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Contraception Corner

Noncontraceptive Health Benefits of Hormonal Contraception

Barbara Clark, RN, MSN, MPH; Ronald T. Burkman, MD

Hormonal contraception is associated with certain risks, but in most cases these are outweighed by health benefits that can guide contraceptive selection and enhance compliance. Some noncontraceptive health benefits of hormonal contraception may last a lifetime. If women are educated about these benefits, they may be more likely to adhere to their contraceptive regimen. Ultimately, this will result in fewer unintended pregnancies.

CONTRACEPTIVE CHOICES

All hormonal contraceptives confer noncontraceptive advan- tages. However, combination estrogen/progestin oral contraceptives (COCs) confer considerably more proven bene- fits than other modalities.

Oral Contraceptives

Combination oral contraceptives confer menstrual benefits, including relief of dysmenorrhea and menorrhagia,1 as well as nonmenstrual health benefits. Combined oral contraceptives can reduce the risk of ovarian cancer by 40% to 80% after approximately 1 year of use, and decrease the risk by 10% to 12% annually thereafter.2 Even after discontinuing COC use, protection continues for 15 to 20 years. They also can reduce the risk of endometrial cancer by 40% to 50%; this protection increases with duration of use.2

Although some studies have suggested that COCs decrease the risk of pelvic inflammatory disease (PID),3 more recent research did not show this effect.4They also reduce the risk of ectop-ic pregnancy by approximately 90%, and decrease the likelihood of benign breast disease.2 They are particularly beneficial for perimenopausal women, relieving vasomotor symptoms such as hot flashes and night sweats.1

Other potential beneficial effects include protection against uterine fibroids,5 colorectal cancer,2 and rheumatoid arthritis,6 plus improvement of acne.7 Research on the effect of COCs on bone mineral density has yielded conflicting results.8

Extended-regimen Contraception

Extended regimens of hormonal contraception for delaying or eliminating menstruation can alleviate menstrual-related disorders. One extended COC regimen containing levonorgestrel (LNG) and ethinyl estradiol provides 84 days of active pills, followed by a 7-day pill-free interval. The traditional cyclic OC can also be used for extended contraception by eliminating the hormone-free week. Similarly, an extended regimen of the contraceptive ring or transdermal contraceptive patch may be used via continuous dosing. However, the US Food and Drug Administration (FDA) has not approved the ring, patch, or traditional cyclic OC for extended use.

According to recent research, extended COCs provide greater relief of menstrual symptoms such as headache and dysmenorrhea than the 28-day cycle.9 In addition, studies have shown that women using the contraceptive patch in an extended regimen have fewer median bleeding days and bleeding/ spotting episodes.10 Similarly, women using the vaginal ring had fewer bleeding days, but more spotting days.11

Levonorgestrel-releasing Intrauterine System

At 3 to 6 months' postinsertion, the LNG-releasing intrauterine system (IUS) has been found to reduce menstrual flow; about 50% of users develop amenorrhea by 12 months.12 It can also be useful in decreasing dysmenorrhea, increasing hemoglobin levels, and treating idiopathic menorrhagia.12 In fact, studies have shown that the LNG-IUS was as effective as endometrial ablation in improving the quality of life in women with heavy menstrual bleeding.13 It also protects against ectopic pregnancy and PID.12

Single-rod Implant

A single-rod etonogestrel implant, developed to provide contraception for up to 3 years, has recently been approved by the FDA. Preliminary research has suggested that it may improve dysmenorrhea, menstrual blood loss, and acne.14

Depot Medroxyprogesterone Acetate

Depot medroxyprogesterone acetate, an injectable, progestin-only contraceptive, reduces the risk of endometrial cancer by up to 80%, with continuing protection after discontinuation,15 and reduces the risk of PID and uterine leiomyomata.16 Furthermore, it can improve iron-deficiency anemia, dysmenorrhea, menorrhagia, and pain from endometriosis.16 It also can decrease the number and severity of crises in patients with sickle cell anemia.17

Transdermal Contraceptive Patch and Vaginal Ring

Because the transdermal patch and vaginal ring are fairly new contraceptives, there are no long-term studies on their noncontraceptive health benefits. However, because the patch and ring contain the same hormones (steroids) as COCs, studies may show that they provide similar benefits.

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COMMUNICATING NONCONTRACEPTIVE health BENEFITS


As more contraceptive options become available, the amount of information to convey to patients increases. Discussing noncontraceptive health bene-fits presents additional challenges. Furthermore, physicians must consider how changing phases in a woman's life affect contraceptive requirements. Yet, reviewing noncontraceptive benefits with patients may help them choose among the myriad of contraceptive options.

Recognizing the barriers to effective contraceptive counseling, the Association of Reproductive Health Professionals has developed New Dynamics in Health Care: Contraception and the Periodic Well Woman Visit—a curriculum that will help physicians and office staff provide contraceptive counseling.18

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CONCLUSION

Physicians should highlight both the immediate and long-term noncontraceptive benefits of hormonal options, especially for perimenopausal women. With this information, women may be more likely to comply with their contraceptive regimen, increasing efficacy.

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Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, Va. Ronald T. Burkman, MD, is chairman, Department of Obstetrics and Gynecology, Baystate Medical Center, Springfield, Mass.

References

1. Davis A, Wysocki S. Clinician/patient interaction: communicating the benefits and risks of oral contraceptives. Contraception.1999;59(1 suppl):39S-42S.
2. Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol. 2004;190(4 suppl):S5-S22.
3. Peterson HB, Lee NC. The health effects of oral contraceptives: misperceptions, controversies, and continuing good news. Clin Obstet Gynecol. 1989;32(2):339-355.
4. Ness RB, Soper DE, Holley RL, et al. Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study. Am J Obstet Gynecol. 2001;185(1):121-127.
5. Burkman RT. Management of the Fibroid Uterus. Adv Obstet Gynecol. 1996;3:103-128.
6. Spector TD, Hochberg MC. The protective effect of the oral contraceptive pill on rheumatoid arthritis: an overview of the analytic epidemiological studies using meta-analysis. J Clin Epidemiol. 1990;43(11):1221-1230.
7. Redmond GP, Olson WH, Lippman JS, Kafrissen ME, Jones TM, Jorizzo JL. Norgestimate and ethinyl estradiol in the treatment of acne vulgaris: a randomized, placebo-controlled trial. Obstet Gynecol. 1997;89(4):615-622.
8. Martins SL, Curtis KM, Glasier AF. Combined hormonal contraception and bone health: a systematic review. Contraception. 2006;73(5):445-469.
9. Edelman AB, Gallo MF, Jensen JT, Nichols MD, Schulz KF, Grimes DA. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2005;(3):CD004695.
10. Stewart FH, Kaunitz AM, Laguardia KD, Karvois DL, Fisher AC, Friedman AJ. Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial. Obstet Gynecol. 2005;105(6):1389-1396.
11. Miller L, Verhoeven CH, Hout J. Extended regimens of the contraceptive vaginal ring: a randomized trial. Obstet Gynecol. 2005;106(3): 473-482.
12. Luukkainen T, Toivonen J. Levonorgestrel-releasing IUD as a method of contraception with therapeutic properties. Contraception. 1995;52(5):269-276.
13. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006;(2):CD003855.
14. Croxatto HB. Mechanisms that explain the contraceptive action of progestin implants for women. Contraception. 2002;65(1):21-27.
15. Thomas DB, Ray RM. Depot-medroxyprogesterone acetate (DMPA) and risk of invasive adenocarcinomas and adenosquamous carcinomas of the uterine cervix. WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Contraception. 1995;52(5):307-312.
16. Kaunitz AM. Current concepts regarding use of DMPA. J Reprod Med. 2002;47(9 suppl):785-789.
17. Cullins VE. Noncontraceptive benefits and therapeutic uses of depot medroxyprogesterone acetate. J Reprod Med. 1996;41(5 suppl): 428-433. Review.
18. Association of Reproductive Health Professionals. New Dynamics in Health Care: Contraception and the Periodic Well Woman Visit. Available at: http://www.arhp.org/healthcareproviders/visitingfacultyprograms/wellwoman/index.cfm. Accessed July 6, 2006.

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