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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 67 - Noncontraceptive Uses of Hormonal Contraceptives

"If we can stay with the tension of opposites long enough —sustain it, be true to it—we

can sometimes become vessels within which the divine opposites come together and give birth to a new reality." - Marie-Louise von Franz


2018 Pinot Noir from Tres Palacios

PB #110 - Published January 2010 (Reaffirmed 2016)


Five Pearls

1. Most COCs combine a progestin (i.e. synthetic progesterone) for contraceptive effects with 10-35 mcg of an estrogen (usually ethinyl estradiol) to stabilize the endometrium and reduce unwanted spotting

2. COCs are a safe bet for management of heavy menstrual bleeding. If patient responds to COCs, they are most cost-effective for the first year, then it's more effective to switch to a levonorgestrel intrauterine system

3. The levonorgestrel intrauterine systems work better than progestin-only pills (e.g. norethindrone acetate) to reduce heavy menstrual bleeding and patients report greater satisfaction.

4. DMPA and the progestin IUD can regulate the menstrual cycle over the long haul, but will initially increase the irregularity of bleeding.

5. Before prescribing any hormonal contraception, review the US Medical Eligibility Criteria for Contraceptive Use.


Hormonal contraceptives are not just for birth control

- originally, combined oral contraceptives (COCs) were developed to manage heavy menstrual bleeding (with the side effect of contraception!)

- most of them combine a progestin (i.e. synthetic progesterone) for contraceptive effects with 10-35 mcg of an estrogen (usually ethinyl estradiol) to stabilize the endometrium and reduce unwanted spotting

- progestin alone is also an option, and it may be a better option for women due to the side effects of estrogen (e.g. blood clots)

- the vaginal spotting that is associated with progestin-only formulas usually subsides with time

- progestin side effects include hair growth (e.g. drospirenone or cyproterone acetate due to androgenic properties); newer progestins on the market have less androgenicity

- they suppress the hypothalamic-pituitary-ovarian axis thus inhibiting ovulation and menstruation


Monophasic, biphasic, and triphasic preparations

- monophasic: take a pill every day for 21 days (same dose of progesterone, same dose of estrogen), then take a placebo for 7 days

- biphasic: take a pill every day for 7-10 days, then take a different pill for 11-14 days (increased dose of progesterone, same dose of estrogen), then take a placebo for 7 days

- triphasic: three different pills (increasing doses of progesterone, increasing doses of estrogen) taken in ~7 days intervals, then take a placebo for 7 days

- triphasic preparations have been shown to improve acne, reduce the incidence of ectopic pregnancy, reduced menstrual flow, and regulation of periods

- low-dose and triphasic preparations are not as effective as monophasic in preventing benign ovarian cysts

- there are also extended preparations, in which the patient takes a pill for 84 straight days followed by 7 days of placebo


Downsides of COCs

- estrogen component may be contraindicated due to its association with thrombotic events (e.g. smoker ≥ age 35, HTN, history of VTE, history of stroke, ischemic heart disease, etc.)

- check this summary of the U.S. Medical Eligibility Criteria for Contraceptive Use for help in determining safety of various contraceptives based on patient factors

- if taken cyclically, many patients experience PMS, pelvic pain, headaches, breast tenderness, and bloating during the "hormone-free interval"

The patch

- progestin+ estrogen

- comparable efficacy to COCs

- also has anti-androgenic properties

- change it out weekly

- helpful for reducing ectopic pregnancy rate and regulating bleeding

- suppresses ovulation


The ring

- progestin+ estrogen

- sits in the vagina and slowly releases hormones

- change it out every 3-6 weeks

- helpful for dysmenorrhea and (maybe) for premenstrual dysphoric disorder


Levonorgestrel intrauterine system

- progestin-only IUD

- varying lengths of use

- helpful for regulating bleeding, dysmenorrhea (e.g. endometriosis, adenomyosis)

- 20%+ of women achieve amenorrhea within 1 year of use

- side effects include breast tenderness and intermenstrual bleeding

- does not suppress ovulation


Progestin implant

- works by thickening cervical mucus and preventing ovulation

- stays in for 5 years

- early on women will generally experience continuous irregular bleeding, but 30-40% of women achieve amenorrhea within 1 year of use


Depot medroxyprogesterone acetate (DMPA)

- suppresses ovulation

- last 3 months

Hormonal preparations for treating specific disorders

Dysmenorrhea (painful periods)

- COCs can reduce endometrial prostaglandin production in 70-80% of women

- progestin implant (e.g. Nexplanon) helps 80% of women

- levonorgestrel intrauterine system, in theory, should also help, but no data to guide this counseling (though there is data to support its use in endometriosis)

- depot medroxyprogesterone acetate (DMPA) and progestin implant are helpful in managing pain associated with endometriosis (in theory, COCs may, too)


Cycle control (irregularity in cycle length or frequency)

- oligo-ovulation or anovulation can increase risk for endometrial hyperplasia and malignancy and otherwise be quite annoying if very irregular in timing

- COCs are the mainstay (irregular spotting may still be experienced for the first 3-6 months of therapy)

- progestin-only pill will inhibit ovulation in 50% of women (iatrogenic anovulation --> no monthly bleeding)

- DMPA and progestin IUD work, too, over the long haul, but will initially increase the irregularity of bleeding


Heavy menstrual bleeding

- COCs are a reasonable alternative for women who desire future fertility (thus wouldn't want to undergo hysterectomy, ablation, or UAE)

- cyclic COCs reduce menstrual bleeding volume in 40-50% of women, continuous therapy or extended cycle regimens obviously would reduce bleeding even further to boost hematocrit

- progestin-only pills, DMPA, progestin implants (e.g. Nexplanon), and levonorgestrel intrauterine systems also help to shorten the duration of bleeding and can help achieve amenorrhea for many women

- Cochrane concluded that levonorgestrel intrauterine systems work better than progestin-only pills (e.g. norethindrone acetate) for this purpose and patients report greater satisfaction

- levonorgestrel intrauterine systems are comparable for this purpose when compared to endometrial ablation, but the former carries the risks of intermenstrual bleeding and breast tenderness, the latter carries risks of the procedure

- if patient responds to COCs, they are most cost-effective for the first year, then it's more effective to switch to a levonorgestrel intrauterine system

- if patient doesn't respond to COCs, it's more cost-effective to switch right away to the levonorgestrel intrauterine system (surgery is most cost effective next option if that fails)


Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PDD)

- premenstrual dysphoria disorder: severe extension of PMS, often with significant impact on social interactions and psychological well-being

- hormonal agents don't help with PMS

- the only RCTs to demonstrate a positive effect of COCs on PDD used a 24/4 regimen containing 30 mcg of ethinyl estradiol and drospirenone

- alternatively, it might be worth a shot to suppress ovulation continuously through an extended cycle regimen

- vaginal ring may be helpful


Menstrual migraines

- it's unclear how this works but 60% of women with migraines associate them with their period

- in theory, if the hormonal fluctuations that facilitate ovulation and menstruation are responsible for the migraines, then suppressing the hypothalamic-pituitary-ovarian axis would resolve them

- reasonable to try COCs, the patch, or DMPA, though data is limited

- COCs are not your go-to for patients with migraines who have other risk factors for stroke (e.g. smokers or patients ≥35 years)


Ovarian cysts

- any method that suppresses ovulation will inhibit the production of new ovarian cysts

- low-dose COCs may be less effective than higher-dose formulations

- monophasic may work better than triphasic formulations

- existing large cysts are unlikely to resolve even with high doses

- levonorgestrel intrauterine systems, the implant, and progestin-only pills all may contribute to the formation of cysts (rather than prevent)


Leiomyomas

- available data shows no effect of COCs on the growth of fibroids

- COCs may minimize bleeding without stimulating further growth

- mixed results for progestin-only therapies, though levonorgestrel intrauterine systems can help to manage bleeding depending on the size/location of the fibroids


Hirsutism or acne

- all COCs can improve these symptoms as the estrogen component increases sex hormone binding globulin and suppresses luteinizing hormone-driven ovarian androgen production (both of these effects decrease circulating androgen); as such, progestin-only methods are generally not helpful

- this will decrease the appearance of new acne and hair, but the hair that has already grown will have to be permanent removed

- 4th generation progestins are more antiandrogenic than the others; therefore, COCs containing drospirenone have been found to be more effective in some comparative trials

- hormonal devices that bypass the liver (e.g. the patch or the ring) have lesser impact on sex hormone binding globulin







Hormonal contraceptives may decrease the risk of certain cancers


Endometrial cancer

- 50% decreased risk in women who have EVER used COCs (regardless of length of treatment), but the longer the use, the lower the risk

- effect lasts up to 20 years after discontinuation

- risk reduction also seen in newer preparations and lower dose COCs (limited data)

- similar data for DMPA

- levonorgestrel intrauterine systems are so great at this that it can be used to manage hyperplasia without atypia (regression seen in 96% of women) in women who wish to preserve fertility or otherwise avoid hysterectomy (close follow-up is recommended)

- levonorgestrel is approved for use in HRT for its protective effect on the endometrium

- also protective for patients on tamoxifen for adjuvant breast cancer therapy


Ovarian cancer

- any use of COCs decreased risk of ovarian cancer (there have been MASSIVE studies on this)

- risk decreases by ~20% for every 5 years of COC use, even for low dose pills


Colorectal cancer

- maybe a decreased risk with past use, probably a decreased risk with current or recent use of COCs



Do hormonal contraceptives have any effect on bone mass or fracture risk?

- estrogen inhibits bone resorption - mixed data for COC effects on BMD in women of reproductive age

- COCs improve BMD in peri- and postmenopausal women

- no RCTs have looked at fracture risk as primary outcome with COC use, observational studies show a totally mixed bag of results

- DMPA may cause a decrease in BMD, but the bones will recover quickly in premenopausal women (similar to after breastfeeding)

- DMPA hasn't been looked at re: BMD in postmenopausal women

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