Clinical Limitations of Oral Contraceptives in the Management of Functional Hypothalamic Amenorrhea in Female Athletes
DOI:
https://doi.org/10.12775/QS.2026.69.74530Keywords
functional hypothalamic amenorrhea, bone mineral density, oral contraceptives, low energy availability, transdermal estradiolAbstract
Background: Functional hypothalamic amenorrhea (FHA) is a common cause of secondary amenorrhea, typically associated with low energy availability (LEA) and hypothalamic-pituitary-ovarian (HPO) axis suppression. Although combined oral contraceptives (COCPs) are frequently prescribed to mitigate bone mineral density (BMD) loss, their clinical role remains debated, as they may mask underlying metabolic deficits and interfere with anabolic signaling.
Aim: This review evaluates mechanisms by which oral contraceptives may mask energy deficits and impact bone health in female athletes with FHA, assessing alternative pharmacological strategies.
Material and methods: A comprehensive literature search was conducted using PubMed and Web of Science for articles published between 2017 and 2026, focusing on FHA pathophysiology and metabolic outcomes of hormonal interventions.
Results: COCPs induce withdrawal bleeding without restoring HPO axis function, potentially delaying nutritional rehabilitation by masking energy deficits. Oral estrogens may downregulate hepatic IGF-1 synthesis, limiting osteoprotective efficacy. Conversely, transdermal 17-β-estradiol bypasses hepatic first-pass metabolism, preserving physiological IGF-1 levels and offering a safer profile for skeletal health.
Conclusions: COCPs should be used with caution for bone protection in FHA, prioritizing nutritional rehabilitation. Transdermal estradiol represents a physiological alternative when behavioral interventions are insufficient.
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Copyright (c) 2026 Magdalena Markiewicz-Zahorski, Julia Jaszczyńska, Filip Kęska, Zoja Goti, Zofia Łubniewska, Jan Damian, Tomasz Kałużny, Maria Michalska, Aleksandra Markiewicz-Zahorski
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