Hormonal birth control: more than contraception
The American College of Obstetricians and Gynecologists (ACOG) has published a new review of data supporting the noncontraceptive uses of hormonal contraceptives to treat specific conditions.1
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.2 In addition to preventing unplanned pregnancies, hormonal contraceptives are used off-label to effectively treat menstrual disorders including dysmenorrhea and menorrhagia.
"We've known for many years that hormonal contraceptives have health advantages beyond preventing pregnancy," said Robert Reid, MD, professor in the Department of Obstetrics and Gynaecology and chairperson of the Division of Reproductive Endocrinology & Infertility at Queens University, Kingston, Ontario, in a statement accompanying the publication. "These recommendations examine the scientific data supporting the non-contraceptive uses of hormonal contraceptives to treat specific conditions."
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, observes Reid, who led development of the review. Although there is little data on the newer forms of hormonal contraception in terms of their off-label benefits, experts suggest that they might be as effective as the more studied ones in treating the same conditions, he notes.
Check recommendations
After reviewing available research on various methods, the ACOG review lists the following recommendations, which are all based on good, consistent scientific evidence (Level A):
- Combined OCs should not be used to treat existing functional ovarian cysts.
- Use of combined hormonal contraception has been shown to lower the risk for endometrial and ovarian cancer.
- Combined OCs have been shown to regulate and reduce menstrual bleeding, treat dysmenorrhea, reduce symptoms of premenstrual dysphoric disorder, and ameliorate acne.
- Continuous combined hormonal contraception, depot medroxyprogesterone acetate (DMPA), and the levonorgestrel intrauterine system may be considered for long-term menstrual suppression.1
Specific ACOG recommendations based on limited or inconsistent scientific evidence (Level B), include:
- Based on the limited data available, it appears overall that combined OCs do not increase the risk of the development of uterine leiomyomas.
- Hormonal contraception should be considered for the treatment of menorrhagia in women who may desire further pregnancies.1
In addition, the ACOG review calls for a proposed performance that measures the percentage of women using hormonal contraception for symptomatic relief of menorrhagia or dysmenorrhea or both who have no contraindications and wish to preserve reproductive function.
Review the data
In looking at available data, the review finds that oral contraceptives and the single-rod contraceptive progestin implant help relieve or reduce the symptoms of dysmenorrhea, the pain that results from intense uterine contractions triggered by the release of endometrial prostaglandins. Dysmenorrhea is the most commonly reported menstrual disorder; it affects up to 90% of young women and is a leading cause of women missing school and work.3
A variety of hormonal contraceptives also are useful in treating menorrhagia, which, if left untreated, can lead to anemia. Menstrual blood loss is reduced in women who use cyclic combined OCs, extended cycle and continuous combined OCs, as well as progestin-only methods as progestin-only pills, DMPA, progestin implants, and the levonorgestrel intrauterine system.1
The review notes that all combined OCs have the potential to improve hirsutism and acne, since they increase sex hormone binding globulin and suppress luteinizing hormone-driven ovarian androgen production. This chemical mechanism reduces the levels of free androgen, which initiate and maintain acne and hair growth.1 Other potential benefits of hormonal contraceptives include prevention of menstrual migraines, treatment of pelvic pain due to endometriosis, and treatment of bleeding due to uterine fibroids.
Counsel on benefits
Although the noncontraceptive benefits provided by certain methods are not generally the main determinant for women selecting a birth control method, they certainly can help patients decide among suitable options, according to the authors of Contraceptive Technology.4
Potential noncontraceptive benefits include menstrual cycle regularity, treatment of menorrhagia, treatment of dysmenorrhea, inducing amenorrhea for lifestyle considerations, treatment of premenstrual syndrome, prevention of menstrual migraines, decrease in the risk of endometrial cancer, ovarian cancer, and colorectal cancer, treatment of acne or hirsutism, improved bone mineral density, treatment of bleeding due to leiomyomas, and treatment of pelvic pain due to endometriosis.1
Awareness that a method of contraception has major noncontraceptive benefits might increase the likelihood that a patient will continue with a chosen method. Make it a practice to tell patients about the noncontraceptive benefits of various methods, advises Contraceptive Technology.
"If patients have additional reasons for using the contraceptive method, their motivation to use it correctly and consistently will probably be improved," it states.4
References
- ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol 2010; 115:206-218.
- Piccinino LJ, Mosher WD. Trends in contraceptive use in the United States: 1982-1995. Fam Plann Perspect 1998; 30:4-10, 46.
- Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol1996; 87:55-58.
- Trussell J. Choosing a contraceptive: efficacy, safety, and personal considerations. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 19th revised edition. New York: Ardent Media; 2007.
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