Wave of the Future: Using Precision Medicine to Illuminate Side Benefits
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Post written by guest blogger Megan Christofield, MPH, Technical Advisor, Jhpiego
Personally, I love the idea of side benefits. Perhaps that’s because my own hormonal IUD has afforded me one of the best side benefits out there– no menstruation. For five straight years I’ve been lucky to avoid the monthly chore of period management and everything that comes along with it: costs, inconvenience, and so on. Amenorrhea (the absence of monthly bleeding) may not be for everyone, but for me it’s been a real benefit.
I use the word lucky purposefully. A 2019 meta-analysis found that only about 20% of hormonal IUS users experience amenorrhea for over 90 days within the first year after insertion. I don’t know why I am the 1 in 5 who experiences contraceptive-induced amenorrhea. No one does. But I can imagine the possibilities if others had advance notice that they’d be among the 20%: perhaps it would be enough to tip the scales for a potential user who is unsure whether the insertion procedure – sometimes painful – will be worth it in the end. Or perhaps it would be the relief needed by a potential user who’s struggled to afford monthly pads and tampons. Or even the assurance of less disruption to daily activities for a potential user who usually suffers from intense menstrual cramping. Our reality, however, is that a user cannot know the exact side effects or side benefits they’ll experience on any method before they embark on its use. Decades of research have generated important population incidence rates of contraceptive side effects and drug interactions, but ambiguity is the standard for individual users. This leaves contraceptive choice often an arduous game of contraceptive trial and error. For example, a large-scale analysis found that the average American woman tries three different methods of contraception by age 40, and 30 percent try five or more methods by that age. Even trial and error, however, is beyond the reach of many – and thus in cases where switching is not an option, method dissatisfaction often results in discontinuation.
Now imagine if everyone could obtain personalized predictions on contraceptive efficacy, side effects, and non-contraceptive benefits from each contraceptive method prior to embarking on its use. Instead of trial and error, imagine if each of us were provided a full list of contraceptives, and alongside them, a personalized estimate of effectiveness and the likelihood of certain side effects and non-contraceptive benefits for each method. With a list like that, I might not have tried four other methods before landing on the hormonal IUD. With a list like that, we could see better contraceptive fit, less discontinuation, and fewer periods of risk for unintended pregnancy – yielding great benefits at the individual and population levels.
The science behind this fantasy is the field of pharmacogenomics, an area of precision medicine. Pharmacogenomics reveals how genetic differences influence people’s unique responses, like efficacy and tolerability, to specific medications. To date, advances have primarily focused on oncology, psychiatry, and cardiac drugs. Last year, the FDA even cleared the first at-home DNA test to assess personalized drug response to certain medications, like a popular blood thinner. Pharmacogenomic applications in reproductive health have been sparse. But last year, researchers at the University of Colorado shared results from a study that explored etonogestrel concentrations in women using etonogestrel-containing implants (i.e. Nexplanon) and found that the likelihood of contraceptive failure was higher for women with a certain genetic variant. There have also emerged a series of companies using big genetic datasets to predict a variety of reproductive health risks and outcomes around fertility, like Celmatix, Modern Fertility, and a host of others. Pharmacogenomics hasn’t yet revealed findings for contraceptive side effects or side benefits, but it’s a fast-moving field where opportunity abounds.
Non-genetic based approaches to precision contraceptive choice also exist, like the website The Lowdown. The Lowdown is built to leverage big data on individuals’ stated experience with various methods and share it back with potential users. They market themselves as “like Trip Advisor, but for The Pill”. They crunch data and display trends on specific experiences like weight change, sex drive, periods, and moods changes reported by their participants. This reveals not only trends in side effects, but side benefits as well. The Lowdown doesn’t pass into the personalization space yet, but because it’s built on a big data approach, it appears that it could be taken that direction.
The future could bring incredible opportunities to highlight side benefits of existing contraceptive choices for individual users, and minimize unnecessary trial and error. Also exciting, side benefits could get us better new methods: As users recognize and make contraceptive choices that consider side benefits, those contraceptive behaviors signal new market opportunities to those working in product development. And that makes side benefits even more….beneficial.