COMMENTARY

Contraception for Women With Cancer

Peter Kovacs, MD, PhD

Disclosures

October 02, 2012

Cancer and Contraception: Release Date May 2012 SFP Guideline #20121

Polonsky M
Contraception. 2012;86:191-198

Cancer Treatment and Contraception

Malignant diseases typically are diagnosed later in life. Certain types of cancers, however, are more prevalent in children and young adults. Moreover, some of the cancers that usually are diagnosed in the older population can be detected in young adults as well.[1]

Cancer therapy has improved significantly in the past decades. With better understanding of the pathomechanism of most cancers, more effective screening tools have been developed. These tests allow identification of cancer at an early stage, when conservative treatment can be offered and improved survival can be achieved.

Therapy for more advanced-stage disease has improved as well. Radiation therapy can be limited to the organ or tumor involved, and damage to otherwise healthy tissue can be minimized. Chemotherapy is now associated with fewer side effects, and surgical treatments have become more conservative.

These developments have resulted in improved survival, and as a result, the number of cancer survivors is increasing. Persons who receive cancer treatment in their reproductive years could remain fertile afterward and will then have to make decisions about birth control or family planning.

Chemotherapy and radiation therapy are known to have teratogenic effects. Therefore, contraception must be used during treatment and for at least 6 months after its completion. Many contraceptive methods are available, all of which have different adverse effect profiles. These adverse effects have to be taken into consideration in light of the special needs of the patient with cancer.

Contraceptive Guidelines for Women With Cancer

The Society of Family Planning has issued guidelines about the contraceptive choices of women diagnosed with cancer. The society points out that although chemotherapy and radiation therapy can compromise fertility, many women remain fertile. Antimüllerian hormone testing is the best available tool to assess the size of the remaining follicle pool, but pregnancy cannot be ruled out, even with patients with a severely compromised ovarian reserve.

The type of cancer and the specific risks posed to the patient will affect her contraceptive options. Hormones are known to play a role in the development of breast cancer; therefore, the use of combined contraceptive pills or progestin-only pills is not recommended in women undergoing treatment for breast cancer. In these women, the copper intrauterine device (IUD) seems to be the best choice. For women who receive tamoxifen as part of their cancer treatment, the intrauterine system (IUS) seems to offer the most benefit. Its use will counteract the proliferative effects of tamoxifen on the endometrium while concurrently providing effective contraception.

Cancer increases the risk for thromboembolism. Therefore, estrogen/progestin combined contraception is not recommended during cancer treatment. Current data on progestin-only pills are insufficient to make firm recommendations about its effect on thromboembolism risk. Anemic patients, however, may benefit from the use of combined contraceptive pills because they reduce blood loss at menstruation. The same holds true for the levonorgestrel-releasing IUS.

Depot medroxyprogesterone acetate is not recommended for patients with osteoporosis; instead, an estrogen-containing method could benefit such patients. Although not contraindicated, care must be taken with the use of an IUD in immunosuppressed patients.

It is equally important to determine whether contraception is associated with an increased risk for cancer. Combined contraceptive pills have been found to be associated with an increased risk for breast cancer, but newer reports have not confirmed this finding.[2,3] Progestin-only pills were not found to be linked to breast cancer. The use of combined contraceptive pills is associated with a reduction in the risks for ovarian and endometrial cancers. The levonorgestrel-releasing IUS also is associated with a lower risk for endometrial cancer.

Viewpoint

Improvements in the diagnosis and management of cancer have increased quality of life for patients with cancer both during and after treatment. Many cancer patients are in relationships where sexual activity is part of their lives. Unprotected intercourse can result in pregnancy even when the chance of fertility is considered minimal. Pregnancy may be undesired because of the potential teratogenic effects of cancer treatments, or fear that the pregnancy will negatively affect the course of the cancer. Women undergoing cancer treatment and female cancer survivors are more likely to terminate pregnancy, an action that has psychological and emotional consequences. As a result, it is important to provide appropriate counseling about contraception to these women.

Many contraceptive options are available to female cancer patients and survivors, and the choice can be individualized to the patient's circumstances. The type of cancer, the age of the patient, her ovarian reserve, comorbid conditions, and potential noncontraceptive benefits all must be taken into account with this decision. It also should be considered that some of the contraceptive options offer protection against certain types of cancer.

With the use of effective and appropriate contraception, women who are undergoing cancer treatment or who have survived cancer can maintain as normal an everyday life as possible without the fear of an undesired pregnancy or of harming their health.

Abstract

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