Contraceptive choices for women with endocrine complications

Abstract

Previous confusion regarding the interference by oral contraceptives in measurements of endocrine function have been largely eliminated by the advent of improved, more sensitive assays. There are few if any contraindications to oral contraceptive use in patients with thyroid disease. Patients with prolactinoma can be treated with bromocriptine to restore fertility and prevent mineral loss. However, as a less expensive alternative, oral contraceptives can be prescribed to correct mineral loss, because there is no convincing evidence of an adverse effect on prolactinomas by the steroidal content of the pill. Oral contraceptives comprise a near ideal treatment modality for women with polycystic ovary disease because, among other effects, oral contraceptives reduce synthesis of androgen by inhibiting pituitary gonadotropin secretion.

PIP: The steroids in oral contraceptives (OCs) can change the synthesis of binding globulins for three major classes of hormones, thus physicians often cannot use the traditional measurements to evaluate endocrine disease. They should consider this when trying to expand their knowledge on contraception in women with endocrine conditions. Thyroid disease does not preclude OC use, but untreated thyroid disease may increase fetal morbidity and mortality. Women whose thyroid dysfunction is under control can use any contraceptive method. A does of 7.5 mg/day bromocriptine restores ovulation and normal plasma estrogen levels and reduces tumor size in women with prolactinoma (microadenomas are common and tend to be benign while macroadenomas are rare, but tend to be malignant) who do not want to become pregnant. OCs also restore ovulation and prevent bone mineral loss, but they do not reduce tumor size. Physicians do not agree on how to manage prolactinoma in pregnant women. Androgen excess is associated with polycystic ovarian syndrome (POC), the leading symptoms being hirsutism, acne, and abnormally infrequent menstruation. OCs are the most common and cost effective means to suppress gonadotropin secretion which, left unchecked increases ovarian androgen production. The most effective OCs are those with a progestin component which does not significantly affect androgenic activity. Newer progestins appear to have high specificity for the progestin receptor and reduced affinity for the androgenic receptor, thus someday they can perhaps effectively treat POCs. Gonadotropin-releasing hormone superagonists can induce the same effect as OCs, but tend to be cost prohibitive ($300-$500/month). Women with POCs are quite vulnerable to cardiovascular risk factors (e.g., hypertension and insulin resistance). Women with POCs should avoid use of IUDs and progestin-only implants.