Pelvic floor, hormones, and performance: trying to fill in the gap

In recent years, the scientific community has begun to recognize the need for a more nuanced understanding of female athletic performance, one that goes beyond traditional strength, endurance, and conditioning metrics to incorporate sex-specific physiological variables (1). Among these, pelvic floor health, hormonal profiles, and the use of hormonal contraceptives represent three critical yet often underexplored dimensions. Despite their known relevance in clinical and reproductive contexts, their impact on sports performance remains largely neglected in both research and practice.

This commentary seeks to highlight the interconnected roles of pelvic floor function and hormonal modulation, both endogenous and exogenous, as key and interdependent factors in women’s performance. By examining their individual and combined influence on biomechanics, neuromuscular control, and athletic outcomes, we aim to expose a critical blind spot in current sports science paradigms and call for an integrated approach that reflects the physiological complexity of the female athlete.

Pelvic floor and performance

The pelvic floor muscles (PFM), a crucial yet often overlooked component in athletic performance, have traditionally been relegated to the domain of urogynecology and postpartum rehabilitation. However, mounting evidence suggests that PFM functionality plays a significant role in core stability, balance, proprioception, and kinetic chain coordination (2). Despite these connections, the literature has yet to establish a direct link between pelvic floor functionality and measurable athletic performance outcomes, revealing a substantial gap in both research and practical application.

Adding to this concern, recent studies have reported a high prevalence of pelvic floor dysfunctions (PFD), particularly stress urinary incontinence (SUI), among female athletes, with reported rates exceeding 50% of participants in volleyball (3) and approaching 70–80% in demanding, impact-based disciplines such as high-intensity functional training (HIFT) (4) or trampoline gymnastics (5,6). In athletic populations, PFD are often associated with repeated high-impact loading, elevated intra-abdominal pressure during strength or plyometric training, insufficient core muscle coordination, and lack of neuromuscular control (7). These dysfunctions, including SUI as their most common manifestation, are often normalized or underreported among athletes (8), contributing to their persistent invisibility in sports medicine. For instance, the study by Dakic et al. [2025] (9) highlighted the psychological and performance-related toll of PFD in elite athletes, noting that many altered their training or competition routines to manage symptoms, including training intensity reductions, activity avoidance (e.g., not jumping), restricting fluid intake prior to and during competition, wearing dark clothes or using pads.

Despite growing awareness among healthcare and exercise professionals, comprehensive pelvic health screening, including assessment of PFM function, potential dysfunctions, and symptoms such as urinary incontinence (UI), remains uncommon in the athletic population. Many female athletes are never screened, and even those experiencing symptoms rarely seek or receive medical attention (6,10). Evidence from a recent systematic review indicates that most female athletes manage PFD symptoms through self-devised strategies rather than seeking professional care, such as using pads or containment products, restricting fluid intake, pre-voiding before activity, or modifying certain movements or training routines to reduce leakage episodes (8). Furthermore, PFD are associated with emotional distress and reduced athletic confidence or performance, including feelings of embarrassment, fear, anxiety, and frustration, often accompanied by limitations in sport participation (8).

Altogether, these findings emphasize that PFD in female athletes remain a largely self-managed and underrecognized issue, with implications extending beyond physical health to psychological well-being and athletic performance. This strongly suggests that pelvic floor health is not merely a clinical concern but one that directly influences athletic potential.

Although limited in number, some studies have begun to address the role of PFM in postpartum return-to-sport protocols (11). Typically, PFM training (PFMT) is already part of standard medical recommendations during pregnancy and postpartum recovery (12), and recent consensus statements emphasize its role in safe return-to-sport protocols for postpartum athletes (13,14). These investigations typically emphasize components such as core stability, neuromuscular control, and proprioceptive retraining, all of which depend heavily on a functional pelvic floor. Consequently, rehabilitation programs are beginning to incorporate PFM-specific exercises, acknowledging their importance in restoring physical readiness for elite performance. However, these studies focus primarily on recovery after birth-related PFM injuries and do not fully explore how PFMT might actively enhance athletic performance. This leaves a critical question unanswered: can optimizing PFM function contribute not just to returning, but excelling in sport?

This question gains further relevance when considering the PFM’ biomechanical role. The PFM are an integral part of the deep core stabilizing system, working synergistically with the diaphragm, transversus abdominis, and multifidus muscles. Together, this system regulates intra-abdominal pressure, stabilizes the spine, and maintains lumbopelvic alignment during movement (2). The PFM contribute through anticipatory contractions that respond reflexively to postural demands and load variations, particularly during high-intensity or impact movements common in sport. This coordinated action is essential for spinal stiffness and efficient force transmission across the kinetic chain (15). If the PFM function is compromised, due to weakness, poor coordination, or impaired proprioception, the neuromuscular synergy required for athletic efficiency may be disrupted, increasing injury risk and limiting performance. Therefore, PFMT should be considered not only in clinical functional recovery after PFM injury or PFD, but also as a potential tool for performance enhancement in athletic populations.

Despite this, current training and rehabilitation paradigms largely neglect PFMT within strength and conditioning. To move forward, the sports and exercise community, including coaches, strength and conditioning professionals, and sports medicine practitioners, must rethink its approach, shifting from viewing PFM health as a separate domain to recognizing it as a potential factor. Future research should aim to directly examine the effects of PFM function and PFMT on sport-specific domains such as power, agility, coordination, and postural control.

Hormonal regulation and pelvic floor function

The endocrine regulation of pelvic floor tissues has been described across experimental, anatomical, and clinical contexts. When addressing pelvic floor health, it is essential to consider its strong endocrine dependence, particularly the influence of hormonal fluctuations across the menstrual cycle and under exogenous hormonal modulation (16). One experimental study with female rats has demonstrated that PFM, particularly the pubococcygeus, is hormonally responsive, with estrogens exerting a modulatory effect on muscle morphology and counterbalancing androgen-driven hypertrophy, which may be extrapolated to women. This interplay highlights the reciprocal influence of estrogenic and androgenic pathways on pelvic muscle structure and function, reinforcing the concept of the PFM as a hormonally dependent system (17).

Not only the PFM, but also their connective and fascial components demonstrate hormonal responsiveness. Androgen receptor expression has been identified not only in striated muscle fibers of the levator ani, but also within stromal cells and fascial tissue, frequently co-localizing with progesterone receptors. This distribution pattern suggests that androgenic signaling extends beyond muscle fibers to the supporting extracellular matrix, contributing to the structural integrity, stiffness, and functional stability of the pelvic floor complex (18).

Such findings are consistent with current therapeutic approaches, including the use of dehydroepiandrosterone (DHEA) in the management of PFD, such as SUI or pain, particularly in postmenopausal women with vulvovaginal atrophy (19). They also align with clinical observations suggesting that a hyperandrogenic state, such as that observed in polycystic ovary syndrome, may be associated with enhanced PFM activity and strength (20).

These findings provide essential physiological insight into hormonal influences on the pelvic floor; however, most available evidence does not derive from specifically athletic populations and therefore primarily serves as a mechanistic background for this section.

Given the hormonal dependency of the PFM, it is essential to examine how hormonal contraceptives may influence their structure and function. However, current research has not directly examined the effects of hormonal contraceptive use on PFM or their muscle-specific adaptations in women or athletes, instead focusing primarily on general outcomes such as hypertrophy, strength, or power (21). The literature linking hormonal contraceptive use and PFD is limited but indicates potential associations with increased risk of interstitial cystitis, vulvar vestibulitis, and sexual dysfunctions such as decreased libido (22,23). Overall, current evidence remains inconclusive, highlighting the need for well-designed comparative studies in young, physically active women both with and without oral contraceptive use. Recognizing the pelvic floor as a hormonally sensitive system brings attention to a broader question: how do these same hormonal dynamics influence athletic performance more globally? This suggests that the hormonal environment not only shapes pelvic floor functionality but also contributes more broadly to the physiological and psychological dimensions of performance. Understanding these systemic effects, both from natural hormonal fluctuations and exogenous modulation such as contraceptive use, is therefore essential to comprehensively address performance variability in female athletes.

Hormonal contraception and female athletic performance

Among the many factors shaping this hormonal environment, the use of hormonal contraceptives stands out as particularly relevant, both for its widespread prevalence among female athletes and for its potential to alter endocrine patterns in ways that may influence performance.

Over the past decade, there has been a growing interest in understanding how female sex hormones influence women’s performance. Nevertheless, the effects of hormonal contraceptives on physical performance remain unclear. While natural hormonal fluctuations can affect strength, power, and endurance (24), it is unclear how exogenous hormones from contraceptives might impact these performance outcomes (25). Approximately 45% of women in Europe and up to 60% of adult women in the United States report using hormonal contraceptives (26-28). When focusing on the athletic population using hormonal contraceptives, similar data arises (29). The reason for its use not only follows contraceptive reasons but also individual planning for symptom managing and inconvenient withdrawal bleeding (30). When assessing the effects of these contraceptives on athletic performance, it might be of interest to differentiate both by route of administration and by hormonal composition, as these factors could affect distinct endocrine and physiological responses. To date, only a few studies (28,31) have examined the potential influence of intrauterine contraception on athletic performance, while research on oral contraceptive users remains similarly scarce. In fact, studies investigating hormonal contraceptive use often lack detailed reporting on formulation type, dosage, and hormonal composition; a limitation that introduces potential measurement bias, as these variables can substantially influence endocrine and performance-related responses (21).

For example, a recent study found that oral contraceptives with higher androgenic activity, such as levonorgestrel, were associated with greater quadriceps strength compared to formulations containing antiandrogenic compounds like cyproterone acetate (30,32). In this same line, some studies show that estrogen deficiency may be linked to reduced muscle mass (28). Other studies report no significant differences in maximal force between the follicular and luteal phases (28), while others note conflicting outcomes (26,30). Methodological inconsistencies, including the lack of standardization in contraceptive type or hormonal phase assessment, further complicate interpretation (26,33). This highlights the importance of specifying contraceptive type and hormonal composition when interpreting physiological or performance outcomes.

Beyond physiological mechanisms, the menstrual cycle can influence performance through perceived symptoms such as fatigue, mood changes, pain, and motivation fluctuations (30,33,34). These subjective responses may alter training quality and perceived exertion independently of measurable physiological changes. Hormonal contraceptives, by modifying or stabilizing hormonal patterns, can in turn affect the presence and intensity of these symptoms, potentially reducing variability for some athletes while introducing side effects for others (35).

Most existing studies are acute in design, offering only a snapshot rather than a longitudinal view of hormonal effects across cycles (26). Moreover, performance itself can be defined through a wide array of variables, including strength, power, endurance, and metabolic responses, yet few studies assess these comprehensively. Considering that contraceptive use is common among female athletes, with 63% reporting current use in a large cross-sectional study including over one thousand athletes from 57 different sports (33), the lack of systematic research represents a significant gap in sports science.

A deeper understanding of how hormonal contraceptives influence athletic performance is essential not only for optimizing training and competition strategies but also for safeguarding athletes health and longevity. Evidence-based insights could guide individualized training periodization, improve recovery strategies, and inform contraceptive counseling within sports medicine. Furthermore, integrating this knowledge would advance gender-specific approaches in performance science, moving beyond male-based physiological models to ensure that female athletes receive guidance truly reflective of their unique hormonal and physiological profiles.

An integrated perspective on pelvic floor, hormones, and performance

Taken together, the existing evidence reveals a pressing need to adopt a more integrative and physiology-informed approach to the study of female athletic performance (1), one that acknowledges the interconnected roles of pelvic floor function, hormonal modulation, and performance outcomes. These three branches have traditionally been treated as separate lines of study, often isolated within clinical urogynecology, endocrinology, or sports science. However, as we have outlined throughout this commentary, the pelvic floor is not merely a clinical concern, but a biomechanical and neuromuscular structure with direct implications for movement quality and performance efficiency. At the same time, its hormonal responsiveness links it intrinsically to the wider endocrine environment, positioning it at the crossroads between reproductive biology and physical performance (17).

The hormonal system, both in its natural cyclical forms and when modulated exogenously through contraceptives, exerts complex and dynamic effects on the pelvic floor and, through shared mechanisms, also influences skeletal muscle, connective tissue, thermoregulation, energy availability, and psychological factors such as mood, motivation, and perceived exertion (36). Despite this, current performance models in sport science continue to rely heavily on male-derived physiological frameworks, often ignoring or minimizing the hormonal variability inherent to the female athlete. This oversight contributes to a significant gender data gap, where key determinants of female performance remain understudied, misunderstood, or insufficiently integrated into training, rehabilitation, and coaching strategies.

We have the data showing that a large proportion of female athletes experience PFD, yet these are frequently normalized, underreported, or self-managed, further limiting visibility and appropriate intervention. In parallel, hormonal contraceptives are widely used in this population, yet their implications for both pelvic function and athletic performance remain poorly understood, with few studies adopting rigorous, longitudinal, and sport-specific methodologies.

To move forward, researchers must embrace a more systematic and intersectional perspective that considers how endocrine factors influence not only reproductive health but also musculoskeletal integrity, neuromuscular performance, injury risk, and recovery capacity. Pelvic floor training should be reframed not solely as a rehabilitative or postpartum tool, but as a potential performance enhancer, especially in disciplines requiring high-impact loading, core stability, and precise motor control. Similarly, hormonal profiling and contraceptive counseling should be individualized and grounded in evidence, considering the athlete’s training goals, sport demands, and physiological responses.

Filling this gap will require collaboration across disciplines (including sports medicine, endocrinology, pelvic health physiotherapy, neuroscience, and exercise physiology) to design research that captures the full complexity of female performance. Such efforts should prioritize longitudinal data, standardized outcome measures, and diverse athlete populations.

Ultimately, acknowledging the pelvic floor-hormone-performance triad is not a matter of academic interest alone, but a necessary step toward optimizing performance, enhancing athlete health, and advancing gender equity in sports science. Addressing this blind spot is not just about filling a gap; it is about redefining the foundation on which we build evidence-based, inclusive, and effective performance models for women in sport.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article has undergone external peer review.

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-60/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-2025-1-60/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hunter SK, S, Angadi S, Bhargava A, et al. The Biological Basis of Sex Differences in Athletic Performance: Consensus Statement for the American College of Sports Medicine. Med Sci Sports Exerc 2023;55:2328-60. [Crossref] [PubMed]
2. Bordoni B, Sugumar K, Leslie SW. Anatomy, Abdomen and Pelvis, Pelvic Floor. In: StatPearls. Treasure Island: StatPearls Publishing; 2023.
3. da Silva Pereira F, Haupenthal A, Da Roza TH, et al. Urine Loss during a Volleyball Competition: Comparison between Amateur and Professional Athletes. PM R 2021;13:1122-6. [Crossref] [PubMed]
4. Elks W, Jaramillo-Huff A, Barnes KL, et al. The Stress Urinary Incontinence in CrossFit (SUCCeSS) Study. Female Pelvic Med Reconstr Surg 2020;26:101-6. [Crossref] [PubMed]
5. Eliasson K, Larsson T, Mattsson E. Prevalence of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports 2002;12:106-10. [Crossref] [PubMed]
6. de Jager E, Willemsen M, Kempe M, et al. Breaking barriers: Exploring female-specific health challenges affecting performance in an elite multisport training environment. J Sci Med Sport 2024;27:466-71. [Crossref] [PubMed]
7. Rial Rebullido T, Chulvi-Medrano I, Faigenbaum AD, et al. Pelvic floor dysfunction in female athletes. Strength Cond J 2020;42:82-92.
8. Culleton-Quinn E, Bø K, Fleming N, et al. Elite female athletes’ experiences of symptoms of pelvic floor dysfunction: A systematic review. Int Urogynecol J 2022;33:2681-711. [Crossref] [PubMed]
9. Dakic J, Perraton L, Lindstrom J, et al. The Hidden Challenge: Pelvic Floor Symptoms and Their Impact on Performance and Well-Being in Elite Female Rugby Players. Eur J Sport Sci 2025;25:e70013. [Crossref] [PubMed]
10. Giagio S, Adami PE, Bermon S, et al. Nearly half of 325 athletes reported pelvic floor symptoms: a cross-sectional study at the Lima 2024 World Athletics U20 Championships. BMJ Open Sport Exerc Med 2025;11:e002564. [Crossref] [PubMed]
11. Woodroffe L, Slayman T, Paulson A, et al. Return to Running for Postpartum Elite and Subelite Athletes. Sports Health 2025;17:614-20. [Crossref] [PubMed]
12. American College of Obstetricians and Gynecologists. Physical Activity and Exercise During Pregnancy and the Postpartum Period. ACOG Committee Opinion. Obstet Gynecol 2020;135:e178-88. [Crossref] [PubMed]
13. Bø K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1-exercise in women planning pregnancy and those who are pregnant. Br J Sports Med 2016;50:571-89. [Crossref] [PubMed]
14. Bø K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3-exercise in the postpartum period. Br J Sports Med 2017;51:1516-25. [Crossref] [PubMed]
15. Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn 2007;26:362-71. [Crossref] [PubMed]
16. Söderberg MW, Johansson B, Masironi B, et al. Pelvic floor sex steroid hormone receptors, distribution and expression in pre- and postmenopausal stress urinary incontinent women. Acta Obstet Gynecol Scand 2007;86:1377-84. [Crossref] [PubMed]
17. Carrasco-Ruiz Á, Sánchez-García O, Pacheco P, et al. Differential estrogen-related responses in myofiber cross-sectional area of pelvic floor muscles in female rats. Gynecol Endocrinol 2021;37:528-33. [Crossref] [PubMed]
18. Ho MH, Bhatia NN, Bhasin S. Anabolic effects of androgens on muscles of female pelvic floor and lower urinary tract. Curr Opin Obstet Gynecol 2004;16:405-9. [Crossref] [PubMed]
19. Misasi G, Russo E, Montt Guevara MM, et al. Effects of vaginal DHEA on stress urinary incontinence in postmenopausal women with vulvovaginal atrophy. Maturitas 2025;196:108232. [Crossref] [PubMed]
20. Micussi MT, Freitas RP, Varella L, et al. Relationship between pelvic floor muscle and hormone levels in polycystic ovary syndrome. Neurourol Urodyn 2016;35:780-5. [Crossref] [PubMed]
21. Nolan D, McNulty KL, Manninen M, et al. The Effect of Hormonal Contraceptive Use on Skeletal Muscle Hypertrophy, Power and Strength Adaptations to Resistance Exercise Training: A Systematic Review and Multilevel Meta-analysis. Sports Med 2024;54:105-25. [Crossref] [PubMed]
22. Champaneria R, D'Andrea RM, Latthe PM. Hormonal contraception and pelvic floor function: a systematic review. Int Urogynecol J 2016;27:709-22. [Crossref] [PubMed]
23. Segarra I, Menárguez M, Roqué MV. Women's health, hormonal balance, and personal autonomy. Front Med (Lausanne) 2023;10:1167504. [Crossref] [PubMed]
24. McNulty KL, Elliott-Sale KJ, Dolan E, et al. The Effects of Menstrual Cycle Phase on Exercise Performance in Eumenorrheic Women: A Systematic Review and Meta-Analysis. Sports Med 2020;50:1813-27. [Crossref] [PubMed]
25. Taylor MY, Osborne JO, Topranin VM, et al. Menstrual Cycle Phase Has No Influence on Performance-Determining Variables in Endurance-Trained Athletes: The FENDURA Project. Med Sci Sports Exerc 2024;56:1595-605. [Crossref] [PubMed]
26. Hirschberg AL. Challenging Aspects of Research on the Influence of the Menstrual Cycle and Oral Contraceptives on Physical Performance. Sports Med 2022;52:1453-6. [Crossref] [PubMed]
27. Rechichi C, Dawson B, Goodman C. Athletic performance and the oral contraceptive. Int J Sports Physiol Perform 2009;4:151-62. [Crossref] [PubMed]
28. Cabre HE, Gould LM, Redman LM, et al. Effects of the Menstrual Cycle and Hormonal Contraceptive Use on Metabolic Outcomes, Strength Performance, and Recovery: A Narrative Review. Metabolites 2024;14:347. [Crossref] [PubMed]
29. Martin D, Sale C, Cooper SB, et al. Period Prevalence and Perceived Side Effects of Hormonal Contraceptive Use and the Menstrual Cycle in Elite Athletes. Int J Sports Physiol Perform 2018;13:926-32. [Crossref] [PubMed]
30. Elliott-Sale KJ, McNulty KL, Ansdell P, et al. The Effects of Oral Contraceptives on Exercise Performance in Women: A Systematic Review and Meta-analysis. Sports Med 2020;50:1785-812. [Crossref] [PubMed]
31. Henderson ZJ, Scribbans TD. Intrauterine Contraception and Athletic Performance: Where is the Data? Health Fitness J Can 2020;13:37-45.
32. Güven AG, Kara M, Güneri S, et al. Assessment of Quadriceps Muscle Strength and Thickness in Adolescents with Polycystic Ovary Syndrome: A Case-control and Longitudinal Follow-up Study. J Clin Res Pediatr Endocrinol 2025;17:202-10. [Crossref] [PubMed]
33. Ekenros L, von Rosen P, Solli GS, et al. Perceived impact of the menstrual cycle and hormonal contraceptives on physical exercise and performance in 1,086 athletes from 57 sports. Front Physiol 2022;13:954760. [Crossref] [PubMed]
34. Carmichael MA, Thomson RL, Moran LJ, et al. The Impact of Menstrual Cycle Phase on Athletes' Performance: A Narrative Review. Int J Environ Res Public Health 2021;18:1667. [Crossref] [PubMed]
35. Dragutinovic B, Moser F, Notbohm HL, et al. Influence of menstrual cycle and oral contraceptive phases on strength performance, neuromuscular fatigue, and perceived exertion. J Appl Physiol 1985;2024:919-33. [Crossref] [PubMed]
36. Thompson BM, Drover KB, Stellmaker RJ, et al. The Effect of the Menstrual Cycle and Oral Contraceptive Cycle on Muscle Performance and Perceptual Measures. Int J Environ Res Public Health 2021;18:10565. [Crossref] [PubMed]