Contraception and Menstrual Suppression for Adolescent and Young Adult Oncology Patients


Categories of medical eligibility criteria for contraceptive use

1. A condition for which there is no restriction for the use of the contraceptive method

2. A condition for which the advantages of using the method generally outweigh the theoretical or proven risks

3. A condition for which the theoretical or proven risks usually outweigh the advantages of using the method

4. A condition that represents an unacceptable health risk if the contraceptive method is used



The only cancers outlined specifically are ovarian, cervical, breast, gestational trophoblastic neoplasia, and malignant hepatoma. However, there is a special designation under high risk of DVT/PE for active cancer (metastatic, on therapy, or within 6 months of clinical remission, excluding non-melanoma skin cancer) that is also of great importance in the oncology patient population.

The WHO also classifies contraception based on efficacy into four tiers [4]:



  • Tier 1 (most effective): Sterilization, implants, intrauterine devices (IUD)


  • Tier 2: Depot medroxyprogesterone acetate (DMPA), combined hormonal methods


  • Tier 3: Barrier methods


  • Tier 4: Behavioral methods

Below we will outline all available methods of contraception and discuss their efficacy, safety profiles, ease of use, and common side effects. We will also note any particular concerns in the oncology population (see also Table 4.1).


Table 4.1
Contraception options













































































































































































Category

Contraception

Medication names

Failure ratea (%)

Continued use at 1 year (%)

ADRs

Cancer-specific issues/contraindications

Best use

Common use

Behavioral methods

Abstinence/no method
 
0

0–85
   
These methods are especially ineffective for patients undergoing cancer treatments. Discussions should focus on counseling more effective methods

Timing

3–5

24

47

Withdraw

4

22

46

Barrier methods

Male condom
 
2

18

43

Latex or spermicide sensitivities can be seen

Condoms should be advised in ALL sexually active AYA patients to decrease the risk of STI transmission

Female condom

5

21

41

Diaphragm may be a viable option in hormone-sensitive cancer patients who cannot have copper IUD

Diaphragm

6

12

57

Estrogen progesterone methods

Pills

Lutera, Levora, Yaz, Sprintec, Ortho-Cyclen …

0.3

9

67

Increased risk of VTE

Advantageous for bone health

Should be avoided in cancer pts if possible due to increased risk of VTE

Nausea/vomiting

Transdermal patch

Xulane Ortho Evra

0.3

9

67

Serum EE levels higher than 35 EE COC

Advantageous for bone health

VTE risk similar to 35 EE COC

Not recommended for patients >90 kg

Transient skin reactions

More initial BTB than COCs

Transvaginal ring

Nuva ring

0.3

9

67

Serum EE levels lower than most COCs

May not have positive effect on bone health

Headache

Vaginal wetness

Short- or intermediate-acting progesterone methods

Progesterone-only pills

Norethindrone (Ortho Micronor)

0.3

9

67

Breakthrough bleeding
 

Headache

Nausea

Breast tenderness

Acne

Injectable progesterone

DMPA (Depo-Provera)

0.2

6

56

Irregular vaginal bleeding

Not recommended in treatments resulting in osteopenia/osteoporosis

Amenorrhea

Weight gain

Transient decrease in bone mineral density

LARC – progesterone based

Progesterone implant

Implanon Nexplanon

0.05

0.05

84

May cause unpredictable vaginal bleeding

Irregular bleeding pattern may not be the best choice in patients with concerns for anemia

LNG IUD

Mirena

Skyla

0.2

0.2

80

Chance for amenorrhea

Used for treatment of endometrial hyperplasia and low-grade cancer

May be considered for select breast cancer patients on tamoxifen

LARC – nonhormonal

Copper IUD

ParaGard

0.8

0.6

78

May increase menstrual blood flow

First line for breast cancer patients

Not recommended if Concern for anemia

Emergency contraception

Combined OCPs LNG methods ulipristal copper IUD

Yuzpe method Plan B/Next Choice Ella ParaGard
   
NA

N/V, Irregular vaginal bleeding. Some breast tenderness, abdominal pain, dizziness, HA, fatigue

There are absolutely no situations in which risks outweigh the benefits of EC


aPercentage of women experiencing unintended pregnancy within the first year


Contraception





  1. 1.


    Behavioral methods


    1. (a)


      Abstinence


      1. (i)


        Abstinence is a wise and safe choice at any life stage, particularly for young patients who do not feel ready for a sexual relationship. However, abstinence-only programs are ineffective in delaying sexual debut or in reducing sexual risk behaviors among teens that are already sexually active [5]. Comprehensive sexual education has been shown to significantly decrease teen pregnancy rates, increase age at first intercourse, and significantly increase the likelihood of contraception use at first intercourse [57]. Furthermore, female participants in comprehensive sexual education programs were more likely to choose age-appropriate sexual partners, less likely to note first intercourse as an unwanted event, and more likely to express overall healthier partnerships associated with their first sexual encounter. Sexual education has not been shown to be associated with an earlier onset of sexual debut [5]. Therefore, although a patient who notes abstinence as their form of contraception should be encouraged to continue, sexual health should always be part of the discussion.

         

       

    2. (b)


      Noncoital sexual behaviors


      1. (i)


        Noncoital sexual behavior includes mutual masturbation, oral sex, and anal sex and is a common expression of sexuality. The National Survey of Family Growth found that 45 % of females aged 15–19 years have had oral sex with an opposite-sex partner, but these numbers have remained stable over the past two decades. Compared with oral or vaginal sex, which are common in more than 90 % of males and females by age 25 years, anal sex is less common (10 % of female adolescents aged 15–19 years) and often is initiated later. Noncoital sexual behavior commonly coexists with coital behavior. The prevalence of oral sex among adolescents jumps dramatically in the first 6 months after initiation of vaginal intercourse, suggesting that both are often initiated around the same time and with the same partner. Although there is little risk of pregnancy with strictly noncoital activities, given this association, contraceptive discussion is warranted. Sexually transmitted infections, including HIV, HSV, HPV, hepatitis virus, syphilis, gonorrhea, and chlamydia, can be transmitted through noncoital sexual activity, and patients should be strongly counseled regarding safe sexual practices [8].

         

       

    3. (c)


      Coitus interruptus/withdrawal method


      1. (i)


        This method involves the withdrawing of the penis from the vagina and away from the external genitalia prior to ejaculation. It is mentioned here as a point of discussion, as it is practiced widely, with 55 % of adolescent women aged 15–19 years reporting having used the method before [9]. The failure rate of such technique is high (22 % with typical use) and it does not provide protection against sexually transmitted infections [9].

         

       

     

  2. 2.


    Barrier methods


    1. (a)


      Male condoms


      1. (i)


        The male condom acts as a physical barrier, covering the penis and blocking the passage of sperm into the vagina. According to the 2013 YRBS, 41 % of US high school students did not use a condom during the last sexual intercourse [1]. All sexually active adolescents should be encouraged on regular condom use for the prevention of sexually transmitted infections including HIV, as well as increased contraceptive efficacy. In the general population, condom use has an overall reassuring failure rate of 2 %. However, in typical use, the male condom alone has a failure rate of 18 % [9]. For this reason, a more reliable form of contraception should be counseled as first line.

         

       

    2. (b)


      Vaginal barriers/spermicides


      1. (i)


        Female condom


        1. 1.


          The female condom is a soft, loose polyurethane sheath with two rings, one on either end. One ring is placed in the vagina; the other is placed outside the introitus. These devices are available over the counter. Efficacy is poor, with a typical use failure rate in the general population of 21 % [9].

           

         

      2. (ii)


        Diaphragm


        1. 1.


          The diaphragm is a dome-shaped flexible rubber cup. Spermicide is applied to the dome, and the device is inserted into the vagina prior to intercourse so that the posterior rim rests in the posterior fornix and the anterior rim fits behind the pubic bone with the dome of the device covering the cervix. The diaphragm must be sized and prescribed by a physician. Once in position, it can provide contraceptive protection for up to 6 h before additional spermicide is required. After intercourse, it should be left in place for at least 6 h but should not be left in place for a combined duration of longer than 24 h due to a rare risk of toxic shock syndrome. The diaphragm also has a lower efficacy rating with typical use failure rates of 12 %. However, this may be a good option in a very select subset of patients with hormone-sensitive cancers and an aversion or contraindication to the copper intrauterine device (IUD) [9].

           

         

      3. (iii)


        Spermicides


        1. 1.


          Spermicidal gels, creams, and foams are available for use with the diaphragm but can also be used individually for contraception. Spermicidal suppositories can be used alone or with condoms. However, efficacy is low with a typical use failure rate of 28 % in the general population, when used alone for contraception [9]. Given the difficulty of correct usage and high failure rate, we would not commonly recommend this method for use in the adolescent population. However, it may be useful in the subset of patient for whom the diaphragm would be indicated.

           

         

       

     

  3. 3.


    Estrogen-containing contraceptives

    The current options for combined estrogen and progesterone contraceptive methods are the oral pill, the transdermal patch, and the vaginal ring (PPR). There are many non-contraceptive benefits of using a combined regimen, including but not limited to regulation of menstrual cycles, treatment of menorrhagia/dysmenorrhea, and treatment of acne and pelvic pain [10]. Studies are variable on the possible improvement of bone mineral density in premenopausal women. These regimens have also been shown to decrease the risk of endometrial, ovarian, and colorectal cancers, and modern formulations have no increase in breast cancer risk [11]. As a class, all estrogen-based contraceptives are tier 2 efficacy, with a typical use first-year failure rate of 9 %. The continuation rates of these methods at 1 year are also the same, at 67 % [9].

    As a class, there is an increased risk of venous thromboembolism (VTE) that is dependent on the estrogen dose and duration. Although the relative risk of VTE is increased, the absolute risk for each individual user is low, as thrombosis is a rare event in the healthy young female population that commonly uses this contraceptive method. However, these combined regimens may pose a high risk of VTE if patients are not carefully selected [9].

    For the malignant diagnoses specifically listed in the MEC, PPR are noted as a category 4 (unacceptable risk) for relationship to elevated DVT/VTE risk (active cancer, or within 6 months after clinical remission, excluding non-melanoma skin cancers), current breast cancer, and malignant liver tumors. They are classified as a category 1 for gestational trophoblastic disease and a category 2 for cervical cancer awaiting treatment. It is important to take the overall medical condition into consideration, as other conditions such as obesity, hyperlipidemia, diabetes, and liver and renal failure may be part of the medical history in chronically ill children. Similarly, it is important to note that any patient with a complicated solid organ transplant is not a candidate for estrogens (category 4), but for an uncomplicated transplant patient, estrogen-containing contraceptives are considered a category 2.


    1. (a)


      Pills


      1. (i)


        Combined oral contraceptive pills (COCs) are available in a wide variety of formulations. The choice of pill should be determined by the patient and physician based on clinical picture, medical history, and patient preference. The basic mechanisms of action are the same for all formulations and include both inhibition of ovulation and folliculogenesis and thickening of cervical mucus. COCs are taken daily and depending on the cycling pattern chosen can be given between 21 and 90 days with a 4–7-day pill-free interval for withdrawal bleeding. Use among adolescents is popular, with 19 % of sexually active US high school students endorsing use of COCs to prevent pregnancy prior to their last act of sexual intercourse [1]. However, compliance and continuation may prove challenging in this age group.

         

       

    2. (b)


      Patch


      1. (i)


        The contraceptive transdermal patch is a thin, flexible patch that contains 6 mg of norelgestromin (active metabolite of norgestimate) and 0.75 mg of ethinyl estradiol (EE). The patch releases 150 mcg of norelgestromin and 20 mcg of EE daily. The patch provides serum levels of EE that are higher than the common 35 mcg EE COC formulations; however, the VTE risk of the patch is equivalent to a 35EE/norgestimate oral contraceptive pill. The patch is applied to the buttocks, upper arm, lower abdomen, or upper torso and changed once weekly for 3 weeks. The fourth week is a hormone-free interval to allow for cycling. Its mechanism of action is the same as that of oral contraceptive pills. In some studies, the patch appears to enhance consistent and correct use as compared to COCs; however, their overall continuation rates and failure rates are the same. Patch users may note a transient skin reaction and more initial breakthrough bleeding than COCs users; the latter effect improves with use. Patients greater than 90 kg may have a higher risk of pregnancy when using the patch [9].

         

       

    3. (c)


      Ring


      1. (i)


        A soft, transparent flexible ring that releases 120 mcg of etonogestrel (major metabolite of desogestrel) and 15 mcg of EE daily. Although several cases of VTE have been reported in vaginal ring users, the serum EE levels are two and threefold lower than that found in 35EE COCs and the birth control patch. However, there have been studies linking the progesterone component of the ring to an increased risk of VTE. Possibly due to the lower estrogen output, studies have not shown improvement in bone mineral density using the ring, even after 24 months of use [9].

        The ring is placed vaginally once every 28 days, with the last 7 days being a ring-free time frame to allow for withdrawal bleeding. The mechanism of action is mostly ovulation suppression, similar to oral contraceptive pills. In theory, the ease of once-monthly use should improve patient compliance and improve method success rates. However, in randomized comparative trials, the ring and COCs showed similar compliance and continuation rates. The vaginal ring has excellent cycle control, even in the first few cycles. It can be removed for up to 3 h without compromising effectiveness and is safe to use with tampons or during intercourse. The most commonly reported side effects are headache and vaginal wetness [9].

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Sep 24, 2017 | Posted by in GYNECOLOGY | Comments Off on Contraception and Menstrual Suppression for Adolescent and Young Adult Oncology Patients
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