Is it safe to use a hormonal Intrauterine Device (IUD) in patients with a history of breast cancer?

Hormonal IUD Use in Patients with Breast Cancer History

For patients with a history of breast cancer, copper IUDs are recommended over hormonal IUDs due to the potential risk of cancer progression with hormonal options. 1

Safety Assessment of IUD Types in Breast Cancer Patients

Copper IUD

• Category 1 (no restriction for use) for patients with current or past breast cancer 1
• Provides highly effective contraception without hormonal effects
• Safe option regardless of time since breast cancer diagnosis

Levonorgestrel IUD (Hormonal)

• Category 4 (unacceptable health risk) for patients with current breast cancer 1
• Category 3 (risks usually outweigh benefits) for patients with past breast cancer within 5 years 1
• Concern exists about potential progression of hormone-sensitive tumors 1

Decision Algorithm for Contraception in Breast Cancer Patients

1. Current breast cancer diagnosis:

   • Copper IUD: Recommended (Category 1)
   • Hormonal IUD: Contraindicated (Category 4)

2. History of breast cancer within past 5 years:

   • Copper IUD: Recommended (Category 1)
   • Hormonal IUD: Generally not recommended (Category 3)

3. History of breast cancer >5 years ago with no evidence of disease:

   • Copper IUD: Recommended (Category 1)
   • Hormonal IUD: Generally not recommended (Category 3), though risk is lower than with current disease

Evidence Quality and Considerations

The U.S. Medical Eligibility Criteria for Contraceptive Use provides clear guidance on this topic 1. These recommendations are based on the understanding that breast cancer is a hormonally sensitive tumor, and exposure to hormones, even locally delivered ones like in a levonorgestrel IUD, may potentially influence disease progression or recurrence.

The Society for Maternal-Fetal Medicine guidelines confirm that for women with current breast cancer, "the levonorgestrel IUD and etonogestrel implant are category 4, but the copper IUD is category 1" 1.

Recent research has raised additional concerns about hormonal contraception and breast cancer risk. A 2017 nationwide prospective cohort study found that women who used the progestin-only intrauterine system had a higher risk of breast cancer than women who had never used hormonal contraceptives (relative risk, 1.21; 95% CI, 1.11 to 1.33) 2.

Important Clinical Considerations

• The European Society for Medical Oncology (ESO-ESMO) guidelines specifically state that "exogenous hormonal contraception is generally contraindicated in breast cancer survivors" 1
• The guidelines recommend alternative strategies including barrier methods and copper IUDs 1
• The safety of levonorgestrel-releasing IUDs in breast cancer patients remains controversial, with some studies suggesting increased risk 1

Key Pitfalls to Avoid

1. Don't assume local hormone delivery means systemic effects are negligible - Even with primarily local effects, there is concern about potential systemic absorption of hormones from LNG-IUDs

2. Don't overlook the high efficacy of copper IUDs - They provide comparable contraceptive efficacy to hormonal IUDs without the potential cancer risks

3. Don't delay contraception counseling - Effective contraception is essential during cancer treatment due to teratogenic risks of many therapies 1

4. Don't assume all IUDs are equivalent - The distinction between copper and hormonal IUDs is critical in breast cancer patients

For patients with a history of breast cancer who need contraception, the copper IUD represents the safest and most effective option according to current guidelines.