Dr. Stacy Sims: The Truth About MHT for Women Over 40: Is It Really the Holy Grail?

Sims explains that the withdrawal bleed on OCs is not a true menstrual bleed, so it doesn't reflect endocrine status. However, the recent study shows that the pituitary hormones LH and FSH change in response to low energy availability in both groups. Therefore, testing these hormones can reveal underfueling that might otherwise be missed. This is a practical tool for coaches and clinicians to identify the need for nutritional intervention.

Sims notes that women on OCs have a greater total body inflammatory and oxidative response. She suggests that being aware of this allows for dietary interventions to dampen it, though she does not detail the specific diet. This is a general recommendation to consider anti-inflammatory foods.

Sims emphasizes that the right kind of training—heavy resistance training and some sprint work—is crucial for muscle, bone, and brain health. This, along with nutrition, has a stronger longitudinal impact than MHT. She positions this as a non-negotiable foundation, even for those using hormone therapy.

Sims is alarmed that girls are still prescribed OCs for camps. She suggests that an IUD or simply using period underwear can manage menstruation without the risks of hormonal interference with brain development. This is a practical, low-risk alternative.

Stacy Sims explains that when an athlete on hormonal contraception is not responding to training, experiencing poor sleep, or soft tissue injuries, testing FSH and LH can reveal if they are in a state of low energy availability. The paper showed that both groups exhibit similar changes in these hormones, so the contraceptive does not hide the problem. This is crucial because many athletes and clinicians might dismiss symptoms assuming the pill is protective. She emphasizes that if the pattern matches low energy availability, the focus should shift to fueling. From a performance perspective, she notes that while consistency and gains are possible on OCs, top-end anaerobic capacity is somewhat muted, and there is a greater systemic inflammatory and oxidative response. However, dietary interventions can help dampen that response. For high-performance athletes, the choice of progestin generation can be fine-tuned for reaction time, but that's a nuanced area.

Sims explains that during teenage years, key brain structural development occurs. Introducing exogenous hormones at this time can alter that development in ways that are not reversible, according to research. In contrast, once brain development is complete in the 20s, any changes from hormonal contraception are reversible. She advocates for delaying use until the 20s to avoid permanent effects. She suggests alternatives like IUDs or simply using period underwear to manage menstruation. This is a call to rethink the widespread prescription of OCs to adolescents, emphasizing that the long-term implications are not discussed enough.

Sims points out that the Depo injection has a significant impact on bone density, and the recommendation is not to use it for more than a year. However, many athletes are not informed of this, and even the prescribing doctors may be unaware. This is particularly concerning for athletes who rely on bone health for performance and injury prevention. She emphasizes the need for better education and questioning of contraceptive options.

Sims argues that while MHT can help with symptoms and has some protective effects for women under 60, it is not the 'golden goose.' The stronger impetus for bone, brain, and cardiovascular health is lifestyle: specifically, heavy resistance training, sprint work, and a diet rich in fiber and protein. These interventions improve muscle, bone, brain, immune function, body composition, and gut microbiome diversity. She stresses that even if a woman uses MHT, she must still adopt these lifestyle modifications for a long and healthy life. MHT is a tool in the toolbox, not a replacement for foundational health behaviors.