What is the best contraception for a patient with ovarian cysts?

Best Contraception for Patients with Ovarian Cysts

Combined hormonal contraceptives (CHCs) are the best contraceptive option for patients with ovarian cysts as they provide both contraceptive efficacy and therapeutic benefits for managing ovarian cysts. 1

Understanding Ovarian Cysts and Contraceptive Options

Ovarian cysts are common gynecological findings that may require specific consideration when selecting contraception. The evidence shows:

• CHCs (pills, patch, or ring) provide non-contraceptive benefits including decreased menstrual cramping, reduced blood loss, and improvement in conditions that may be associated with ovarian cysts 1
• Extended or continuous CHC regimens are particularly appropriate for patients with conditions such as endometriosis and abnormal uterine bleeding, which may coexist with ovarian cysts 1
• CHCs help with ovarian suppression, which can prevent the formation of new functional ovarian cysts 1, 2

Specific Recommendations for Patients with Ovarian Cysts

First-Line Option: Combined Hormonal Contraceptives

• Start with a monophasic combined oral contraceptive containing 30-35 μg of ethinyl estradiol and a progestin such as levonorgestrel or norgestimate 1
• Consider extended or continuous regimens to optimize ovarian suppression and minimize hormone fluctuations 1
• Benefits include:
  • Reduced menstrual pain and bleeding
  • Protection against endometrial and ovarian cancers with use >3 years 2
  • Completely reversible with no negative effect on long-term fertility 1

Alternative Option: Vaginal Ring

• The vaginal ring provides comparable efficacy (9% typical-use failure rate) to other CHCs but with a simpler regimen 1
• Releases 15 μg ethinyl estradiol and 120 μg etonogestrel
• Can be particularly convenient for patients who have difficulty with daily pill taking

Alternative Option: Levonorgestrel IUD

• For patients who cannot use estrogen-containing methods
• Very effective contraception (0.1-0.2% failure rate) 3
• May reduce bleeding over time, with approximately 50% of users experiencing amenorrhea or oligomenorrhea by 2 years of use 3

Important Considerations and Caveats

Treatment Expectations for Existing Cysts

• Important caveat: While CHCs can help prevent new functional ovarian cysts, multiple randomized controlled trials show that they do not hasten resolution of existing functional ovarian cysts 4, 5
• Most functional ovarian cysts resolve spontaneously within a few menstrual cycles without specific treatment 5
• Watchful waiting for 2-3 cycles is appropriate for existing cysts; persistent cysts may require surgical evaluation as they are more likely to be pathological 5

Safety Considerations

• The risk of venous thromboembolism with CHCs is 3-4 per 10,000 woman-years, which is still lower than the risk associated with pregnancy (10-20 per 10,000 woman-years) 1
• CHCs are contraindicated in women with certain conditions, including:
  • Women over 35 who smoke
  • History of venous thromboembolism, stroke, or cardiovascular disease
  • Uncontrolled hypertension 3

Follow-up Recommendations

• For patients with existing cysts who start contraception, follow up with ultrasound in 2-3 months to assess cyst resolution
• If cysts persist beyond 2-3 cycles, further evaluation is warranted to rule out pathological cysts 5
• For patients experiencing spotting or bleeding irregularities on hormonal contraception, NSAIDs for 5-7 days may help manage these symptoms 1

In conclusion, while CHCs are the preferred contraceptive method for patients with ovarian cysts due to their preventive benefits and management of associated symptoms, it's important to understand that they will not accelerate the resolution of existing cysts. Proper follow-up and monitoring remain essential components of care.