Post written by Lillian Rountree and Margaret Gaw, interns at FHI 360
Last year, the CTI Exchange launched a blog series on rethinking contraceptive side effects that explored underappreciated and non-contraceptive health and lifestyle benefits of methods, both currently available and those under development. Contraceptives have many potential advantages for health, but not all get equal attention. In contraceptive research and development, more studies and conversations are needed to investigate the use of contraceptives to address health benefits other than preventing pregnancy. This post focuses attention specifically on the use of hormonal contraceptives for individuals with endometriosis, polycystic ovarian syndrome (PCOS), and premenstrual dysphoric disorder (PMDD), three menstrual disorders that, despite their differing origins, pathogeneses, and symptoms, can often be effectively managed with hormonal contraceptives. We hope to raise awareness about the current status of research aiming to understand these disorders, the extent to which contraceptives help or hinder when part of treatment options for individuals experiencing these health concerns, and the potential role of contraceptive researchers in this area.
Endometriosis
Endometriosis is one of the most common and researched menstrual disorders, in which the tissue that normally lines the uterine cavity grows outside of the uterus, on other organs inside the pelvis, or sometimes, the abdomen. Much about endometriosis, including its pathogenesis, is still unknown. This dearth of information can spell a long road for up to 17% of reproductive-age menstruators affected worldwide. Individuals with endometriosis can face intense and disruptive pain, and approximately half of them suffer negative impacts on fertility. Many providers prescribe hormonal contraceptives (HCs), particularly those composed of certain progestins, to alleviate symptoms. The use of HCs has been shown to alleviate dysmenorrhea and pelvic pain, and they have become a common first line of treatment prescribed by providers, though an off-label one: very few HCs are explicitly cleared for endometriosis pain management by the FDA. For many, HCs are a welcome, effective, and non-invasive option—if they can be obtained—to treating their pain. Yet HCs are far from a perfect fix: up to a third of individuals with endometriosis will not find symptom relief from HCs, and they do not address infertility caused by the disorder. Beyond HCs, the treatment landscape for endometriosis is similarly imperfect: while there are other holistic strategies for pain management, such as changes in diet and nutrition, physical therapy, and acupuncture, done alone they can prove insufficient for addressing the severity of symptoms. Surgery exists but is far from an attractive option. Only a handful of practitioners are trained in the current gold standard, excision surgery, in comparison to the more common—and less effective—options of ablation surgery or a last-line hysterectomy.
Polycystic Ovarian Syndrome
Polycystic ovary syndrome (PCOS)—a condition in which numerous small cysts form in the ovaries—is a hormonal disorder affecting an estimated 4 to 20% of menstruators globally each year, a proportion that has increased over the last decade due in part to both better diagnostics and rising rates of people with diabetes (which has been associated with PCOS). Though it is known that family history of PCOS plays a significant role, more research is needed for investigating the exact genetic and environmental factors that may increase risk of developing PCOS. A current theory is that an excess of insulin or low-grade inflammation in individuals with PCOS leads to excessive production of androgen (male hormone), which impacts the regular release of eggs. Common symptoms and signs of PCOS include infrequent, irregular or prolonged menstrual periods; excess facial and body hair (hirsutism), weight gain, thinning hair, and acne. People with PCOS are also more likely to develop such health problems as infertility, diabetes, heart disease, hypertension, depression, and endometrial cancer.
Current treatments respond to the symptoms of PCOS rather than the root of the disorder due to how little is known about its origins. Combined oral contraceptives are often used in the treatment of PCOS because they can regulate periods, lessening the toll of painful, heavy, or irregular periods caused by PCOS; they can also counteract the effects of excess androgens, improve acne and lower the risk of endometrial cancer. Medications given to induce ovulation and increase fertility include clomiphene, often in combination with antidiabetic agents, and hormones such as gonadotropins. Beyond medication, self-care—exercise, good diet, and healthy habits—is key in managing PCOS.
Premenstrual Dysphoric Disorder
Premenstrual dysphoric disorder (PMDD) is a cyclical mood disorder affecting around 3 to 8% of reproductive-age menstruators. The exact cause of PMDD is unknown, but it is believed to be triggered by an increased sensitivity to the hormonal changes that occur each menstrual cycle, seven to 10 days before one’s period starts. It can cause mood swings, irritability, anger, anxiety, fatigue, and feelings of hopelessness or being out of control that, as those with PMDD attest, can be life-ruining.
Treatment of PMDD is directed at minimizing symptoms and includes antidepressants or/and medications that prevent ovulation. Oral contraceptive pills containing a combination of drospirenone and low dose of ethinyl estradiol are an effective first-line treatment for those with PMDD. Yet many other HC methods that suppress ovulation and prevent regular hormonal fluctuation that follows have not been shown to alleviate symptoms of PMDD. The reasons for such mixed efficacy are unclear. Fortunately, use of antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), is another evidence-based, effective treatment option for PMDD and is currently considered a gold standard. They can be taken either continuously, intermittently (only during ~ 10 days preceding menstruation), or at symptom onset. A hysterectomy with a bilateral oophorectomy is another, surgical treatment option.
Contraceptives and Menstrual Disorders: Are side benefits enough?
Though these three disorders all have different pathogeneses, hormonal contraceptives are still effective in managing symptoms. Given this, promoting these “side benefits” for current and new contraceptive technologies should be promoted through family planning programs globally. In addition, research and product developers should understand these "side benefits" and use this as a starting point for further research. While public awareness, research, and designated funding for these three menstrual disorders continue to grow, currently there are very few treatment options that are specifically designed to treat these disorders, even though they affect millions. Potential directions include:
Better understanding what makes certain existing HCs, particularly combined oral contraceptives, so effective in managing symptoms, alongside in-depth exploration of other contraceptive options. Understanding what makes current HCs effective for disorder management can then inform those developing new hormonal methods, shaping these methods’ potential design and use.
Contraceptive methods with longer duration of action can decrease the requirement for ongoing access to care (to obtain more pills or receive injections) and improve contraceptive adherence, which in turn can improve the menstrual symptoms of affected individuals. Thus, more research is needed on the efficacy of existing long-acting reversible hormonal contraceptives such as implants or hormonal IUDs in managing these disorders.
For those who want to space or prevent childbearing, HCs can be an excellent solution for preventing both pregnancy and managing disorder symptoms. However, there is also a need for research on treatment options that have no effect on fertility, as many women with these disorders do not wish to also prevent pregnancy. For disorders that cause such pain in such large populations, the advice to “just take some birth control” can seem—while remaining a genuinely viable form of pain management—an unideal fix.
Developing additional contraceptive options that offer improved treatment options for menstrual disorders and are accessible and acceptable, especially for individuals without access to the invasive, expensive, and/or specialized procedures used for treatment. As more research and funding are committed to endometriosis, PCOS, and PMDD, contraceptive product developers should also reconsider the way and reasons HCs are used for menstrual disorders, taking these side benefits as potential starting points for developing more tailored treatment options and seeing them as an opportunity to better understand HCs’ overall impact on users’ health and wellbeing.
Photo credit: The Pill Club