The Trouble With the Pill

Many college athletes say they took oral birth control unaware of potentially devastating side effects. In the wake of Roe v. Wade’s fall, they might be more reliant on the contraceptive than ever.

Starting back in high school in 2015, Annie Uyeki was always anxious when she had to leave a class. “I wondered, What does my teacher think?” she says. Anywhere from two to three times in an 82-minute class period, Uyeki had to step out. Her body demanded it.

Now a lacrosse player at Vassar College, Uyeki was used to infrequent occurrences of excruciating pain that came with irregular and unbearable periods. She started taking birth control pills to help regulate them—she just wanted to feel comfortable in her own body, function as an athlete and compete at the highest level without pain.

But, as she tried to find a birth control method that would prevent pregnancy and help her body cope with relentless cramps and pain, the pill only made her life worse. Maybe this type of pill was a bad fit, she thought. Uyeki switched from one type to another, but her pain didn’t change. Her mental health suffered.

Multiple doctors sent a message to Uyeki: “[It] might just be your body. You might just be uncomfortable in your body.”

Frustrated, she refused to believe it was normal, that it was fine to not get through her day because she was in so much pain.

“I feel like birth control almost changed my personality a little bit. I was just so on edge all the time, so irritable. When I told my doctor about this, there seemed to be no real solution,” Uyeki says.

Somehow, sometime, it became normal for the insufferable pain, negative side effects and an altered mental state to seamlessly find its way into the athlete lifestyle.

For many collegiate athletes, the birth control pill has brought more harm than good, negatively impacting their bodies and minds. On June 24, the Supreme Court added an additional complicating factor to athlete’s relationship with the pill. The reversal of Roe v. Wade, the 1973 landmark decision that protected abortion rights in the United States, strips reproductive control further, which naturally may increase the pill’s popularity. A lack of in-state abortion access may be an athlete’s sole reason for going on the pill or another form of hormonal birth control (even as advocates say the restrictions on abortions may also lead to restrictions on contraceptives).

With increasing restrictions around reproductive health care, athletes are calling for more conversation and research about the pill’s health hindrances, some of which have existed long before the overturn of Roe.

Dorothy DiMascio-Donohue, a student at Tufts and member of the nationally ranked women’s ultimate Frisbee team, laughed on the phone when explaining how vocal she’s been to her teammates about life on the pill.

“It feels like a wash of gray has been painted over everything you see and feel,” she says. “[It is] a little less passionate, a little less colorful, a little worse to endure. And the worst part is that we were told that this is normal. … It’s almost indescribable how it feels to be on these hormones, but it is noticeable and important. Especially as an athlete, I want to choose a form of birth control that won’t make my cramps worse, impeding my performance. I might even want to choose one that will make me feel better.”

For DiMascio-Donohue, the relationship between her mental health and athletic performance is the biggest factor. In pursuit of physical control, she lost mental control, with the pill worsening her anxiety and depression. To manage period cramps and take control over pregnancy prevention with a form of birth control she has agency over, she sacrificed her mental and physical wellbeing—what her athletic performance depends on.

Even as so many athletes and non-athletes alike do reap great benefits from the pill, the side effects are a common conundrum.

Lizzie, who asked Sports Illustrated to identify her by first name only, was aware from a young age that her body was on display. It started with ice skating, before she hit her teen years. She always compared her body to her older sister’s; she wanted to be thinner. That thought pattern led to restrictive eating habits, low nutrition and low food consumption, which began to impact her menstrual cycle. Her mother found out that her period stopped and immediately brought her to the doctor. Lizzie left with a birth control prescription to regulate her hormones. She was 15, and there was no conversation about side effects. Months later, she was crushed by anxiety.

“I had never experienced anything like this and I never correlated it to birth control, but I do know I started this one thing, then this happened,” Lizze says.

Birth control—and the side effects that came with it—remained part of Lizzie’s daily timeline. As a Division I college rower, the mental health downfall conflicted with the lifestyle of a collegiate athlete. She gained more weight during her monthly cycle, which added extra stress to regular team weigh-ins. Every mood swing, every period of anxiety or depression, was brought to the next level while rowing in college. Her GPA suffered even when her school-focused anxiety heightened and her depression was at a peak, torpedoing her athletic performance.

A 2018 report shows that the pill is most popular with patients between 20 and 29—the prime age for college athletes. When Dr. Alysia Robichau, a sports medicine physician in Conroe, Texas, prescribes the pill, she looks at five criteria: weight, period flow/length, acne, mood swings and reason for going on the pill. Robichau also considers a family history of blood clots, one of the pill’s more severe possible side effects. There are roughly 150 to 200 types, brands and styles of birth control pills. They each have different combinations of hormones that work for different reasons, and different pills may cause mood or mental health issues. They normally contain estrogen and progesterone, two hormones key in reproductive development that help regulate menstrual cycles. Progesterone-only pills are more commonly given to people who are breastfeeding.

For Sophia Worth, the tiny pill she takes at 10 every night helps manage the onset of endometriosis, which plagues her family lineage. Endometriosis, simply put, is a painful disorder that involves the tissue that lines one’s uterus. Symptoms include, but are not limited to, extreme pain in the back, stomach, irregular menstrual cycles and heavy bleeding.

Worth was just 15 when she started taking the pill because symptoms were far too severe to ignore. A rising junior at Missouri as the goalie for the women’s soccer team, she found success with the pill, but it has to be taken at the same time every day to work properly. The strict schedule it requires doesn’t mix well with the demanding life of a D-I athlete. Road games are a recipe for prescription mishaps; time-zone changes almost ensure a missed dosage—even just one missed pill can cause a hormonal imbalance.

“In terms of your athletic performance, when your hormones are out of whack, your mood is messed up, your body feels wack, it messes with your sleep and all of those things are aspects that are always hammered home to us as athletes,” Worth says.

The pill helps to avoid physical pain that would trouble her athletic lifestyle, but the solution adds a hormonal imbalance and her body chemistry is nonetheless altered. Weight gain is the most expected side effect, as Robichau explained that doctors estimate users typically gain two to eight pounds on the pill. Uyeki gained roughly 20 pounds. Robichau herself was an elite level gymnast at LSU and went on birth control pills in college, but with strict instructions to not gain weight.

Uyeki remembers when practices would end with a lecture about the importance of staying hydrated or a reminder to maximize sleep. One common issue among the athletes standing around her in the huddle wasn’t insomnia or dehydration. It was hormone-related, but that wasn’t ever valued; the topic was flat-out ignored.

For decades, information about birth control in relation to athletes was sparse. With women already more likely to tear their ACLs than men, research recently took off to study how oral contraceptive pills factor in. Robichau says most research is not yet conclusive, but a 2021 study from Penn State College of Medicine found that a large percentage of women who sustained ACL tears were taking an estrogen and progesterone birth control pill at the time of injury.

In 2009, researchers from Texas A&M found that oral birth control use impaired muscle gains in young women and was associated with lower hormone levels. The conclusion was followed with a clear statement: There still needs to be more research about the relationship between muscle loss and birth control. Especially in a Roe-overturned world.

In 1988, IUDs were reintroduced to the U.S. market after approval from the FDA. But doctors had always been hesitant to insert them in people who had not given birth previously. The procedural aspect of IUD insertion sparked uncertainty, especially for athletes who could spoil their careers with one mishap.

With IUDs given to only a limited group as a birth control option, the pill’s popularity increased.

In college athletic communities, it wasn’t uncommon for a student to be instructed by a coach or program to go on the pill. High-intensity training meant athletes were at risk of losing their regular period if they didn’t get enough fuel to support their training. “Red S” or Relative Energy Deficiency in Sport, the formal name for when athletes suffer from low bone density, energy deficiency or potentially disordered eating, scared coaches.

In the early 2000s, the vast majority of college programs were run by men, which meant less talk of periods and hormones. To combat “Red S,” and avoid potential conversations of periods or pregnancy, coaches encouraged their athletes to take the pill. If they weren’t eating enough, if bones weakened, at least they got their period.

Instead of individualized methods that fit one’s body, blanket approaches put the pill in many athlete’s daily routine, with no warning of side effects or the realization that the pill is not the solution for everyone, or that there are other options.

Victoria Jackson, a pro runner with endorsements from Nike who was a Pac-10 champion at Arizona State, was on the pill like many other endurance athletes in the early 2000s. She didn’t go off the pill until she was ready to start a family.

“When I went off the pill, it was like the clouds parted,” Jackson says. “For the last decade and half, I was a little bit sad all the time. … I was in a low-level depressive state. I am not an expert but from my personal experience, I realized [the pill] had an effect on my mental health, and that had never been part of the conversation.”

In the mid-to-late 2000s, Jackson says “research-based coaches” began reversing the standard that those before them set and encouraged athletes to go off the pill. A decision with good intentions was made by the wrong people.

“You would have coaches involved in the reproductive health and women’s health decisions made by athletes, sometimes not in consultation with medical professionals, making those athletes vulnerable,” Jackson says.

Jackson, a professor and historian at ASU, is advocating for clear conversations about life off birth control since many athletes have stopped taking the pill.

Other athletes who spoke to SI had similar beneficial results. Lizzie switched off the pill junior year of college to an IUD and says her mental health benefited greatly, as did her athletic performance. DiMascio-Donohue is in a similar place.

“I was miserable for so long,” she says, now off birth control. “This gray filter on life is now removed.”

The landscape of college athletes will be different heading into the fall—especially in states with abortion bans. In Missouri, where Worth plays, an added anxiety now lingers.

“Thinking about the intimate and sexual details of my life having to be disclosed to my coaching staff in the case that something happened and I were to get pregnant, all these other questions arise, what if they are allowed to say, ‘No, you can’t go to another state and do this?’” she says.

The decision to prevent people from receiving in-state procedures may be the one reason an athlete needs to go on the pill, despite its health risks.

Data gathered by The Washington Post revealed that “many elite women’s college sports programs are also disproportionately concentrated in states with abortion bans and expected bans or where the future of abortion rights is uncertain.”

Given the universal uncertainty but life altering repercussions, Jackson encourages college coaches to develop a plan. Future recruits and parents will have questions, especially in states that ban abortions: where to go, what to do. But medically, the plan should be advised by outside professionals.

Team meetings can no longer focus just on nutrition, and practices can’t end with only a reminder to sleep well that night like Uyeki and other athletes have dealt with their entire life. The bodily autonomy athletes once had is now restricted. The pill may be an athlete’s best bet in a post-Roe landscape—and, students and advocates say, that’s far from ideal.