Quiz: Risks and benefits of hormonal contraception

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This month's quiz reviews some of the major takeaways from Dr. Lockwood's May 2018 editorial, Risks and benefits of hormonal contraception.

Which of the following statements about combined oral contraceptives (OCPs) is not true?

a.   Risk of VTE is increased in users compared to non-users.

b.   Estrogen is the major influence on the effects of OCP use.

c.   There appears to be a modest link in incidence of breast cancer among women who use progestin-containing contraceptives. 

d.   Studies from the mid-1990s show that women who began OCPs after age 20 had a higher relative risk of breast cancer

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Answer: D. Studies from the mid-1990s show that women who began OCPs after age 20 had a higher relative risk of breast cancer.

Studies conducted in 1996 by the Collaborative Group on Hormonal Factors and Breast Cancer noted that, although the absolute risk of cancer was low, women who showed a higher relative risk of developing breast cancer are those who began OCPs prior to age 20.

2. Benefits of hormonal contraception include:

a.   Lower overall rates of cancer, including colon, endometrial, and ovarian cancers.

b.   Treatment of dysmenorrhea, polycystic ovarian disease-associated hirsutism, acne, and anovulatory bleeding.

c.   Reduction in menorrhagia

d.   All of the above

e.   All except C

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Answer: D. All of the above

Benefits of hormonal contraception include all of the above. Progestin-containing IUDs are an effective treatment for menorrhagia.

3. Older studies of OCPs and breast cancer:

a.   Included patients who were taking higher-dose formulations of OCPs
b.   Showed that cancers among OCP users tended to be later-stage, higher-risk lesions.
c.   Are consistent in their observations that showed significant association between use of OCPs and breast cancer.
d.   Reported that specific use of triphasic levonorgestrel formulations of OCPs was associated with a significantly lower risk of breast cancer.

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Answer: A. Included pateints who were taking higher-dose formulations of OCPs

One of the major criticisms of older studies such as the Nurses’ Health Study  that showed elevated risks of breast cancer was that they included patients who were taking OCPs at higher doses than are in current products. In addition, other large observational and case-control studies have shown no association between current and past use of OCPs and breast cancer.^1,2

4. What do more recent studies of OCPs and breast cancer reveal?

a.   The risk of breast cancer increased with duration of exposure to OCPs
b.   After stopping use of OCPs, risk of breast cancer decreased but did not disappear entirely.
c.   The results were not altered when risks were adjusted for body mass index (BMI) or smoking.
d.   A and B
e.   All of the above

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Answer: E. All of the above.

All of the choices are true according to a recent large prospective Danish study by Mørch and colleagues.³

5. What important points should the practitioner keep in mind about use of OCPs?

a.    Studies have shown that there is a significant difference in breast cancer risks between different OCP formulations.

b.   Unfortunately, the increased incidence of breast cancer among users of progestin-containing contraceptives does not decrease even after a patient stops using OCPs.

c.    Switching from hormonal contraceptives to non-hormonal methods of birth control, such as copper IUDs, tubal ligation and barrier methods, is a prudent choice to help decrease incidence of breast cancer in women over 35.

d.   All of the above are true.

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Answer: C. Switching from hormonal contraceptives to non-hormonal methods of birth control, such as copper IUDs, tubal ligation and barrier methods, is a prudent choice to help decrease incidence of breast cancer in women over 35.

Because most breast cancers occur in women over age 40, switching to non-hormonal forms of birth control can be a good strategy for decreasing incidence of breast cancer in these patients.

References:

• Vessey M, Yeates D. Oral contraceptive use and cancer: final report from the Oxford-Family Planning Association contraceptive study. Contraception. 2013 Dec;88(6):678-83.

• Marchbanks PA, McDonald JA, Wilson HG, et al. Oral contraceptives and the risk of breast cancer. N Engl J Med. 2002 Jun 27;346(26):2025-32.

• Mørch LS, Skovlund CW, Hannaford PC, Iversen L, Fielding S, Lidegaard Ø. Contemporary hormonal contraception and the risk of breast cancer.  N Engl J Med. 2017 Dec 7;377(23):2228-2239.