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Aussie Stingers water polo player Keesja Gofers tried taking an oral contraceptive pill once — and the experience was enough to turn her off for life.
"I [took the pill] when I was much younger and I didn't like how I felt on it, and then essentially didn't try anything else," she told ABC Sport.
"Because I felt it was not right for me, I might have really switched off from any education that was given about contraceptives."
Three-time Olympic diver Anabelle Smith had a similar experience when a doctor advised her to go on the pill after joining a high-performance program in Queensland.
"I trialled the pill to try and change my period around competition times," she told ABC Sport.
"That was a total disaster and fully messed my body up. I did not feel like myself at all.
"I gave it away. I ended up having a blood clot, which was not enjoyable at all, especially being away from home and away from my mum.
"So I went off that pretty quickly. And then for a long period of time I was pretty scarred [and reluctant] to try anything else."
Common side effects of the combined oral contraceptive pill (which includes synthetic estrogen and progesterone) include mood changes, bloating, headaches, nausea, and sore or tender breasts.
There is also a small risk of developing blood clots.
Brianna Larsen from the University of Southern Queensland has found athletes have a low level of understanding of oral contraceptives and the menstrual cycle.
"We need to do better to be educating athletes so that they can make evidence-based decisions around if they are naturally cycling, that they know what to look for, they know what a normal menstrual cycle looks like, and what the flags are for menstrual dysfunction," she told ABC Sport.
"Or, if they're deciding to use a hormonal contraceptive, that they're actually picking an option that is best suited for them and that they're aware of different side effects that can occur and don't just think that they need to suck those up."
Dr Larsen is currently developing resources to assess hormonal contraceptive (HC) and menstrual cycle knowledge among athletes, coaches, and support staff.
"I think oftentimes, because [HCs are] such a prolific medication, there's not always a high level of diligence when prescribing these things," she said.
"Certainly, some of the research that I've done has shown that a lot of athletes didn't have really basic things measured, like their body mass or their blood pressure, [there was] no discussion of any mood issues they might have. So they are prescribed very readily.
"I think the onus, unfortunately, at this point does have to be on the individual to be on the lookout for things that might crop up when taking a new medication."
Hormonal contraceptives becoming a more popular choice
It is estimated that about 50 per cent of elite female athletes in Australia take some form of HC, which is more than the general population, and most athletes opt to use an oral contraceptive pill.
John Owen Osborne is an Australian researcher and the project leader of the Female Endurance Athlete (FENDURA) project, based in Norway.
He says in Scandinavia about 65 per cent of elite female athletes use HCs, with most using long-acting reversible contraceptives (LARCs).
These include implants which are inserted into the arm and can last up to three years, and intra-uterine devices (IUDs) such as Mirena, which are inserted into the uterus and can last for five years or more.
Dr Osborne suggests there are fewer elite female athletes in Australia using LARCs because of difficulties finding trained professionals who can insert the devices, and also because people in Norway who are younger than 20 can access LARCs for free.
The Norwegian government also recommends that more women use LARCs.
FENDURA's research has also found the key reason athletes choose to use HCs is to manage symptoms of their period.
"The non-hormonal contraceptive users have slightly higher frequency and severity of negative symptoms like cramps, fatigue, mood changes, things like that," Dr Osborne said.
As he explains, it's unclear if the women who use HCs would have more severe symptoms without it.
Dual summer/winter Paralympian and current Para Matilda Rae Anderson started using the pill when she was about 19.
"I haven't come off that since, just so I can use the pill to regulate my whole mood and menstruation cycle around what my program looks like," she told ABC Sport.
"So whether that's training or competition, I just know that I'm going to be on top of it. No surprises."
The pill is also a better option for Anderson than implants or IUDs due to her undergoing many medical procedures for her cerebral palsy as a child.
"I have PTSD (post-traumatic stress disorder) and that's medical intervention-affected, so I really struggle with the psychology of dealing with anything that is medically intubating," she said.
After her poor experience with the pill, diver Anabelle Smith didn't feel the need to go on any contraceptives until the Tokyo Olympics.
"I woke up the day of my individual prelim competition and it was day one of my period — and quite often on my day one I'd get pretty bad cramps and then it would be fine," she said.
"But when those two things collided on the same day, it was obviously not ideal."
After that, she decided to get the Mirena IUD in preparation for the Paris Olympics.
"I'm 10 years older than the first time around and have a lot more knowledge [about contraceptives now]," she said.
"But I also have a much better relationship with my support team and have a really good doctor, dietitian, nurse who all help me to make the best decision for myself."
One less thing to worry about
Two-time Olympian Keesja Gofers is now 33. Along with bad experiences with the pill, she also had menstrual irregularities as a younger athlete.
She went nine months without getting her periods and thought "it was a great thing".
"It was something I didn't have to think about, some hassle I didn't have to worry about," she said.
"I didn't seek any advice, didn't ask any medical opinions about it. I just waited for it to come back and then it did.
"But I definitely do not recommend that."
During that time, Gofers had low energy and was constantly tired.
"My iron would have been quite low, but only now years and years later, I realise that I wasn't able to perform my best in the pool, and also in general life," she said.
"But at the time, I was like, this is what it means to be an athlete, you're always meant to be tired."
Anderson had the same experience as a teenage athlete, losing her period for six months.
"I definitely knew it [wasn't healthy] and, looking back on it, it was probably not the greatest thing but I was pretty chuffed because it was just one less thing that I had to be worried about," she said.
The absence of periods, amenorrhoea, is more common among athletes than the general population, and Dr Larsen says it's a red flag for health.
"If an athlete has had a regular cycle and then that's gone away, don't just assume that that's just a normal part of training harder," she said.
"It likely is a result of under-fuelling for that training and can have really negative consequences on health down the line, impacting bone mineral density and immunity.
"So not only from a performance perspective, in terms of slower recovery and being more prone to getting sick, but also longer-term health can be affected by amenorrhoea as a result of relative energy deficiency in sport (RED-S)."
RED-S means there isn't enough food intake to account for the energy output.
Gofers, who has an 11-month-old daughter, now understands the importance of keeping track of her menstrual cycle.
"Not only for reproduction but also the health of your body and getting the best out of your body," she said.
"Now it's really one of those major tick boxes for me to know that I'm in the best physical condition that I can be in."
Dr Larsen says it's important for athletes using hormonal contraceptives to also keep on top of their symptoms.
"It can be really hard to associate particularly mood-related symptoms with a medication if you're not keeping track of that," she said.
Tracking for performance
While experts recommend tracking menstrual cycles for health reasons, it is becoming more popular for athletes to use apps to track their cycles and advise them on what types of training to do based on the phase they are in.
"If you have an app like that, don't use it because it's not accurate," Victorian Institute of Sport chief medical officer Susan White told ABC Sport.
"We know that generalising advice around time of cycle and training has no scientific validity as a generalised tool.
"We encourage athletes to monitor their own cycles, absolutely. But then we get them to talk to us and their coaches and their strength-and-conditioning coaches about tailoring specifically to them because everyone is different."
FENDURA's research on the topic backs up that advice.
"We found within the same woman massive differences cycle to cycle," Dr Osborne said.
"You can't just say, oh all women are going to have worse performance during their menses or there's no difference across the cycle or whatever it happens to be."
However, FENDURA has also found that while objectively there doesn't seem to be any effect on performance at different stages of the cycle, athletes perceive it differently.
"Between a third to two-thirds of the athletes think that their menstrual cycle influences performance," Dr Osborne said.
"And so we have this disconnect between what we're measuring in the lab, and then what these athletes are saying. So what does that mean?"
More talk needed
Conversations and education around the menstrual cycle are increasing in sport but, according to athletes and experts, there's still a way to go.
"I don't think there's that much communication amongst the sporting community about contraception," Smith said.
"There's higher levels of conversation between teammates than there is across to the coaching staff," Dr Larsen said.
"And I think having that kind of environment where it feels a bit taboo, what it has the potential to do is delay a diagnosis of a menstrual dysfunction.
"Because an athlete might sit on information for a lot longer than they might have if they felt comfortable bringing these issues to attention.
"So I think it's really important that education is happening across the board."