We thank Dr Alouini et al for their thoughts on our recent article regarding continuation and satisfaction of long-acting reversible contraception among Hispanic women in the Contraceptive CHOICE Project (CHOICE). They state that “women were not informed on the potential risks of levonorgestrel on the breast where progestagen as contraception seems to play an important role in the development of breast cancers in vitro and in vivo.” However, the references Dr Alouini et al present do not support a causal association between the levonorgestrel intrauterine (LNG-IUS) system and breast cancer.

Despite the claims of Dr Alouini et al, there is no clear association of the LNG-IUS system and breast cancer. In their letter, they fail to mention 2 other large epidemiologic studies that found no increased risk of breast cancer with the use of the LNG-IUS system. The one study that found a modest association (odds ratio, 1.19) failed to control for important confounders such as parity, family history, lifestyle factors, and use of exogenous hormones.

In our report, only 1 of the participants had a diagnosis of breast cancer. She received a copper intrauterine device, which may be an ideal, nonhormonal, contraceptive method for women with this medical history. No CHOICE participants who chose the LNG-IUS system had breast cancer. Thus, the point that “recurrence of breast cancer is increased” in women who use the LNG-IUS system is irrelevant.

It is not the standard of care to screen for BRCA1 and BRCA2 before contraceptive use. Family history of breast cancer and positivity for these gene mutations are not contraindications to progestin-containing contraceptive use. In fact, according to the Centers for Disease Control and Prevention’s US Medical Eligibility Criteria (MEC) for Contraceptive Use, both the LNG-IUS system and etonogestrel implant received a “1” recommendation (a condition for which there is no restriction for the use of the contraceptive method) for women with family history of breast cancer. In the CHOICE Project, counselors screened participants per MEC guidelines and informed them of the risks that are associated with contraceptive method use.

Readers of the medical literature should examine the totality of the evidence, not just the studies that support their point of view. Intrauterine devices and implants are outstanding methods of contraception. Clinicians and patients should follow the Centers for Disease Control and Prevention’s MEC guidelines, and should offer the most effective contraceptive methods to all women.