Matthew L. Zerden, MD, MPH.

Patient choice, contraceptive effectiveness, and medical eligibility all need to be incorporated into the contraceptive counseling for reproductive-age women who have cancer or are in remission. Based on these principles, women can minimize the risk of an unintended pregnancy, continue to receive necessary adjuvant or preventive therapy, and maintain high levels of contraception satisfaction.

The Centers for Disease Control and Prevention (CDC) has published medical eligibility criteria (MEC) to assist providers in selecting medically appropriate contraception for women with various health conditions, including cancer (MMWR Recomm. Rep. 2010;59(RR-4):1-6).

Certain classes of hormonal contraception are contraindicated in specific cancer types. It is important to note that the copper intrauterine device (ParaGard) is very effective (with a first-year failure rate of 0.8%) and has no cancer-related contraindications. Any contraceptive with estrogen or progesterone is relatively contraindicated in hormonally mediated cancers, including breast, endometrial, or other cancers that have estrogen (ER) or progesterone (PR) positive receptors. Combined hormonal contraception is contraindicated even in breast cancers that are ER/PR negative for the first 5 years, after which they are CDC MEC category 3 (risks likely outweigh the benefits).

Venous thromboembolism (VTE) is an important cancer-related morbidity. Active cancer increases the risk of VTE by fourfold, which is further increased if the patient is on chemotherapy (Arch. Intern. Med. 2000;160:809-15). Estrogen is known to increase thrombotic risk, and therefore it is contraindicated in any patient at risk for VTE or with a history of a VTE. There is some debate about the use of progestin-only contraceptives in those at risk of (or with a history of) VTE. The best evidence and CDC guidelines indicate that progestin-only methods can be used in patients with cancer or with a history of VTE. Importantly, no known association exists between emergency contraception and VTE (Obstet. Gynecol. 2010;115:1100-9).

Other cancer-specific problems that may impact contraception include thrombocytopenia, gastrointestinal side effects, and drug interactions. Thrombocytopenia may exacerbate or cause abnormal uterine bleeding. Therefore, menstrual suppression with continuous combined hormonal contraception or progestin-only methods, including the hormonal IUD and implant, may be ideal. Regarding gastrointestinal side effects, emesis and mucositis from cancer and treatment may reduce absorption of oral contraceptives, so alternatives should be considered. Antacids, analgesics, antifungals, anticonvulsants, and antiretrovirals are all known to affect hepatic metabolism and may affect oral contraceptive efficacy.

Given the possibility of chemotherapy-induced immunosuppression, there is a theoretical concern about the infectious risk of an indwelling foreign body such as an IUD or implant. The best evidence to date, however, does not support an increased risk, even in the setting of neutropenia. Chemotherapy also increases osteoporosis. Gynecologists should use caution with depot medroxyprogesterone acetate (DMPA), although there is no absolute contraindication, especially for shorter durations of use.

Many breast cancer patients are prescribed tamoxifen as adjuvant therapy, but the antiestrogenic effects of tamoxifen may not prevent pregnancy (Cancer Imaging 2008;8:135-45). Therefore, it is critical for reproductive-age women taking tamoxifen to be given effective contraception. Experts have not reached a consensus on the use of levonorgestrel intrauterine systems (LNG-IUS, Mirena, or Skyla) in the setting of breast cancer.

On the one hand, patients on long-term tamoxifen may benefit from the endometrial protective effect of an LNG-IUS (Lancet 2000;356:1711-7). It is uncertain if women with an LNG-IUS in place at the time of breast cancer diagnosis should have the device removed. Placing a LNG-IUS is contraindicated in all cases of active cancer, but if the patient has no evidence of disease for more than 5 years, the CDC lists the LNG-IUS as category 3. Expert consensus is that studies are needed with LNG-IUS use in women with breast cancer and that use of the LNG-IUS in this population should be made with careful consideration of the risks and benefits (Fertil. Steril. 2008;90:17-22; Contraception 2012;86:191-8).

Physicians should consider the contraceptive needs of women who are actively being or have recently been treated for cancer, as 17% of female cancers occur in women of reproductive age. The copper IUD is a highly effective option with very few contraindications. In patients with a history of non–hormonal related cancer (and without any history of VTE), all contraceptive options can be considered, including those containing estrogen. Estrogen-containing contraceptives should be avoided in those with a history of hormonally related cancers. Those not familiar with the wide array of options should consider referring early, and family planning specialists should consider medical eligibility while counseling women about the most effective contraceptive options.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. He reported having no financial disclosures. E-mail Dr. Zerden at [email protected].

Patient choice, contraceptive effectiveness, and medical eligibility all need to be incorporated into the contraceptive counseling for reproductive-age women who have cancer or are in remission. Based on these principles, women can minimize the risk of an unintended pregnancy, continue to receive necessary adjuvant or preventive therapy, and maintain high levels of contraception satisfaction.

The Centers for Disease Control and Prevention (CDC) has published medical eligibility criteria (MEC) to assist providers in selecting medically appropriate contraception for women with various health conditions, including cancer (MMWR Recomm. Rep. 2010;59(RR-4):1-6).

Certain classes of hormonal contraception are contraindicated in specific cancer types. It is important to note that the copper intrauterine device (ParaGard) is very effective (with a first-year failure rate of 0.8%) and has no cancer-related contraindications. Any contraceptive with estrogen or progesterone is relatively contraindicated in hormonally mediated cancers, including breast, endometrial, or other cancers that have estrogen (ER) or progesterone (PR) positive receptors. Combined hormonal contraception is contraindicated even in breast cancers that are ER/PR negative for the first 5 years, after which they are CDC MEC category 3 (risks likely outweigh the benefits).

Venous thromboembolism (VTE) is an important cancer-related morbidity. Active cancer increases the risk of VTE by fourfold, which is further increased if the patient is on chemotherapy (Arch. Intern. Med. 2000;160:809-15). Estrogen is known to increase thrombotic risk, and therefore it is contraindicated in any patient at risk for VTE or with a history of a VTE. There is some debate about the use of progestin-only contraceptives in those at risk of (or with a history of) VTE. The best evidence and CDC guidelines indicate that progestin-only methods can be used in patients with cancer or with a history of VTE. Importantly, no known association exists between emergency contraception and VTE (Obstet. Gynecol. 2010;115:1100-9).

Other cancer-specific problems that may impact contraception include thrombocytopenia, gastrointestinal side effects, and drug interactions. Thrombocytopenia may exacerbate or cause abnormal uterine bleeding. Therefore, menstrual suppression with continuous combined hormonal contraception or progestin-only methods, including the hormonal IUD and implant, may be ideal. Regarding gastrointestinal side effects, emesis and mucositis from cancer and treatment may reduce absorption of oral contraceptives, so alternatives should be considered. Antacids, analgesics, antifungals, anticonvulsants, and antiretrovirals are all known to affect hepatic metabolism and may affect oral contraceptive efficacy.

Given the possibility of chemotherapy-induced immunosuppression, there is a theoretical concern about the infectious risk of an indwelling foreign body such as an IUD or implant. The best evidence to date, however, does not support an increased risk, even in the setting of neutropenia. Chemotherapy also increases osteoporosis. Gynecologists should use caution with depot medroxyprogesterone acetate (DMPA), although there is no absolute contraindication, especially for shorter durations of use.

Many breast cancer patients are prescribed tamoxifen as adjuvant therapy, but the antiestrogenic effects of tamoxifen may not prevent pregnancy (Cancer Imaging 2008;8:135-45). Therefore, it is critical for reproductive-age women taking tamoxifen to be given effective contraception. Experts have not reached a consensus on the use of levonorgestrel intrauterine systems (LNG-IUS, Mirena, or Skyla) in the setting of breast cancer.

On the one hand, patients on long-term tamoxifen may benefit from the endometrial protective effect of an LNG-IUS (Lancet 2000;356:1711-7). It is uncertain if women with an LNG-IUS in place at the time of breast cancer diagnosis should have the device removed. Placing a LNG-IUS is contraindicated in all cases of active cancer, but if the patient has no evidence of disease for more than 5 years, the CDC lists the LNG-IUS as category 3. Expert consensus is that studies are needed with LNG-IUS use in women with breast cancer and that use of the LNG-IUS in this population should be made with careful consideration of the risks and benefits (Fertil. Steril. 2008;90:17-22; Contraception 2012;86:191-8).

Physicians should consider the contraceptive needs of women who are actively being or have recently been treated for cancer, as 17% of female cancers occur in women of reproductive age. The copper IUD is a highly effective option with very few contraindications. In patients with a history of non–hormonal related cancer (and without any history of VTE), all contraceptive options can be considered, including those containing estrogen. Estrogen-containing contraceptives should be avoided in those with a history of hormonally related cancers. Those not familiar with the wide array of options should consider referring early, and family planning specialists should consider medical eligibility while counseling women about the most effective contraceptive options.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. He reported having no financial disclosures. E-mail Dr. Zerden at [email protected].

Patient choice, contraceptive effectiveness, and medical eligibility all need to be incorporated into the contraceptive counseling for reproductive-age women who have cancer or are in remission. Based on these principles, women can minimize the risk of an unintended pregnancy, continue to receive necessary adjuvant or preventive therapy, and maintain high levels of contraception satisfaction.

The Centers for Disease Control and Prevention (CDC) has published medical eligibility criteria (MEC) to assist providers in selecting medically appropriate contraception for women with various health conditions, including cancer (MMWR Recomm. Rep. 2010;59(RR-4):1-6).

Certain classes of hormonal contraception are contraindicated in specific cancer types. It is important to note that the copper intrauterine device (ParaGard) is very effective (with a first-year failure rate of 0.8%) and has no cancer-related contraindications. Any contraceptive with estrogen or progesterone is relatively contraindicated in hormonally mediated cancers, including breast, endometrial, or other cancers that have estrogen (ER) or progesterone (PR) positive receptors. Combined hormonal contraception is contraindicated even in breast cancers that are ER/PR negative for the first 5 years, after which they are CDC MEC category 3 (risks likely outweigh the benefits).

Venous thromboembolism (VTE) is an important cancer-related morbidity. Active cancer increases the risk of VTE by fourfold, which is further increased if the patient is on chemotherapy (Arch. Intern. Med. 2000;160:809-15). Estrogen is known to increase thrombotic risk, and therefore it is contraindicated in any patient at risk for VTE or with a history of a VTE. There is some debate about the use of progestin-only contraceptives in those at risk of (or with a history of) VTE. The best evidence and CDC guidelines indicate that progestin-only methods can be used in patients with cancer or with a history of VTE. Importantly, no known association exists between emergency contraception and VTE (Obstet. Gynecol. 2010;115:1100-9).

Other cancer-specific problems that may impact contraception include thrombocytopenia, gastrointestinal side effects, and drug interactions. Thrombocytopenia may exacerbate or cause abnormal uterine bleeding. Therefore, menstrual suppression with continuous combined hormonal contraception or progestin-only methods, including the hormonal IUD and implant, may be ideal. Regarding gastrointestinal side effects, emesis and mucositis from cancer and treatment may reduce absorption of oral contraceptives, so alternatives should be considered. Antacids, analgesics, antifungals, anticonvulsants, and antiretrovirals are all known to affect hepatic metabolism and may affect oral contraceptive efficacy.

Given the possibility of chemotherapy-induced immunosuppression, there is a theoretical concern about the infectious risk of an indwelling foreign body such as an IUD or implant. The best evidence to date, however, does not support an increased risk, even in the setting of neutropenia. Chemotherapy also increases osteoporosis. Gynecologists should use caution with depot medroxyprogesterone acetate (DMPA), although there is no absolute contraindication, especially for shorter durations of use.

Many breast cancer patients are prescribed tamoxifen as adjuvant therapy, but the antiestrogenic effects of tamoxifen may not prevent pregnancy (Cancer Imaging 2008;8:135-45). Therefore, it is critical for reproductive-age women taking tamoxifen to be given effective contraception. Experts have not reached a consensus on the use of levonorgestrel intrauterine systems (LNG-IUS, Mirena, or Skyla) in the setting of breast cancer.

On the one hand, patients on long-term tamoxifen may benefit from the endometrial protective effect of an LNG-IUS (Lancet 2000;356:1711-7). It is uncertain if women with an LNG-IUS in place at the time of breast cancer diagnosis should have the device removed. Placing a LNG-IUS is contraindicated in all cases of active cancer, but if the patient has no evidence of disease for more than 5 years, the CDC lists the LNG-IUS as category 3. Expert consensus is that studies are needed with LNG-IUS use in women with breast cancer and that use of the LNG-IUS in this population should be made with careful consideration of the risks and benefits (Fertil. Steril. 2008;90:17-22; Contraception 2012;86:191-8).

Physicians should consider the contraceptive needs of women who are actively being or have recently been treated for cancer, as 17% of female cancers occur in women of reproductive age. The copper IUD is a highly effective option with very few contraindications. In patients with a history of non–hormonal related cancer (and without any history of VTE), all contraceptive options can be considered, including those containing estrogen. Estrogen-containing contraceptives should be avoided in those with a history of hormonally related cancers. Those not familiar with the wide array of options should consider referring early, and family planning specialists should consider medical eligibility while counseling women about the most effective contraceptive options.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. He reported having no financial disclosures. E-mail Dr. Zerden at [email protected].

Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.

Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).

In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).

Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).

Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.

Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.

Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.

As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.

Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.

Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).

In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).

Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).

Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.

Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.

Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.

As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.

Approximately 740,000 women are diagnosed with cancer every year in the United States, and because of improved screening, diagnosis, and treatment, women of reproductive age have an 80%-90% 5-year survival rate. The most common cancers in reproductive age women include breast, thyroid, melanoma, colorectal, and cervical cancers. Fertility intention is a critical topic to discuss with reproductive-age cancer patients. Women with cancer often have unmet contraception needs during and following cancer treatment. Providing women with a desired, effective form of contraception that is appropriate with regard to the cancer is critical.

Multiple studies have demonstrated that pregnancy prevention is not adequately addressed in cancer patients. On the one hand, many patients believe they are no longer fertile because of a combination of the illness and the cancer treatment, and on the other hand, many providers may not be adequately trained to offer their patients the full range of contraceptive options (Am. J. Obstet. Gynecol. 2009;201:191.e1-4). One study demonstrated that discussions around fecundity and contraception are occurring about 50% of the time (J. Natl. Cancer. Inst. Monogr. 2005:98-100).

In response, the American Society for Reproductive Medicine has issued guidelines regarding fertility planning in cancer patients (Fertil. Steril. 2005;83:1622-8). While every patient’s circumstance is unique, recommendations are for patients to avoid pregnancy for at least 1 year beyond the completion of medical and surgical treatment of cancer. For those cancers that are hormone mediated, recommendations are to wait 2-5 years before attempting to conceive (J. Obstet. Gynaecol. Can. 2002;24:164-80; J. Gen. Intern. Med. 2009; 24: S401-6).

Unless patients are educated about and offered the most effective forms of contraception, they are at risk of unintended pregnancy, which may result in severe consequences, as patients may be on teratogenic medications or dealing with comorbid conditions originating from cancer and cancer treatment (Contraception 2012;86:191-8).

Cancer treatments have variable impact on subsequent fertility (with the obvious exception of surgical removal of gynecologic organs resulting in sterilization). With all nonsurgical cancer treatments, the potential for subsequent fertility depends on the chemotherapeutic agents, the duration of treatment, or use of pelvic radiation. As in patients without cancer, age is inversely related to subsequent fertility. Reviews of the literature have shown that fecundability decreases by 10%-50% post chemotherapy.

Clinicians caring for these women may find it challenging to assess future fertility. Some chemotherapies induce amenorrhea, but spontaneous return of menstruation and ovarian function is possible in younger women. Traditional diagnostic tests to assess fertility, including serum FSH (follicle stimulating hormone) and/or AMH (anti-Müllerian hormone), may help in predicting future fertility. These tests can be used both in patients who desire to pursue pregnancy and in those desiring to avoid pregnancy as menstrual status may not accurately predict fertility.

Contraception counseling should begin by informing women of the most effective forms of contraception (Obstet. Gynecol. 2011;118:184-96). It is important to consider the option of sterilization, especially when this desire predated the cancer diagnosis. In patients who are in a monogamous relationship with a male partner, vasectomy should be encouraged as a safe and effective alternative. When a woman is considering sterilization, she needs to be counseled as to the risk of regret, which is higher in younger women. Sterilization should not be performed if the consent or decision-making process is rushed by the cancer treatment.

As cancer screening, diagnosis, and treatment continue to improve, more reproductive-age women will be living longer with a need for effective contraception. In the next edition of Gynecologic Oncology Consult, I will review the safety and efficacy of specific contraceptive methods in patients with cancer.

Dr. Zerden is a family planning fellow in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. His research interests include postpartum contraception, methods of female sterilization, and family planning health services integration. He reported having no financial disclosures.