ACOG Practice Advisory: Counseling Patients About Breast Cancer Risk and Hormonal Contraception
SUMMARY:
ACOG reaffirmed a practice advisory in 2022 that had initially been in response to a prospective cohort study. The results from the paper by Mørch and colleagues (NEJM, 2017) was based on Danish nationwide registries (see ‘Related ObG Topics’ below) and identified the following
Overall risk of breast cancer in current or recent users compared to women who never used hormonal contraception
Increased Risk of breast cancer: Relative Risk (RR): 1.20 (95% CI, 1.14 to 1.26)
Risk increased with duration of use: RR 1.09 (95% CI, 0.96 to 1.23) at < 1 year vs 1.38 (95% CI, 1.26 to 1.51) after > 10 years (P=0.002)
Risk remains elevated after ≥5 years but not < 5 years
Oral Combined Contraceptives
Little evidence of major differences between various OCPs after statistical adjustments for multiple testing
Levonorgestrel-releasing intrauterine system (LNG-IUD)
No significant differences compared to OCPs
RR of breast cancer was 1.21 (95% CI, 1.11 to 1.33)
Contraceptive implants
Few breast-cancer events among users of the progestin-only implant and depot medroxyprogesterone acetate
KEY POINTS:
Relative vs Absolute Risk
Absolute risks remain low
Overall: 1 additional case of invasive breast cancer for every 7,690 women using hormonal contraception
Women <35 years: 1 additional case of invasive breast cancer for every 50,000 women using hormonal contraception
Benefits of Hormonal Contraceptives
ACOG addresses these benefits clearly in this Practice Advisory
Non-hormonal benefits (see ‘Related ObG Topics’ below)
Decreased risk of ovarian, endometrial, and colon cancer
Overall cancer risk may be lower in hormonal contraceptive users despite possibility of small increased breast cancer risk
Hormonal benefits
Maternal mortality rate in the US: 26.4 deaths per 100,000 women (2015)
The above risk is twice that of developing invasive breast cancer in the NEJM study
More study required regarding relationship between progestin-only contraceptives and breast cancer risk
Study results were inconsistent regarding progestin-only formulations
Counseling recommendations
ACOG supports shared decision making and counseling should include the following
This recent study showed that women who use hormonal birth control methods may have a small increased risk of breast cancer, but the overall risk of breast cancer in hormonal birth control users remains very low
Hormonal birth control is very effective in preventing pregnancy and may lower a women’s overall risk of cancer by providing protection against other types of cancer
There are nonhormonal methods of birth control that are also good options
Women can do things to help lower their risk of breast cancer, like breastfeeding, getting more exercise, and limiting alcohol intake
Heavy menstrual bleeding accounts for 1/3 of gyn visits in the US
Multiple treatment options exist when conservative medical therapy (e.g. oral contraceptives) are not sufficient for good control
Spencer et al. (AJOG, 2017) evaluated the relative cost effectiveness of 4 possible treatments
METHODS:
Researchers constructed a hypothetical cohort of 100,000 premenopausal women
Researchers developed a decision tree which weighed a private payer cost with quality-adjusted life years (QALYs) over 5-years for women with heavy menstrual bleeding
4 treatment options
Hysterectomy
Resectoscopic endometrial ablation (REA),
Non-resectoscopic endometrial ablation (NREA)
Levonorgestrel-releasing intrauterine system (LNG-IUS)
Each treatment option’s probabilities of minor complications, major complications, and treatment failure was derived from literature review
Treatments were compared in terms of total average cost, total quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio
RESULTS:
Compared to hysterectomy:
LNG-IUS had superior quality of life outcomes with lower costs
After analysis, LNG-IUS was more cost-effective in 90% of scenarios
Both REA and NREA had reduced costs, but lower average quality of life
Hysterectomy is associated with superior quality of life and fewer complications but more expensive than other treatments
CONCLUSION:
Strong evidence that LNG-IUS is a cost-saving alternative to hysterectomy for heavy bleeding with comparable quality of life outcomes but reduced costs
If LNG-IUS is not an option (patient choice or clinical reasons), decision is not as clear
Hysterectomy results in better quality of life and fewer complications than either type of ablation but at higher cost
Cost, potential complications and patient choice may drive decision
Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction
CLINICAL ACTIONS:
Abnormal uterine bleeding in the setting of anovulation or oligoovulation (AUB-O) results from chronic estrogen stimulation of the endometrium. In the setting of irregular, prolonged bleeding (menorrhagia)
Perform an age appropriate history and physical exam
Appropriate lab tests include
Pregnancy test
Thyroid function tests
Prolactin level
PT/aPTT
Sexually transmitted disease testing
Complete blood count if bleeding is prolonged and heavy
Endometrial biopsy should be performed in women over age 45 or those of any age with risk factors for endometrial hyperplasia or malignancy
Nulliparity, hypertension, obesity, irregular menses and family history of endometrial cancer
Saline infusion sonohysterography (SIS), hysteroscopy or transvaginal ultrasound may be used to rule out an anatomic abnormality
ACOG states that
Failure of medical management requires further investigation, including imaging or hysteroscopy
SYNOPSIS:
Ovulatory menstrual cycles generally occur between 21 and 45 days, are predictable, and last about 5 days reflecting sequential stimulation of the endometrium first by estrogen alone, then by a combination of estrogen and progesterone and finally by withdrawal of both hormones. The cause of AUB-O can be an abnormality at any level of the hypothalamic-pituitary-ovarian axis. Consequences can include blood loss anemia due to heavy bleeding, as well as endometrial hyperplasia and endometrial cancer.
FIGO Subclassification System
The 4 types can be referred to by the acronym ‘HyPO-P’ | Last ‘P’ separated because it does not track to a single anatomic location
Type 1: Hypothalamic
Genetic
Autoimmune
Iatrogenic
Neoplasm
Type II: Pituitary
Functional
Infectious/Inflammatory
Trauma & Vascular
Type III: Ovarian
Physiologic
Idiopathic
Endocrine
Type IV: PCOS
Diagnosis and categorization and recommended by the International PCOS network
Note: According to FIGO, “The new system provides practical utility and a second layer, or sub-classification, for each of the three anatomically defined entities, including discrete pathophysiological categories. These can be remembered using the acronym ‘GAIN-FIT-PIE'”
KEY POINTS:
The levonorgestrel IUD is effective in treating AUB-O and can be offered to all age groups
Progestin and combination birth control pills are common medical options
Weight loss and exercise should be strongly recommended for overweight anovulatory women
Surgical therapy, such as hysterectomy, is rarely indicated but can be considered in women who have failed medical therapy or in whom medical therapy is contraindicated
Hysterectomy with removal of the cervix can be offered to women who meet above criteria and have completed childbearing, or who have significant intracavitary pathology
Endometrial ablation is not recommended as a first line therapy for AUB-O as traditional methods of endometrial surveillance may not be possible after the procedure
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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