Contraception Good News: Ovarian Cancer Decreased, Effectiveness Increased

By Robert A. Hatcher, MD, MPH

I began my family planning career at the Centers for Disease Control and Prevention 69 years ago. It was the week after July 4, 1966. I learned from Dr. Christopher Tietze that about 50% of all pregnancies in the United States were unintended. Sadly, today that percentage is almost exactly the same, telling us just how strong the inclination to proceed with intercourse continues, even when it is not protected by any contraceptive.

But what has changed very recently is the contraceptive options available to couples. The four contraceptive methods I will tell you about are all very recent and all prevent cancer, endometriosis, and pregnancy. Three of the four also remarkably diminished menstrual blood loss and pain.

When one ponders the contraceptive picture in our country, it is the future that counts. In addition to being more effective at preventing unwanted pregnancies, the four contraceptives this article discusses also reduce a woman’s risk of developing ovarian, colon, and endometrial cancer and, in some studies, provided a slightly reduced risk of death from breast cancer. Obviously, reducing unwanted pregnancies also decreases the need for abortions. As I discuss the four contraceptives, I will point out some of their dramatic noncontraceptive benefits.

If you know of someone in her teens, 20s, or early 30s with endometriosis, you can inform her that one of five treatments provided to women in a large research study found that endometriosis was best treated by one of the contraceptives discussed in the following sections, the levonorgestrel intrauterine device (IUD) called Mirena. Endometriosis is extremely painful and is a major cause of infertility.

Now, the four remarkable and new methods of birth control:

1. The complete removal of both fallopian tubes (or bilateral salpingectomy), a 100% effective method of birth control. This is a method of birth control that is significantly more effective than pills, all of the IUDs, vasectomy, injections, condoms, and diaphragms. Perhaps the most dramatic noncontraceptive benefit of this tubal sterilization technique is that it causes a 49% reduction in a woman’s risk for ovarian cancer. Increasing evidence indicates that the distal end of the fallopian tubes, which is removed in this procedure, is the main site of origin of high-grade serous ovarian carcinoma. [Castellano: Obstet Gynecol 2017] The American College of Obstetricians and Gynecologists now recommends complete salpingectomy when a hysterectomy is being performed, and salpingectomy over tubal occlusion procedures (tying the tubes) for permanent contraception. [ACOG Committee Opinion No. 620: Salpingectomy for ovarian cancer prevention, 2015] To reduce the risk of future ovarian cancer, the majority of surveyed obstetricians and gynecologists in the United States now perform salpingectomy at the time of hysterectomy and for permanent contraception. For those with a family history of ovarian cancer, this is wonderful news. One prospective cohort study of 619,199 patients also suggested a decreased risk of breast cancer mortality (relative risk of 0.82) in women who had a tubal sterilization.

2. The levonorgestrel IUD (Mirena and Liletta) is very close to 100% effective as a contraceptive and also is effective as a treatment for endometriosis, heavy or painful menstrual periods, and as an emergency contraceptive. Jeffrey T. Jensen, MD, professor and vice-chair of research in the Department of Obstetrics & Gynecology at Oregon Health and Science University, expresses his enthusiasm for this IUD as follows: “I love IUDs. They are the single most impactful intervention that has occurred in my medical career stretching back to 1985. The availability of the hormonal IUD and the many problems it has solved is extraordinary. It’s a fantastic system but not for everyone.” [Contraceptive Technology Update, May 2023]

3. The copper T380A IUD also is highly effective as a contraceptive and appears to be effective for 20 or more years. It is the most commonly used effective contraceptive worldwide and is easily reversible. The copper T IUD and the levonorgestrel IUD are both effective as emergency contraceptives and can be left in place as long-term contraceptives.

4. The contraceptive implant Nexplanon is the most effective reversible contraceptive. Both placement and removal can be accomplished quickly. It can be inserted very readily, even in busy practices. Its major downside, compared to the three previously mentioned contraceptives, is that it is effective for only four years. It has been used to treat endometriosis and ovarian cysts, particularly corpus lutein cysts.

You may have noticed that this article has not discussed birth control pills. This is because they are many times more likely to result in a pregnancy in typical users because typical users sometimes have difficulty taking a pill every day, as prescribed. The difficulties range from not being able to afford to buy the pills, forgetting to take the pills while on a trip, losing packages of pills, to almost as many other reasons as you can imagine. Table 1 compares the failure rates in all the methods discussed in this article, together with failure rates in other commonly used methods.

Contraceptives are complicated, sometimes difficult to use, and sometimes difficult to understand.

Unintended pregnancies are common. Two out of my three children are actually happy that they resulted from a contraceptive mistake! Everyone I have worked with in the field of family planning is fully aware that unplanned pregnancies can be a huge blessing. I firmly believe that the response to an unplanned pregnancy should be determined primarily by the woman to whom it happens. But we can hold off on this discussion for another day.

Robert A. Hatcher, MD, MPH, is Professor Emeritus, Gynecology and Obstetrics Department, Emory University School of Medicine, Atlanta.