'The Pill': It's Not Just for Birth Control

GYN for the PCP

Nadine Hammoud, MD

Disclosures

October 08, 2020

Birth control pills (BCPs) have been around since the 1960s. Mainly known for their use in preventing pregnancy, these and other hormonal contraceptives have beneficial effects in many other health conditions. Let's look into some of those clinical entities in some typical patients who might present to primary care.

Ovarian Cyst

A 17-year-old patient of yours was seen in the emergency department for acute stabbing pain in the right lower quadrant. A urine pregnancy test was negative. Imaging showed a normal appendix and a 7-cm cyst torsed over her right ovary. She was taken to the operating room and underwent laparoscopic right ovarian detorsion and cystectomy. When you next see her after her surgery, she asks whether the cyst could grow back and what can be done to prevent future cyst formation.

The answer is that she can begin taking BCPs. The same mechanism that "quiets down ovarian function" and suppresses the hypothalamic-pituitary-ovarian axis for contraception helps prevent cyst formation within the ovary. Combined contraceptives are recommended (unless estrogen is contraindicated) for women with recurrent symptomatic cysts, such as ruptured cysts or torsed cysts, and for patients with polycystic ovary syndrome (PCOS).

Monophasic preparations have been shown in some studies to prevent benign ovarian cysts more effectively than low-dose triphasic pills. In addition, oral contraceptives (combined or progesterone only) can be used as a nonsurgical or conservative option for patients with cysts who are not surgical candidates or who do not desire to proceed with surgery.

Patients should be counseled that BCPs will not resolve an existing cyst completely but might prevent the cyst from growing larger and prevent the ovary from forming new cysts. When using this approach, short-term serial ultrasounds are recommended (usually every 6-8 weeks) for follow-up unless otherwise indicated or the cyst resolves.

By decreasing ovulation and the constant low follicle-stimulating hormone and luteinizing hormone stimulation of the ovarian surface epithelium, BCPs reduce the risk for ovarian cancers. They are also used as primary prevention for women at risk for hereditary ovarian cancer (for example, patients with the BRCA gene).

Menorrhagia

A 39-year-old woman presents with heavy and painful menstrual bleeding for the past 20 days. She reports that she has been having heavier periods than usual for about 5 months. Her laboratory tests were reassuring, but an ultrasound showed a 4-cm intramural fibroid.

Menorrhagia is a common menstrual complaint that can be caused by hormonal factors in pubertal girls, teenagers, and perimenopausal women; underlying bleeding disorders; or anatomical factors, such as fibroids or adenomyosis.

After an appropriate workup for abnormal uterine bleeding, it is very common and cost-effective to use hormonal contraceptives (combined or progestin only, or hormonal intrauterine device [IUD]) as an initial therapy or as an alternative to surgical therapy. Furthermore, hormonal contraceptives can improve iron deficiency anemia in women with menorrhagia. It takes longer (a couple of months) to achieve a more favorable bleeding pattern with a medical, compared with a surgical, approach.

The mechanism of action of hormonal treatments on bleeding patterns is not fully understood, but it is believed that a steady state of hormonal exposure thins out the endometrial lining, thereby decreasing blood flow.

The type and size of the fibroid is a factor in predicting the success of medical therapy: A submucosal (intracavitary) fibroid is less likely to respond to hormonal treatment, as is a large subserosal fibroid.

Premenstrual Dysphoric Disorder

A 22-year-old woman presents with complaints of irritability, marked anxiety, tension and emotional lability, which always begin about a week before her period. Her symptoms remit with the onset of her menstrual flow. This has been affecting her personal and work relationships, and she now seeks your help. After your assessment, you determine that she meets the criteria for premenstrual dysphoric disorder (PMDD).

One option is to offer this patient a combined oral contraceptives containing ethinylestradiol (30 µg) and drospirenone, a progestin with a strong antimineralocorticoid effect.

Another option for PMDD or premenstrual syndrome (PMS) is to suppress menstruation and "stabilize the hormones" with continuous combined or extended cycle contraceptives. The vaginal ring has also been shown to help with PMDD.

Hormonal stabilization also underlies the use of hormonal contraception in the treatment of patients with menstrual migraines (without auras) or recurrent ovulation pain, and to achieve cycle regularity. Continuous (skipping placebo pills) or cyclical regimens can be used for those conditions.

Chronic Pelvic Pain

A 27-year-old woman presents to your clinic with chronic pelvic pain, severe dysmenorrhea, and dyspareunia. You suspect clinical endometriosis and recommend that she start on BCPs. She asks whether there are other options to treat her symptoms because she doesn't think she'll be compliant with daily pill use.

Several non-pill hormonal options are effective for endometriosis pain. Combined contraceptives (pill, patch, or ring) reduce prostaglandin production and relieve dysmenorrhea regardless of whether the patient has primary dysmenorrhea or the source of her pain is endometriosis, chronic pelvic inflammatory disease, inflammatory bowel disease, or pelvic congestion. Oral contraceptives have also been shown to reduce the size of endometriosis lesions.

Non-pill options, such as progestin implants and depot injection, have also been used to improve dysmenorrhea by achieving menstrual suppression. The levonorgestrel (LNG) IUD, which has the same mechanism of action, is another option to help women with dysmenorrhea and dyspareunia if long-acting reversible contraceptive is preferred. However, the LNG IUD might not achieve the same pain relief effect as the systemic hormonal options in endometriosis because this condition may also have extrauterine manifestations.

Acne and Hirsutism of PCOS

A 32-year-old woman with PCOS wants help for her acne and hirsutism. She has already seen a dermatologist and tried several common acne treatments without success.

Combined oral contraceptives can improve acne and hirsutism in PCOS by increasing sex hormone–binding globulin, decreasing luteinizing hormone stimulation of ovarian androgen production, and reducing the level of circulating free androgens.

Formulations containing antiandrogenic progestins (drospirenone or cyproterone acetate) are usually preferred, and triphasic preparations have been shown in some studies to improve acne. BCPs help prevent ovarian cyst formation and improve insulin resistance in PCOS and, along with medroxyprogesterone acetate, LNG IUD, and cyclical progesterone, reduce risk for endometrial cancer by decreasing unopposed estrogen.

Premature Ovarian Insufficiency

A 37-year-old woman with a 14-month history of amenorrhea has undergone an extensive workup and has been diagnosed with spontaneous premature ovarian insufficiency (POI).

The many important health conditions to address when managing patients with POI include vasomotor symptoms, emotional and sexual health, fertility options, bone health, cardiovascular disease, and overall mortality.

Unless contraindicated, women with POI are started on hormonal therapy, such as BCPs, to help prevent cardiovascular disease, osteopenia and osteoporosis, atrophic vaginitis, and bothersome vasomotor symptoms. The American College of Obstetricians and Gynecologists recommends systemic hormonal therapy in women with POI until age 50-51 years (with yearly assessment of risk factors and contraindications).

Systemic hormonal therapy (eg, oral or vaginal contraceptives) are also used in the perimenopausal hormonal transition to help with the many symptoms that women typically experience, such as hot flashes, night sweats, mood lability, low sexual drive, and menstrual cycle changes. The need for hormonal treatment is assessed yearly until age 51 and is managed on a case-by-case basis.

Summary: Health Indications for Noncontraceptive Use of Hormonal Contraceptives

  • Treatment of menorrhagia and bleeding due to leiomyomas/adenomyosis

  • Treatment of dysmenorrhea and pelvic pain from endometriosis

  • Inducing amenorrhea and menstrual cycle regularity for lifestyle/medical considerations

  • Treatment of PMS/PMDD

  • Prevention of ovarian cysts

  • Prevention of menstrual migraines (without aura)

  • Chemoprevention of endometrial cancer, ovarian cancer, and colorectal cancer

  • Treatment of acne and hirsutism (hyperandrogenism)

  • Treatment of vasomotor symptoms of perimenopause and in POI

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