What are the birth control options for a patient with a history of ovarian cysts?

Birth Control Options for Patients with a History of Ovarian Cysts

Combined oral contraceptives (COCs) are the recommended birth control method for patients with a history of ovarian cysts, as they provide highly effective contraception while preventing new functional cyst formation through ovulation suppression, though they do not treat existing cysts. 1

Primary Recommendation: Combined Oral Contraceptives

Mechanism and Prevention Benefits

• COCs are the most effective birth control method for reducing the risk of new functional ovarian cysts by suppressing ovulation and eliminating the physiological process that leads to functional cyst formation. 1
• The prevention of ovulation means no corpus luteum formation and no follicular development beyond the early stages, which are the primary sources of functional cysts. 1

Specific Formulation Recommendations

• Start with a monophasic COC containing 30-35 μg of ethinyl estradiol combined with levonorgestrel or norgestimate. 1, 2
• Monophasic formulations provide consistent hormone levels throughout the cycle, which optimizes ovulation suppression. 1
• Standard pill packs include 21-24 hormone pills followed by 4-7 placebo pills, though extended or continuous regimens can be used. 1

Additional Benefits Beyond Cyst Prevention

• COCs decrease menstrual cramping and blood loss, which may be beneficial if the patient has had symptoms from previous cysts. 1
• They improve acne and provide protection against endometrial and ovarian cancers with use for more than 3-4 years. 1
• Extended or continuous cycle regimens may benefit patients with anemia, severe dysmenorrhea, endometriosis, or abnormal uterine bleeding. 1

Alternative Hormonal Options

Contraceptive Vaginal Ring

• The contraceptive vaginal ring (NuvaRing) releases 15 μg ethinyl estradiol and 120 μg etonogestrel daily, providing comparable effectiveness to COCs with a simpler once-monthly insertion regimen. 1
• This option is suitable for patients who prefer not to take daily pills or have difficulty with adherence. 1

Progestin-Only Options

• Progestin-only pills (norethindrone 0.35 mg) prevent conception by suppressing ovulation in approximately half of users, thickening cervical mucus, and altering the endometrium. 3

• The typical failure rate is approximately 5% due to the narrow window for taking pills (must be taken at the same time daily). 3

• This option is appropriate for patients with contraindications to estrogen-containing contraceptives. 3

• Depot medroxyprogesterone acetate (DMPA) 150 mg intramuscularly every 12 weeks can be used, though it causes fluid retention and is inappropriate for patients with heart failure. 2, 4

Levonorgestrel IUD

• The levonorgestrel IUD provides highly effective long-acting contraception and results in 71-95% reduction in menstrual blood loss. 4
• Backup contraception is needed for 7 days only if inserted more than 7 days after menses starts. 2, 4

Critical Safety Considerations

Contraindications to COCs

• Do not prescribe COCs for patients with severe uncontrolled hypertension, ongoing hepatic dysfunction, complicated valvular heart disease, migraines with aura, thromboembolism or thrombophilia. 1
• The risk of venous thromboembolism increases from 1 per 10,000 to 3-4 per 10,000 woman-years during COC use. 1
• Blood pressure should be monitored at follow-up visits. 2

Managing Common Side Effects

• Common transient side effects include irregular bleeding, headache, and nausea, typically resolving within 3-6 months. 1
• For unscheduled spotting or light bleeding with COCs, NSAIDs for 5-7 days may help. 1
• If breakthrough bleeding occurs with extended regimens, a 3-4 day hormone-free interval can be taken (but not during the first 21 days of use and not more than once per month). 2

Important Clinical Pitfalls

COCs Do Not Treat Existing Cysts

• Although widely used historically for treating functional ovarian cysts, combined oral contraceptives provide no benefit in hastening resolution of existing cysts. 5, 6
• This finding held true for cysts that occurred spontaneously as well as those that developed after ovulation induction. 5, 6
• Most functional cysts resolve without treatment within two to three cycles through watchful waiting. 5, 6
• Persistent cysts beyond 2-3 cycles tend to be pathological (endometrioma or para-ovarian cyst) rather than physiological and often require surgical management. 5, 6

Evaluation of Persistent Cysts

• If a patient presents with an existing ovarian cyst, watchful waiting for 2-3 cycles is appropriate before considering surgical intervention. 5, 6
• Transvaginal ultrasound is the preferred imaging modality for evaluating ovarian cysts. 7
• Fine-needle aspiration for cytological examination of ovarian masses (solid or mixed) is contraindicated. 8

Special Population: PCOS

• For patients with polycystic ovary syndrome (PCOS), COCs are recommended for long-term management, with benefits including suppression of ovarian androgen secretion and increase in sex hormone binding globulin. 8, 1
• COCs also reduce the risk of endometrial cancer in PCOS patients, though the extent of this effect is not fully quantified. 8