AJSM - 2026-04-09 - Journal Article
Has the Protective Effect of Hormonal Contraception Been Overestimated? A Systematic Review and Meta-analysis of Oral Contraceptive Pills and ACL Injury.
Paska J, Watson SL, Larrabee GA, Ndjonko LCM, Tjong VK
Topics
Key Takeaway
Pooled analysis of 18,103,890 participants yields a non-significant risk ratio of 0.88 (95% CI, 0.77–1.01), indicating hormonal contraceptives do not meaningfully reduce ACL injury risk in females.
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Summary
This systematic review and meta-analysis asked whether hormonal contraceptive use reduces ACL injury risk in females by pooling 8 studies identified via PRISMA-compliant search through March 2025. Random-effects meta-analysis produced a pooled risk ratio of 0.88 (95% CI, 0.77–1.01), which did not reach statistical significance. Heterogeneity was extreme (I² = 97.3%), and no significant publication bias was detected on Egger regression (P = .426).
Key Limitation
Extreme heterogeneity (I² = 97.3%) across only 8 studies, driven by inconsistent HC formulation reporting and variable athletic exposure definitions, makes the pooled risk ratio unreliable as a single summary estimate.
Original Abstract
BACKGROUND
Hormonal contraception (HC), including oral contraceptive pills (OCPs) and long-acting reversible contraceptives, is widely used by reproductive-aged women for various medical indications. Emerging evidence suggests a possible association between HC use and reduced anterior cruciate ligament (ACL) injury risk; however, no meta-analysis has systematically evaluated this relationship.
PURPOSE
To determine whether HC use reduces the risk of ACL injury in females through a systematic review and meta-analysis.
STUDY DESIGN
Meta-analysis; Level of evidence, 3.
METHODS
A systematic search of the PubMed, OVID (MEDLINE), and Embase databases was conducted from inception through March 2025 following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they reported ACL injury incidence among both HC users and nonusers. Data were synthesized using a random-effects meta-analysis to calculate a pooled risk ratio. Publication bias was evaluated using funnel plots and Egger regression.
RESULTS
Eight studies consisting of 18,103,890 participants met inclusion criteria. All studies evaluated OCPs, and 3 included other forms of HC. The pooled risk ratio for ACL injury among HC users versus nonusers was 0.88 (95% CI, 0.77-1.01). Heterogeneity was high ( I 2 = 97.3%), and Egger regression showed no significant publication bias ( P = .426).
CONCLUSION
Hormonal contraceptive use, particularly OCPs, does not appear to reduce ACL injury risk in females. Given the potential side effects of HC and the lack of conclusive benefit, clinicians should not recommend HC use solely for injury prevention. Future research should focus on non-OCP preventive strategies for ACL injury, diverse athletic populations, and standardized reporting of HC formulations.