Contraception for a Patient with an Ovarian Cyst
Combined oral contraceptives (OCPs) containing 30-35 μg ethinyl estradiol are the recommended contraceptive choice for a patient with an ovarian cyst, as they provide effective contraception while also reducing the risk of future functional cyst formation. 1, 2
Rationale for Combined Oral Contraceptives
OCPs do not treat existing functional ovarian cysts - multiple randomized controlled trials demonstrate that combined oral contraceptives do not hasten resolution of functional ovarian cysts, and most cysts resolve spontaneously within 2-3 cycles regardless of treatment 3
OCPs prevent future cyst formation - combined oral contraceptives significantly reduce the risk of developing new functional ovarian cysts, with a relative risk of 0.22 (78% reduction) compared to women not using hormonal contraception 4
Monophasic formulations with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate are the preferred first-line option, as they provide reliable ovulation suppression which is the mechanism for cyst prevention 2, 5
Why NOT Progesterone-Only Pills
Progesterone-only pills (POPs) actually increase the risk of functional ovarian cysts - POPs inhibit ovulation in only about 50% of cycles, and studies show an 8-fold increased incidence of functional ovarian cysts (38% vs 5% in controls) among POP users 1, 6
POPs allow follicular development to continue without consistent ovulation suppression, leading to enlarged follicles that meet criteria for functional cysts (>25-30mm) 6
These cysts are often symptomatic, with pain reported in 11 of 14 POP users who developed cysts in one study 6
Why NOT IUD (Copper or Levonorgestrel)
Copper IUDs provide no hormonal suppression of ovulation and therefore offer no protective effect against functional ovarian cyst formation - prevalence rates are similar to women using no contraception 4
Levonorgestrel IUDs may be considered if the patient has contraindications to estrogen-containing contraceptives, though they provide less consistent ovulation suppression than combined OCPs 1
The levonorgestrel IUD is classified as Category 1 (no restriction) for ovarian cancer in the U.S. Medical Eligibility Criteria, but this addresses cancer risk, not functional cyst management 1
Management Approach
Watchful waiting for 2-3 cycles is appropriate for the existing cyst while initiating combined OCP therapy, as most functional cysts resolve spontaneously 3, 7
If the cyst persists beyond 2-3 cycles, surgical evaluation is indicated as persistent cysts are more likely to be pathological (endometrioma, dermoid, cystadenoma) rather than functional 3
No examinations or tests are required before initiating OCPs in healthy women, though baseline blood pressure and BMI may be useful for monitoring 1
Backup contraception is needed for 7 days if OCPs are started more than 5 days after menses begins 1
Safety Considerations
Screen for venous thromboembolism (VTE) risk factors before prescribing combined OCPs, as they increase VTE risk 3-4 fold 2, 5
Smoking is not a contraindication in women under age 35 5