Benefits of Hormonal Contraception May Extend Beyond Pregnancy Prevention
By Laurie Barclay, MD
Medscape Medical News
December 31, 2009 — The benefits of hormonal contraceptives may extend beyond pregnancy prevention, according to a practice bulletin issued by the American College of Obstetricians and Gynecologists (ACOG) and published in the January 2010 issue of Obstetrics Gynecology.
"We've known for many years that hormonal contraceptives have health advantages beyond preventing pregnancy," lead author Robert L. Reid, MD, from Kingston, Ontario, Canada, said in a news release. "These recommendations examine the scientific data supporting the noncontraceptive uses of hormonal contraceptives to treat specific conditions."
During their reproductive years, more than 80% of women in the United States use some form of hormonal contraception, such as oral contraceptive (OC) pills, patches, single-rod progestin and other implants, injections, vaginal rings, and the intrauterine device. In addition to preventing unplanned pregnancies, hormonal contraceptives are used off-label to effectively treat menstrual disorders including dysmenorrhea and menorrhagia.
Up to 90% of young women report dysmenorrhea, which is a leading cause of school and work absenteeism among women. If left untreated, menorrhagia can cause anemia. Approximately three quarters of women with dysmenorrhea respond favourably to combined OC treatment, and the vaginal ring may be equally effective.
The most cost-effective treatment strategy for menorrhagia may be combined OC use for 1?year, followed by use of a levonorgestrel intrauterine device. The levonorgestrel intrauterine system appears to be better than cyclical norethindrone for the treatment of heavy bleeding. Cyclic combined OCs decrease menstrual blood loss by 40% to 50%, or even more, for extended-cycle (84-day) OCs. However, extended-cycle OCs may cause higher rates of spotting.
Some evidence suggests that the combination of ethinyl estradiol plus drospirenone may reduce symptoms of premenstrual dysphoric disorder.
Use of combined contraceptives containing both estrogen and progesterone is associated with a lower risk for the development of endometrial cancer (50% reduction in risk vs never-use), ovarian cancer (27% decrease in risk), and colorectal cancers. Studies to date suggest that longer duration of OC use is linked to a decreased risk for the development of endometrial and ovarian cancer for up to 20 years after discontinuing use. Current or recent use of oral contraception also may protect against colorectal cancer in the short term (18% decrease in risk).
In addition, combined contraceptives block androgen production and may therefore reduce hirsutism and acne. Contraceptives containing drospirenone or cyproterone acetate may be most effective for treatment of hirsutism, but all combined contraceptives appear to be similarly effective against acne.
Hormonal contraceptives may also be of theoretic or actual benefit in preventing menstrual migraines, treating pelvic pain caused by endometriosis, and treating bleeding from uterine fibroids. Extended-cycle or continuous hormonal contraception may reduce the frequency of menstrual migraine, but combined OCs have been associated with possible increased stroke risk in women with migraine who are 35 years or older, who smoke, or who have focal neurologic signs. Combined OCs should therefore be avoided in these women.
"Combined oral contraceptives are effective in normalizing irregular periods, reducing symptoms of premenstrual dysphoric disorder, improving acne, and allowing women to avoid having their period at inconvenient times, such as during a business trip, vacation, or honeymoon," Dr. Reid said. "Although there is little data on the newer forms of hormonal contraception in terms of their off-label benefits, experts suggest that they may be as effective as the more studied ones in treating the same conditions."
Specific recommendations, based on good, consistent scientific evidence (level A), are as follows:
Combined OCs should not be used to treat existing, functional ovarian cysts.
Combined hormonal contraceptive use has been shown to lower the risk for endometrial and ovarian cancer.
Combined OCs have been shown to regulate and decrease menstrual bleeding, to treat dysmenorrhea, to reduce symptoms of premenstrual dysphoric disorder, and to treat acne.
Specific recommendations based on limited or inconsistent scientific evidence (level B), are as follows:
Combined OCs are not associated with increased risk for the development of uterine leiomyoma, based on limited evidence to date.
In women who may wish to become pregnant, hormonal contraception should be considered for treatment of menorrhagia.
A performance measure proposed by the ACOG is the percentage of women wishing to preserve reproductive potential who are using hormonal contraception to treat symptoms of menorrhagia and/or dysmenorrhea, provided they have no contraindications to use of hormonal contraception.
