated: HC use ≥3 months prior to recruitment (i.e., length of usage), with the type (e.g., implants, injections, intrauterine devices/ coils that are hormone releasing and NOT copper-based, vaginal rings, contraceptive transdermal patches), and formulation (e.g., combined or progesterone only, names and concentration of exogenous hormones) stated. One type of HC per group of participants
Silver	Two of three stated: OCP length of usage, type, and formulation, Do/do not stipulate and consider OCP-taking (i.e., active OCP) days and OCP-free (i.e., inactive/placebo OCP) days. One or more than one brand/type/generation of OCP per group of participants	Two of three stated: HC length of usage, type, and formulation One or more than one type of HC per group of participants
Bronze	One of three stated: OCP length of usage, type, and formulation. Do not stipulate and consider OCP taking (i.e., active OCP) days and OCP free (i.e., inactive/placebo OCP) days. More than one brand/type/generation of OCP per group of participants	One of three stated: HC length of usage, type, formulation More than one type of HC per group of participants
Ungraded	Insufficient detail to award a gold, silver, or bronze	Insufficient detail to award a gold, silver, or bronze

OCP criteria has been updated from Smith et al. (2022) to include generation (alongside brand/type) to aid understanding in the context of this audit.

Figure 1. Flow diagram of studies.

Table 4. All studies included in the audit and the outcomes.

	Outcome 1	Outcome 2	Outcome 3	Outcome 4	Outcome 5
Reference	HCs included (Brand/Formulation included)	Athlete calibre	Outcome of study	Study design	Quality tier (HC)	Quality tier (OCP)	Missing quality criteria
Ali et al. (2016)	Monophasic combined pill (brand and formulation)	Tier 2: Trained/Developmental	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Gold	Gold
Anderson et al. (2017)	Monophasic combined pill (no brand/formulation)	Tier 0: Sedentary	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Silver	One brand/generation per group Formulation/Brand
Armstrong et al. (2005)	Un-specified oral contraceptives (brand) Injection (brand)	Tier 0: Sedentary	Athletic/Sports Performance	2. Grouped with other contraceptives	Silver	Silver	Type of HC One type of HC per group One brand/generation per group
Bell et al. (2011)	Monophasic combined pill (no brand/formulation)	Tier 1: Recreationally Active	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Silver	Formulation/Brand One brand/generation per group
Bozzini et al. (2021)	Un-specified oral contraceptives (no brand/formulation)	Tier 3: Highly trained/national	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Bronze	Bronze	Type of HC One type per group Formulation/Brand Active/Inactive days
Bryner et al. (1996)	Monophasic combined pill (formulation)	Does not state	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	Active/Inactive days
Casazza et al. (2002)	Extended phasic combined pill (formulation)	Tier 1: Recreationally active	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Gold
Dalgaard et al. (2019)	Monophasic combined pill (brand and formulation)	Tier 0: Sedentary	Strength or Resistance Training	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group Active/inactive days
Dam et al. (2022)	Monophasic combined pill (brand and formulation)	Tier 1: Recreationally Active	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Drake et al. (2003)	Un-specified oral contraceptives (no brand or formulation)	Does not state	Muscular Strength	1. Hormonal contraceptives separated into single groups	Bronze	Bronze	Type of HC One brand/generation per group Formulation/Brand Active/inactive
Ekenros et al. (2013)	Monophasic combined pill (formulation)	Tier 1: Recreationally active	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Silver	One brand/generation per group Length of usage
Elliott et al. (2005)	Monophasic combined pill (brand and formulation)	Tier 0: Sedentary	Muscular Strength	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Giacomoni and Falgairette (1999)	Monophasic combined pill (formulation)	Does not state	Anaerobic Power/performance	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group Active/inactive days
Giacomoni et al. (2000)	Monophasic combined pill (formulation)	Does not state	Anaerobic Power/performance	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group Active/Inactive days
Gordon et al. (2013)	Monophasic combined pill (no brand/formulation)	Tier 2: Trained/Developmental	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Bronze	One brand/generation per group Formulation/Brand Active/Inactive days
Gordon et al. (2017)	Monophasic combined pill (formulation)	Tier 1: Recreationally active	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	Active/Inactive days
Grucza Pekkarinen et al. (1993)	Monophasic combined pill (brand and formulation) Phasic combined pill (brand)	Tier 1: Recreationally active	Endurance Performance/Capacity	2. Grouped with other contraceptives	Silver	Silver	One type of HC per group One brand/generation per group Active/Inactive days
Hicks et al. (2017)	Monophasic combined pill (no brand or formulation)	Tier 1: Recreationally active	Fatigue/Recovery	1. Hormonal contraceptives separated into single groups	Silver	Silver	Formulation/Brand One brand/generation per group
Isacco et al. (2015)	Monophasic combined pill (formulation)	Tier 1: Recreationally active	Aerobic Power/Performance	1. Hormonal contraceptives separated into single groups	Silver	Silver	One brand/generation per group
Joyce et al. (2013)	Monophasic combined pill (formulation)	Tier 2: Trained/Developmental	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Joyce et al. (2014)	Monophasic combined pill (no brand or formulation)	Tier 1: Recreationally active	Fatigue/Recovery	1. Hormonal contraceptives separated into single groups	Silver	Silver	One brand/generation per group Brand/Formulation
Lebrun et al. (2003)	Phasic combined pill (brand and formulation)	Tier 2: Trained/Developmental	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Gold	Gold
Lee et al. (2014)	Monophasic combined pill (formulation)	Tier 0: Sedentary	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Bronze	One brand/generation per group Formulation/Brand Active/inactive days
Lei et al. (2019)	Monophasic combined pill (brand and formulation)	Tier 2: Trained/Developmental	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group Active/inactive days
Loureiro et al. (2011)	Un-specified oral contraceptives (no brand or formulation)	Tier 1: Recreationally active	Muscular Strength	3. Grouped with eumenorrheic women	Bronze	Bronze	One type of HC per group Type of HC Brand/formulation Active/Inactive
Lynch et al. (2001)	Monophasic combined pill (brand and formulation)	Tier 0: Sedentary	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Lynch and Nimmo (1998)	Monophasic combined pill (brand and formulation)	Tier 1: Recreationally active	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Mackay et al. (2019)	Monophasic combined pill (formulation)	Tier 0: Sedentary	Fatigue/Recovery	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group Active/inactive days
A. C. Martin et al. (2019)	Un-specified oral contraceptives (no brand or formulation)	Tier 3: Highly trained/national	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Ungraded	Ungraded	Type of HC Formulation/Brand Length of usage Active/inactive days
Mattu et al. (2020)	Monophasic combined pill (formulation)	Tier 1: Recreationally active	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Minahan et al. (2015)	Monophasic combined pill (no brand or formulation)	Tier 1: Recreationally active	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Silver	One brand/generation per group Formulation/brand
Myllyaho et al. (2021)	Monophasic combined pill (formulation) Progestogen only pill (formulation) Intrauterine system (formulation)	Tier 1: Recreationally active	Athletic/Sports Performance	2. Grouped with other contraceptives	Silver	Silver	One type of HC per group One brand/generation per group Active/Inactive days
Nichols et al. (2008)	Un-specified oral contraceptives (no brand or formulation)	Tier 4: Elite/international	Strength or Resistance Training	1. Hormonal contraceptives separated into single groups	Bronze	Bronze	Type of HC One brand/generation per group Active/Inactive days
Nicolay et al. (2007)	Monophasic combined pill (no brand or formulation)	Does not state	Muscular Strength	1. Hormonal contraceptives separated into single groups	Bronze	Ungraded	One brand/generation per group Formulation/Brand Length of usage Active/inactive days
Notelovitz et al. (1987)	Un-specified oral contraceptives (brand and formulation)	Tier 2: Trained/Developmental	Aerobic Power/Performance	1. Hormonal contraceptives separated into single groups	Silver	Bronze	Type of HC One brand/generation per group Active/inactive days
Peters and Burrows (2006)	Monophasic combined pill (formulation)	Tier 2: Trained/Developmental	Muscular Strength	1. Hormonal contraceptives separated into single groups	Gold	Gold
Quinn et al. (2018)	Monophasic combined pill (no brand or formulation)	Tier 1: Recreationally active	Aerobic Power/Performance	1. Hormonal contraceptives separated into single groups	Silver	Silver	One brand/generation per group Formulation/brand
Rebelo et al. (2010)	Un-specified oral contraceptives (formulation)	Tier 0: Sedentary Tier 1: Recreationally active	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Silver	Bronze	Type of HC Active/inactive days
Rechichi et al. (2008)	Extended monophasic combined pill (formulation)	Tier 2: Trained/Developmental	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Rechichi and Dawson (2009)	Extended monophasic combined pill (formulation)	Tier 3: Highly trained/national	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Rechichi and Dawson (2012)	Extended monophasic combined pill (formulation)	Tier 3: Highly trained/national	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Gold	Gold
Redman and Weatherby (2004)	Extended phasic combined pill (brand and formulation)	Tier 3: Highly trained/national	Anaerobic Power/Performance	1. Hormonal contraceptives separated into single groups	Gold	Gold
Rickenlund et al. (2004)	Monophasic combined pill (formulation)	Tier 2: Trained/Developmental	Athletic/Sports Performance	1. Hormonal contraceptives separated into single groups	Gold	Gold
Riechman and Lee (2022)	Monophasic combined pill (brand and formulation) Phasic combined pill (brand and formulation)	Tier 1: Recreationally active	Strength or Resistance Training	2. Grouped with other contraceptives	Silver	Bronze	One type of HC per group One brand/generation per group Length of usage Active/inactive days
Romance et al. (2019)	Monophasic combined pill (formulation) Phasic combined pill (formulation)	Tier 2: Trained/Developmental	Strength or Resistance Training	2. Grouped with other contraceptives	Silver	Silver	One type of HC per group One brand/generation per group Active/Inactive days
Sarwar et al. (1996)	Monophasic combined pill (no brand or formulation)	Tier 0: Sedentary	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Bronze	One brand/generation per group Formulation/brand Active/inactive days
Savage and Clarkson (2002)	Un-specified oral contraceptives (no brand or formulation)	Does not state	Fatigue/Recovery	1. Hormonal contraceptives separated into single groups	Bronze	Bronze	Type of HC One type of HC per group One brand/generation per group Formulation/brand
Schaumberg et al. (2017)	Monophasic combined pill (no brand or formulation)	Tier 1: Recreationally active	Aerobic Power/Performance	1. Hormonal contraceptives separated into single groups	Silver	Silver	One brand/generation per group Formulation/brand
Simpson et al. (2018)	Monophasic combined pill (no brand or formulation)	Tier 0: Sedentary	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Bronze	Formulation/brand Active/inactive days
Sims et al. (2007)	Phasic combined pill (no brand or formulation)	Tier 2: Trained/Developmental	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Bronze	Ungraded	One brand/generation per group Formulation/brand Length of usage
Sousa et al. (2020)	Un-specified oral contraceptives (no brand or formulation)	Tier 2: Trained/Developmental	Muscular Strength	1. Hormonal contraceptives separated into single groups	Bronze	Bronze	Type of HC One brand/generation per group Formulation/brand Active/inactive days
Sunderland et al. (2011)	Monophasic combined pill (brand)	Tier 2: Trained/Developmental	Anaerobic Power/Performance	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Sunderland and Nevill (2003)	Monophasic combined pill (brand)	Tier 2: Trained/Developmental	Anaerobic Power/Performance	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Sung et al. (2022)	Monophasic combined pill (no brand or formulation)	Tier 0: Sedentary Tier 1: Recreationally active	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Bronze	One brand/generation per group Formulation/brand Active/inactive days
Taipale-Mikkonen et al. (2021)	Monophasic combined pill (brand) Vaginal Ring (brand)	Tier 1: Recreationally active	Endurance Performance/Capacity	2. Grouped with other contraceptives	Silver	Silver	One type of HC One brand/generation per group
Thompson et al. (2021)	Monophasic combined pill (brand and formulation)	Does not state	Muscular Strength	1. Hormonal contraceptives separated into single groups	Gold	Silver	One brand/generation per group
Vaiksaar et al. (2011)	Monophasic combined pill (formulation)	Tier 4: Elite/international Tier 1: Recreationally active	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Gold	Silver	Active/inactive days
Weidauer et al. (2020)	Monophasic combined pill (no brand or formulation)	Tier 1: Recreationally active	Muscular Strength	1. Hormonal contraceptives separated into single groups	Silver	Bronze	One brand/generation per group Formulation/brand
Wickham et al. (2019)	Un-specified hormonal contraceptives (no brand or formulation)	Tier 1: Recreationally active	Endurance Performance/Capacity	2. Grouped with other contraceptives	Bronze		Type of HC Formulation/brand
Wirth and Lohman (1982)	Un-specified oral contraceptives (no brand or formulation)	Does not state	Endurance Performance/Capacity	1. Hormonal contraceptives separated into single groups	Bronze	Bronze	Type of HC Formulation/brand Active/inactive
Yanovich et al. (2019)	Un-specified oral contraceptives (no brand or formulation)	Tier 1: Recreationally active	Endurance Performance/Capacity	3. Grouped with eumenorrheic women	Ungraded	Ungraded	Type of HC Formulation/brand Length of usage

Figure 2. Types of HCs investigated in the studies within the audit.

Note. Some of the 61 studies investigated had more than one type of HC, providing a total of 68 separate investigation of HCs.

Figure 3. Study design: how the HCs were incorporated within the research design of the study.

Note. Figure 3 includes studies where un-specified OCPs were reported which could inflate the outcomes presented due to difficulties in knowing which OCPs were used (see Table 1 for types of OCP which could be included in these studies).

Figure 4. Standard of methodological control when assessed by (a) HC tier system and (b) OCP tier system.

Figure 5. Yearly distribution of tier rankings for (a) HCs and (b) OCPs specifically alongside the cumulative total of papers.

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