What birth control options are suitable for individuals with Relative Energy Deficiency Syndrome (RED-S)?

Birth Control Options for Individuals with Relative Energy Deficiency Syndrome (RED-S)

For individuals with Relative Energy Deficiency Syndrome (RED-S), progestin-only contraceptives or non-hormonal methods like copper IUDs are the most appropriate options as they avoid potential exacerbation of hormonal imbalances and bone health concerns associated with combined hormonal contraceptives.

Understanding RED-S and Contraceptive Considerations

RED-S is characterized by low energy availability that negatively affects multiple physiological systems including menstrual function, bone health, metabolism, and hormonal balance 1. When selecting contraception for individuals with RED-S, several key factors must be considered:

Impact on Hormonal Function

• RED-S often presents with hypothalamic amenorrhea due to energy deficiency suppressing gonadotropin-releasing hormone pulsatility, leading to reduced estrogen levels 2, 1
• Oral contraceptives may mask the underlying energy deficiency without addressing the root cause of menstrual dysfunction 2
• Combined hormonal contraceptives can potentially compromise the attainment of peak bone density in individuals with functional hypothalamic amenorrhea 2

Recommended Contraceptive Options for RED-S

First-Line Options:

1. Progestin IUD

   • Safe for individuals with RED-S 2
   • Highly effective with failure rates <1% 2
   • May decrease menstrual bleeding, which is beneficial for athletes 2
   • Does not interfere with recovery of natural menstrual function 2
   • Minimal systemic hormonal effects 2

2. Copper IUD

   • Non-hormonal option that's safe for all individuals with RED-S 2
   • Highly effective with failure rates <1% 2
   • May increase menstrual bleeding, which could be a consideration for athletes 2
   • Does not mask underlying hormonal issues 2

Alternative Options:

1. Progestin-only pill

   • Safe for individuals with RED-S 2
   • Moderate effectiveness (5-8% failure rate with typical use) 2
   • Must be taken at the same time daily for optimal efficacy 2
   • Higher rate of breakthrough bleeding than combined methods 2

2. Barrier methods (condoms, diaphragm)

   • Safe for all individuals with RED-S 2
   • Lower effectiveness (12-18% failure rate with typical use) 2
   • No hormonal impact 2
   • Condoms provide STD protection 2

Contraceptive Methods to Use with Caution or Avoid

1. Combined hormonal contraceptives (pills, patch, ring)

   • Use with caution as they may mask the underlying energy deficiency without addressing the root cause 2
   • May compromise attainment of peak bone density in adolescents with functional hypothalamic amenorrhea 2
   • Can suppress androgen secretion, potentially affecting bone health 2

2. Depot medroxyprogesterone acetate (DMPA)

   • Avoid in individuals with RED-S due to its potential negative effects on bone mineral density 2
   • Can cause amenorrhea and adversely affect bone mass accrual, particularly concerning in RED-S where bone health is already compromised 2

Management Approach

1. Address the underlying energy deficiency

   • Implement an eating plan that increases current energy intake by 300-600 kcal/day 2
   • Address suboptimal practices related to energy distribution throughout the day 2
   • Consider introducing rest days to the weekly training program 2

2. Monitor bone health

   • Ensure adequate calcium intake (1500 mg/day) through dietary sources with supplementation if required 2
   • Maintain vitamin D levels above 32-50 ng/mL 2
   • Implement high-impact loading and resistance training 2-3 days/week 2

3. Regular reassessment

   • Monitor menstrual function and response to treatment 2
   • Weight gain is the strongest predictor of recovery of normal menstrual function 2
   • Ensure adequate protein and carbohydrate intake to restore liver glycogen and facilitate LH pulsatility 2

Key Considerations for Healthcare Providers

• The time frame for resumption of menses varies according to the severity of energy deficiency and duration of menstrual dysfunction 2
• Contraceptive choice should balance effectiveness with potential impact on bone health and recovery from RED-S 2
• Emergency contraception should be discussed with all patients as the risks are low compared to unplanned pregnancy 2
• For individuals requiring both menstrual cycle regulation and contraception, progestin IUDs may provide benefits by reducing menstrual bleeding while having minimal systemic effects 2, 3

By prioritizing contraceptive methods that don't further compromise bone health or mask important clinical indicators of recovery, healthcare providers can help individuals with RED-S maintain reproductive health while addressing the underlying energy deficiency.