PCOS and Contraception

A background to birth control

Birth control has helped women advance their educational and professional goals and plan their lives and families on their own terms. Among the 1.9 billion women of reproductive age (15–49 years) living in the world today, 842 million (44%) use modern, mostly hormonal, methods of contraception (oral contraceptive pills, implants, injectables, contraceptive patch and vaginal ring, intrauterine device) and 80 million (5%) use traditional methods.1 We often think that the only purpose of birth control is pregnancy prevention, but it does much more than that.

Birth control pills, transdermal patches, and the vaginal birth control ring are combined hormonal contraceptive (CHC) methods. They contain two hormones: oestrogen and progestogen. The pill (combined oral contraceptive, COC) is used by over 20%of women of reproductive age in 27 countries worldwide, with the highest prevalence in European countries.1 Combined oral contraceptives offer a variety of non-contraceptive health benefits and therapeutic effects. The hormones in the pill have also been used to treat other medical conditions, such as PCOS, endometriosis, adenomyosis, acne, hirsutism, amenorrhea, menstrual cramps, menstrual migraines, menorrhagia (excessive menstrual bleeding), menstruation-related or fibroid-related anaemia and dysmenorrhea (painful menstruation).2

What is PCOS?

Polycystic ovary syndrome is a heterogeneous endocrine disorder among women of reproductive age and prevalence rates range from 5% to 13.9%. Of those with PCOS, around 7 in 10 may go undiagnosed.3,4 The condition is mainly characterised by chronic anovulation, polycystic ovary morphology, and hyperandrogenism.5 The symptoms of PCOS, the factors associated with its development, the related conditions and the diagnostic challenges are briefly summarised in our previous blog post.

Even for those with manageable periods, it is often the worst time of the month with cramping, bloating, nausea, or diarrhoea. For those with PCOS, periods can be severely painful. In honour of PCOS Awareness Month this September, we will explore how using hormonal birth control can help control the symptoms of PCOS.

The exact causes of PCOS are unknown, but we do know that the main underlying problem with PCOS is a hormonal imbalance that causes multiple cysts to develop on the ovaries and can also cause heavy, irregular, or painful periods. Because the ovarian cysts interfere with the normal menstrual cycle, women with PCOS may not ovulate each month resulting in irregular cycles, rare or unusually long periods. Due to the hormone imbalance, people may also experience weight gain, acne, thinning hair or excess body hair. Moreover, when left untreated, PCOS leaves people at a higher risk for type 2 diabetes, infertility, high blood pressure, ovarian cancer, and heart disease.6

PCOS can be managed using contraceptives

There is no cure yet, but there are many ways patients can decrease or eliminate PCOS symptoms and feel better. Management of clinical manifestations of PCOS, such as menstrual irregularities and hyperandrogenism symptoms (acne, excess body hair) includes lifestyle changes,7,8 and for those who do not want to become pregnant, the use of CHCs. The pill, the patch, and the ringwork by preventing ovulation which reduces the number of cysts on the ovary. Combined hormonal contraceptives contain oestrogen that exerts antiandrogenic properties by triggering the hepatic synthesis of sex hormone-binding globulin (SHBG) that reduces free testosterone levels, thereby reducing hair growth and acne breakouts. Moreover, the progestogen present in CHCs and in progestogen-only contraceptives suppresses luteinizing hormone secretion. In addition, some types of progestogens directly antagonize the effects of androgens on their receptor and reduce the activity of the 5α reductase enzyme.5

In addition to CHCs, types of contraception that reduce the overall number of periods for months or even years at a time can reduce period-related symptoms of PCOS. Many women who use a hormonal intrauterine device (IUD) (159 million users worldwide1) stop getting periods after one year of use. Similarly, around half of all who use injectable contraceptives (74 million users worldwide1) stop getting their periods after one year. The pill, the patch, the ring, hormonal IUDs, the implant, and injectable contraceptives can all make periods lighter because these birth control methods make the lining of the uterus thinner. A thinner uterine lining has less tissue to shed, resulting in lighter periods.

However, PCOS is related to clinical and metabolic comorbidities that may limit the prescription of CHCs. Common risk factors for cardiovascular diseases (CVD), such as systemic arterial hypertension (SAH), obesity, dyslipidaemia, metabolic syndrome and type 2 diabetes mellitus can develop in women with PCOS by the fourth decade of life.9,10,11 Consequently, clinicians should still evaluate each patient individually and consider the presence of risk factors, such as age, smoking, obesity, diabetes, SAH, dyslipidaemia, and a personal or family history of venous thromboembolic events or thrombophilia.5 When the use of oestrogen is contraindicated for the patient or when multiple risk factors for CVD are present or oestrogen intolerance occurs, the use of progestogen-only contraceptives (POCs) or nonhormonal contraceptives is recommended. If these methods do not adequately control the symptoms of hyperandrogenism, an alternative is to combine a POC or a nonhormonal method with an antiandrogen medication, such as spironolactone, cyproterone or finasteride.3

Although guidelines do not suggest one formulation over another in terms of effectiveness, low-dose oral contraceptives containing neutral or antiandrogenic progestins may be the choice in the treatment of PCOS regarding the androgen excess and the metabolic disturbances associated with the disorder. Despite the potential adverse cardiovascular and metabolic effects of CHCs, current evidence suggests that the benefits of hormonal contraception outweigh the risks for its use in most women with PCOS.12

Because the characteristics and severity and risk factors of PCOS can vary from person to person, treatment plans are highly individual. It is very important to talk to a provider about all the potential treatment options. It is also possible to be on hormonal birth control and start investigating the drivers behind a patient’s hormone imbalance.

The future of PCOS management

Overall, contraception is an effective method of controlling and minimising symptoms of PCOS, thereby improving a woman’s quality of life and reducing the burden of disease. Although there are certain risk factors that may limit the prescription of contraceptives to manage PCOS, it is vital that women are diagnosed, and treatment plans are assessed on an individual basis so that women are able to take control of their health and experience greater autonomy over all aspects of their daily lives. Therefore, research, awareness, and funding for PCOS research is vital. Additionally, implementing research findings into clinical practice and ensuring women are receiving appropriate care is paramount.

Useful links for more information

More on PCOS and management:

  • NHS website for PCOS: https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/
  • NICE guidelines for PCOS: https://cks.nice.org.uk/topics/polycystic-ovary-syndrome/
  • PCOS charity organisation and support group (UK): https://www.verity-pcos.org.uk/
  • PCOS Awareness Month calendar 2021: https://blog.verity-pcos.org.uk/2021/08/30/pcos-awareness-month-calendar-2021

References:

  1. United Nations, Department of Economic and Social Affairs, Population Division. Contraceptive Use by Method 2019: Data Booklet (ST/ESA/SER.A/435). United Nations; 2019. Available at: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_contraceptiveusebymethod_databooklet.pdf
  2. Carey MS, Allen RH. Non-contraceptive uses and benefits of combined oral contraception. The Obstetrician & Gynaecologist 2012;14:223–8.Available at: https://elearning.rcog.org.uk/sites/default/files/Abnormal%20uterine%20bleeding/Carey_et_al-2012-The_Obstetrician_%26_Gynaecologist.pdf
  3. March WA, Moore VM, Willson KJ, Phillips DI, Norman RJ, Davies MJ. The prevalence of polycystic ovary syndrome in a community sample assessed under contrasting diagnostic criteria. Hum Reprod. 2010;25(2):544-551.
  4. Sharif E, Rahman S, Zia Y, Rizk NM. The frequency of polycystic ovary syndrome in young reproductive females in Qatar. Int J Womens Health. 2016;9:1-10.
  5. de Melo AS, Dos Reis RM, Ferriani RA, Vieira CS. Hormonal contraception in women with polycystic ovary syndrome: choices, challenges, and noncontraceptive benefits. Open Access J Contracept. 2017;8:13-23.
  6. Daniilidis A, Dinas K. Long term health consequences of polycystic ovarian syndrome: a review analysis. Hippokratia. 2009;13(2):90-92.
  7. Asemi Z, Esmaillzadeh A. DASH diet, insulin resistance, and serum hs-CRP in polycystic ovary syndrome: a randomized controlled clinical trial. Horm Metab Res. 2015;47(3):232-238.
  8. Barbieri RL, Ehrmann DA. Treatment of polycystic ovary syndrome in adults. Uptodate. 2014. Available at: https://www.uptodate.com/contents/clinical-manifestations-of-polycystic-ovary-syndrome-in-adults
  9. Fauser BC, Tarlatzis BC, Rebar RW, et al. Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012;97(1):28-38.e25.
  10. Elting MW, Korsen TJ, Bezemer PD, Schoemaker J. Prevalence of diabetes mellitus, hypertension and cardiac complaints in a follow-up study of a Dutch PCOS population. Hum Reprod. 2001;16(3):556-560. doi:10.1093/humrep/16.3.556
  11. Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2010;16(4):347-363.
  12. Yildiz BO. Oral contraceptives in polycystic ovary syndrome: risk-benefit assessment. Semin Reprod Med. 2008;26(1):111-120.
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