Hormonal contraception in women with polycystic ovary syndrome: choices, challenges, and noncontraceptive benefits

Open Access Journal of Contraception Dovepress open access to scientific and medical research REVIEW Open Access Journal of Contraception downloaded from https://www.dovepress.com/ by 54.37.111.135 on 12-Jul-2018 For personal use only. Open Access Full Text Article Hormonal contraception in women with polycystic ovary syndrome: choices, challenges, and noncontraceptive benefits This article was published in the following Dove Press journal: Open Access Journal of Contraception 2 February 2017 Number of times this article has been viewed Anderson Sanches de Melo Rosana Maria dos Reis Rui Alberto Ferriani Carolina Sales Vieira Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil Introduction Correspondence: Carolina Sales Vieira Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo, Av. dos Bandeirantes, 3900 - 14049-900 Ribeirão Preto, São Paulo, Brazil Tel +55 16 3602 2818 Fax +55 16 3633 0946 Email Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder with prevalence rates ranging from 5% to 13.9% in women of reproductive age.1,2 PCOS is mainly characterized by chronic anovulation, polycystic ovary morphology, and hyperandrogenism. However, there is considerable interindividual variation in the presentation of diverse clinical and metabolic symptoms that vary across ethnic groups and geographic regions.1,3 Together with lifestyle changes, combined hormonal contraceptives (CHCs) are the first-line management options for clinical manifestations of PCOS, specifically menstrual irregularity, hirsutism, and acne.4–7 CHCs contain an estrogen component (ethynylestradiol [EE], estradiol valerate, or estradiol) and a progestogen component that vary in terms of composition and affinity to receptors of other steroid hormones (mineralocorticoids, glucocorticoids, androgens, and estrogen). Both estrogen and progestogen contribute to management of the clinical manifestations of hyperandrogenism.8,9 13 submit your manuscript | www.dovepress.com Open Access Journal of Contraception 2017:8 13–23 Dovepress © 2017 de Melo et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms. php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/OAJC.S85543 Powered by TCPDF (www.tcpdf.org) Abstract: Polycystic ovary syndrome (PCOS) is an endocrine disorder among women of reproductive age characterized by chronic anovulation and polycystic ovary morphology and/or hyperandrogenism. Management of clinical manifestations of PCOS, such as menstrual irregularities and hyperandrogenism symptoms, includes lifestyle changes and combined hormonal contraceptives (CHCs). CHCs contain estrogen that exerts antiandrogenic p roperties by triggering the hepatic synthesis of sex hormone-binding globulin that reduces the free testosterone levels. 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 also reduce the activity of the 5α reductase enzyme. However, PCOS is related to clinical and metabolic comorbidities that may limit the prescription of CHCs. Clinicians should be aware of risk factors, such as age, smoking, obesity, diabetes, systemic arterial hypertension, dyslipidemia, and a personal or family history, of a venous thromboembolic event or thrombophilia. This article reports a narrative review of the available evidence of the safety of hormonal contraceptives in women with PCOS. Considerations are made for the possible impact of hormonal contraceptives on endocrine, metabolic, and cardiovascular health. Keywords: polycystic ovary syndrome, hormonal contraceptive, lipid metabolism, carbohydrate metabolism, hyperandrogenism, thrombosis Dovepress Open Access Journal of Contraception downloaded from https://www.dovepress.com/ by 54.37.111.135 on 12-Jul-2018 For personal use only. de Melo et al PCOS are associated with clinical and metabolic comorbidities that may limit the prescription of CHCs in women with PCOS. Common risk factors for cardiovascular diseases (CVDs), such as systemic arterial hypertension (SAH), obesity, dyslipidemia, metabolic syndrome (MeTS), and type 2 diabetes mellitus (DM2), can develop in women with PCOS by the fourth decade of life.5,10–12 According to the Medical Eligibility Criteria for Contraceptive Use of the World Health Organization (WHO), some of these comorbidities (MeTS, SAH, DM2 with vasculopathy, and dyslipidemia plus another risk factors) are considered to be category 3 (a condition where the theoretical or proven risks usually outweigh the advantages of using the method) or 4 (a condition which represents an unacceptable health risk if the contraceptive method is used) (Table 1). In both categories, progestogen-only contraceptives (POCs) are typically considered a safer option for women presenting with risk factors for CVD.13 In cases of presenting with contraindications to CHC, POCs or nonhormonal contraceptives13 can be coadministered with antiandrogen medication to control hyperandrogenism symptoms.14 Because of the paucity of data about the impact of CHCs on cardiovascular and metabolic parameters in PCOS patients, most recommendations are based on studies involving ovulatory women. The objective of this narrative review is to present an evaluation of the evidence on available hormonal contraceptives, their noncontraceptive benefits, and adverse effects in women with PCOS, according to the Medical Eligibility Criteria for Contraceptive Use of the WHO.13 A specific focus of this review is considerations for endocrine, metabolic, and cardiovascular health of women with PCOS. Review criteria The PubMed electronic bibliographic database was searched from January 1960 to September 2015 to identify reviews, Table 1 Eligibility criteria of the World Health Organization Category Eligibility Use of the method 1 A condition for which there is no restriction for the use of the contraceptive method A condition where the advantages of using the method generally outweigh the theoretical or proven risks A condition where the theoretical or proven risks usually outweigh the advantages of using the method A condition which represents an unacceptable health risk if the contraceptive method is used. Yes (...truncated)