Practice Guidelines

ACOG Guidelines on Noncontraceptive Uses  

of Hormonal Contraceptives
CARRIE ARMSTRONG

The contraceptive patch also has effects on androgenic

Guideline source: American College of Obstetricians and
markers that compare favorably with combined oral
Gynecologists (ACOG)
contraceptives; as a result, positive effects on androgenic
Evidence rating system used? Yes conditions such as acne should be expected. The contra-
Literature search described? Yes ceptive intravaginal ring is effective in treating dysmenor-
rhea and premenstrual dysphoric disorder (PMDD). The
Published source: Obstetrics & Gynecology, January 2010
levonorgestrel intrauterine system (Mirena) has noncon-
Available at: http://journals.lww.com/greenjournal/ traceptive benefits in women who have excessive bleeding
toc/2010/01000
and dysmenorrhea, and it has been proven effective in
reducing menstrual blood loss in women with idiopathic
Coverage of guidelines from other organizations does not imply menorrhagia, adenomyosis, leiomyomas, pain associated
endorsement by AFP or the AAFP.
with endometriosis, and hemostatic disorders.
Most women in the United States will use hormonal con-
traception during their reproductive years. Many of these Dysmenorrhea and Menorrhagia
women use hormonal contraception for its noncontracep- Combined oral contraceptives relieve dysmenorrhea in
tive benefits, such as making menstruation more predict- up to 80 percent of women. The single-rod contraceptive
able and correcting menstrual irregularities caused by progestin implant also seems to reduce dysmenorrhea in
oligo-ovulation or anovulation (Table 1). most users. Data on the effects of the levonorgestrel intra-
Most hormonal contraceptives contain a progestin for uterine system on dysmenorrhea are limited, but because
its contraceptive effects and an estrogen to stabilize the the device reduces or eliminates menstruation for many

▲
endometrium and reduce spotting. Progestin-only con-
traceptives do not have the adverse effects associated with
combination methods, and they can be used by women in Table 1. Potential Noncontraceptive Benefits
whom estrogen is contraindicated. of Hormonal Contraceptives
New progestins with less androgenicity and triphasic
preparations that reduce overall progestin exposure have Decreased risk of endometrial, ovarian, and colorectal
led to changes to the progestin constituents of combined cancers
oral contraceptives. Other pills contain drospirenone or Improved bone mineral density in older women
cyproterone acetate, which has additional antiandrogenic Induction of amenorrhea for lifestyle considerations
properties. It is not known whether triphasic combined Menstrual cycle regularity
oral contraceptives differ from monophasic preparations Prevention of menstrual migraines
in effectiveness, bleeding patterns, or discontinuation Treatment of acne
rates. Triphasic preparations have been shown to reduce Treatment of bleeding from leiomyoma
acne, decrease the incidence of ectopic pregnancy, reduce Treatment of dysmenorrhea
menstrual blood loss, and lower the frequency of irregu- Treatment of hirsutism
lar bleeding and menorrhagia. Treatment of menorrhagia
The contraceptive patch is similar in effectiveness to Treatment of pelvic pain from endometriosis
combined oral contraceptives, and therefore would be Treatment of premenstrual syndrome
expected to reduce the risk of ectopic pregnancy, regulate
Adapted with permission from ACOG practice bulletin no. 110:
and reduce bleeding, and diminish dysmenorrhea. The noncontraceptive uses of hormonal contraceptives. Obstet Gynecol.
extended-cycle patch has been used to reduce menstrual 2010;115(1):206.
cycle–related side effects, including menstrual migraine.
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 Practice Guidelines

women, these benefits seem consistent with the mecha- Cancer

nism of action. Combined oral contraceptives confer a 50 percent risk
The use of combined oral contraceptives may reduce reduction for endometrial cancer. Longer duration of
the severity of dysmenorrhea in women with endometrio- use is associated with greater risk reductions, and the
sis. Continuous use of combined oral contraceptives may effect lasts for up to 20 years. Combined oral contracep-
offer additional benefits by eliminating menstruation and tives have also been shown to reduce the risk of ovarian
associated dysmenorrhea. Depot medroxyprogesterone cancer. Greater duration of use is associated with greater
acetate and the progestin contraceptive implant have also risk reductions, amounting to a decrease of approximately
been shown to reduce pain associated with endometrio- 20 percent for every five years of use. The protective effect
sis, and the levonorgestrel intrauterine system is effective also extends to low-dose pills. Combined oral contracep-
in treating dysmenorrhea and chronic pelvic pain that tives have been suggested as chemoprevention against
occurs with endometriosis. ovarian cancer in women with BRCA mutations.
Hormonal contraception should be considered for The levonorgestrel intrauterine system achieves con-
women with menorrhagia who may desire future preg- centrations in the endometrium several hundred-fold
nancies. Blood loss is reduced by up to 50 percent in higher than those achieved with traditional systemic
women who use cyclic combined oral contraceptives. This therapy. It is an effective treatment for hyperplasia with-
effectiveness can be further enhanced by extended-cycle out atypia, but accurate diagnosis and ongoing surveil-
or continuous therapy. The levonorgestrel intrauterine lance are essential.
system reduces blood loss by up to 86 percent after three A meta-analysis reported an 18 percent risk reduction
months, and by up to 97 percent after 12 months. for colorectal cancer among women who used oral con-
traceptives. This reduction was greatest in women with
Premenstrual Syndrome and PMDD recent use, and no duration effect was noted.
The only randomized controlled studies to show improve-
ment in symptoms of PMDD involved a combined oral Bone Mineral Density
contraceptive with a 24/4 regimen containing ethinyl There have been mixed results for the use of hormonal
estradiol with drospirenone as the progestogenic compo- contraceptives in improving bone health. Oral contra-
nent. This regimen provided relief from psychological and ceptives have been reported to have beneficial effects or
physiologic symptoms of PMDD, with improvements in no effect on bone mineral density (BMD). Combined
health-related quality of life. oral contraceptive use is associated with increased BMD
A direct comparison of a drospirenone-containing com- in women in the later reproductive years, with longer
bined oral contraceptive with the intravaginal contracep- duration of use associated with greater BMD. However,
tive ring showed equivalent improvement in symptoms of younger women who use combined oral contraceptives
premenstrual syndrome. Combined oral contraceptives have a lower BMD compared with nonusers.
containing 30 mcg of ethinyl estradiol with 3 mg of dro-
spirenone also decrease premenstrual mood deterioration Leiomyomas
in reproductive-aged women being treated for depression. The effects of combined oral contraceptives on the for-
Using extended-cycle or continuous combined oral con- mation and growth of uterine leiomyomas are poorly
traceptive regimens to suppress menstruation and stabi- understood. Case-control studies have reported no effect
lize hormone levels also seems to be effective. or reduced risk of leiomyomas in women who use
combined oral contraceptives. Two large cohort studies
Ovarian Cysts found that neither current nor past use is associated with
By preventing ovulation, hormonal contraception should an increased risk of developing leiomyoma. The levo-
reduce ultrasound findings of follicular and corpus luteal norgestrel intrauterine system has been shown to reduce
cysts. Such cysts are rarely of clinical significance, but overall uterine volume, with little or no effect on the size
may lead to unnecessary repeat ultrasonography when of existing leiomyomas. ■
discovered incidentally. Not all follicular activity is sup-
pressed with low-dose oral contraceptives, and small
ovarian cysts are common in women who use these Answers to This Issue’s CME Quiz
formulations. In women with larger functional ovarian Q1. A Q5. E Q9. A
cysts, the use of combined oral contraceptives does not Q2. C Q6. A, B, C, D Q10. D
hasten resolution compared with expectant management. Q3. A, C, D Q7. C
Therefore, combined oral contraceptives should not be Q4. B Q8. B
used to treat existing functional ovarian cysts.

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