Hormonal contraceptives, knowing the why is critical
One of the mainstays of gynaecological management are hormonal contraceptives. In some ways they have proven transformative in terms of women's healthcare. Indeed, this is self evident when one considers that one variant, the combined oral contraceptive pill, is the only medication universally recognised by the simple expedient of asking for "the pill". Originally prescribed for menstrual cycle control, in married women only, over the decades they have come to be universally available and arguably have empowered women to embrace the liberation of the 60s sexual revolution with the security of reliable birth control. Though of course the double standard of requiring women to take ownership of their fertility control rather than men controlling theirs remains.
But birth control is not what this entry is about, rather, I wanted to explore the more medicinal role of contraceptives; the why, the what, and, most importantly, the importance of ensuring that options are properly explained, concerns addressed and the time taken to identify the best solution for each individual's presentation. In my own practice I get the distinct impression that a number of women, when discussing their gynaecological complaints with clinicians, are left feeling that a simple boiler-plate answer is all that has been provided, with little explanation - "just take the pill". This is unfortunate, though I should stress not reflective of the majority of clinicians. The problem with this simplified approach is that it dis-empowers women by denying them knowledge of the why behind their own treatment. And the why is all too important if women, and for that matter any patients, are to buy into their treatment and feel in control of their own healthcare journey.
So what are some of the whys? Let's address some of the most common, in brief...
Viewed in a simple sense, the role of hormonal contraceptives is to suppress the growth, and post-surgical excision, regrowth, of endometriosis. This is important in three regards:
- control of endometriosis related symptoms, most commonly pain, and the impact of these symptoms on a woman's quality of life;
- reduction in the likelihood of endometriosis impacting upon fertility; and
- prolongation of the time between surgical procedures associated with endometriosis.
The goal of hormonal treatment is to limit the number of menstrual periods thereby limiting the extra-uterine inflammation and bleeding consequent upon this condition.
Problematic periods - heavy/painful
Particularly in younger women, arguably the control of heavy and/or painful menstrual periods is the number one indication for commencing a hormonal contraceptive and they are most effective at doing so. The obvious advantage to such medications is that they allow for women to skip their periods, in some cases avoid them all together. Generally speaking, women find that, even if they are not skipping periods, their periods become lighter and more manageable than was previously the case. Particularly for women who are struggling because of anaemia and days off of work and school this is transformative.
Certain hormonal conditions, such as polycystic ovarian syndrome, cause women issues with acne, unwanted body hair and 'male pattern' body-fat distribution. These can be attributed to the excess effect of androgens, so called male hormones. All women naturally produce low levels of such hormones but in some cases either the levels are elevated or the response is excessive. In such cases the right hormonal contraceptive can be quite beneficial.
Pre-menstrual syndrome and mid-cycle (ovulation) pain
Unrelated conditions, PMS and mid-cycle pain, are together perhaps the third most common reason that I find myself suggesting a hormonal contraceptive. In both cases the benefit seems to relate to the 'smoothing' out of the hormonal fluctuations associated with the menstrual cycle - in the first case the benefit is in avoiding the changes in 'brain chemistry' that afflict some women in the second half of their menstrual cycle; in the second it is the avoidance of ovulation by removal of the mid cycle hormonal surge.
And what are the whats?
Again, in brief, there are numerous options available in terms of hormonal contraceptives, both as contraceptives and for medicinal control of gynaecological symptoms. A brief breakdown is as follows:
Combined oral contraceptive pills
Myriad are available and the choice, in terms of clinical recommendations is influenced by two factors - the amount of oestrogen, the type of progesterone.
The amount of oestrogen - whether a pill is 'low dose', standard or 'high dose' - will be varied for a variety of reasons. Certain safety considerations and in some cases optimisation of clinical efficacy influence the decision making. It has to be said that standard pills are suitable for the vast majority of women.
The type of progesterone - this is the most important variation in selecting a pill for a particular clinical scenario. A run down of the options, again brief:
Menstrual control - generic pills generally suffice;
Endometriosis - again, generic pills generally suffice, however, a progesterone called dienogest has some evidence to suggest higher efficacy and in challenging or severe cases may be significantly superior;
Hyper-androgenism - a group of progesterones have been developed that have anti-androgenic properties and are quite effective at reducing androgenic symptoms. I refer to these pills as 'the lady pills' as they are almost universally named, no doubt for marketing purposes, after women: Dianne, Yasmin, Evylyn, etc.
IUDs - intra-uterine contraceptive devices
Medically, in terms of gynaecological symptom control, the device of choice is the Mirena IUD. Other IUDs, such as the copper and, a recent device Kyleena, are available but in reality are almost exclusively contraceptive in their benefit. The Mirena IUD has become a mainstay of gynaecological management for both heavy menses and post-surgical suppression of endometriosis. While not tolerated by all women, for the majority who do tolerate the device, clinical experience is that most will achieve complete cessation of menstrual periods within a few months of insertion of the device. Generally speaking, the Mirena is a good option for women who have struggled with side effects from previous contraceptive options as the hormonal exposure of the device is quite small.
Implanon NXT device
With a similar hormonal side effect profile to the pill, the Implanon is a good choice for women who struggle to remember to take the pill and who are perhaps not suited to the Mirena.
The above is by no means a comprehensive list of all hormonal contraceptives but it does capture the mainstays in terms of medicinal applications.
It is when options are being discussed in a medicinal sense that it is so critical that outlines such as the above are presented to women. Furthermore, the conversation shouldn't stop with such outlines. It should allow for women to voice their questions and concerns surrounding a particular recommended course of treatment. Particularly in this age of information overload, women often have concerns that, if left unvoiced, will leave them feeling understandably uncertain about the proposed course of action. Lack of understanding and fear of side effects then leads to disengagement from treatment and loss of the benefit of treatment. Hormonal contraceptives do have side effects and these need to be explored with a woman in such a way that she is empowered to make a personal decision as to the potential risk/benefit of any proposed therapy. Given the often dramatic effect of gynaecological conditions upon a woman's quality of life, as a gynaecologist I find it particularly frustrating when improvement in that quality of life has been lost for want of a clinician simply taking the time to explore options and explain the rationale for treatment.