Menstrual Cycle Manipulation in Female Athletes to Avoid Competition-Day Bleeding: Symptom Control, Performance Limits, and RED-S-Safe Prescribing—A Narrative Review

Background: In elite sport, an increasing number of female athletes use menstrual cycle manipulation (MCM), most commonly via hormonal contraceptives, to delay or suppress withdrawal bleeding during key competitions. Although MCM may address legitimate functional needs, it is often misconstrued as a logistical strategy rather than a pharmacological intervention requiring contraindication screening, adverse-effect monitoring, and vigilance for masked underlying conditions. Objectives: This narrative review synthesizes current evidence on motivations for MCM use, commonly employed pharmacological approaches, limits of performance-related benefits, screening considerations for low energy availability (LEA) and Relative Energy Deficiency in Sport (RED-S), long-term safety, and clinical implementation in female athletes. Main Findings: Hormonal contraceptives improve menstrual predictability and reduce dysmenorrhea, heavy menstrual bleeding, and selected premenstrual symptoms. However, systematic reviews and meta-analyses consistently show no direct ergogenic benefit and no meaningful improvement in VO 2 max, muscular strength, or explosive power. Perceived performance gains likely reflect symptom relief and reduced competition burden rather than intrinsic pharmacological enhancement. Athletes with oligomenorrhea, amenorrhea, rapid weight loss, chronic dietary restriction, or recurrent bone stress injuries should be evaluated for LEA and RED-S before initiating MCM to avoid delayed diagnosis and masking of energy deficiency. Conclusions: MCM can be integrated into individualized menstrual health management when guided by clear objectives, structured risk stratification, an assess-before-prescribing approach, and preseason pharmacological trials with longitudinal monitoring. Within such a framework, MCM may support athlete welfare without obscuring underlying pathology.