Contraception and Breast Cancer

Breast cancer can be hormone-receptor positive, and current or past disease makes hormonal methods unsafe. Patients still need highly effective contraception during chemotherapy, endocrine therapy and the years after, because pregnancy can worsen prognosis, cause foetal harm, and interfere with treatment.

Assessment. Receptor status, stage, treatment (surgery, radiotherapy, chemotherapy, tamoxifen, aromatase inhibitors, ovarian suppression), time since diagnosis, menopausal status, BRCA status, current method and pregnancy intention.

Undiagnosed breast mass. Hormonal methods may be started with category 2 while evaluation is arranged; copper methods are unaffected.

Past breast cancer. No evidence of disease for at least 5 years is category 3 for hormonal methods; earlier is category 4.

Endocrine therapy. Tamoxifen is not contraception and is teratogenic; aromatase inhibitors are used after menopause or with ovarian suppression and do not remove pregnancy risk when ovarian function persists.

Effectiveness. The copper T 380A is over 99% effective.

Eligibility.

Method comparison. The copper T 380A is the method of choice because it is non-hormonal, long-acting and safe. Condoms and sterilisation are alternatives. All hormonal methods are avoided during active disease and treatment.

Heavy bleeding with copper. Treat with ibuprofen 800 mg three times daily for 5 days and tranexamic acid 500 mg three times daily for 5 days if thrombosis risk is low; chemotherapy-related thrombocytopenia may need haematology input.

Special groups. Premenopausal women on tamoxifen may have irregular bleeding and need endometrial surveillance for postmenopausal or persistent bleeding. Women on chemotherapy may have infection risk at intrauterine insertion and need counselling.

Regimen lines.

• Copper T 380A: up to 12 years; insert within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup; defer insertion during neutropenia.

• Male or female condoms at every act: add to any method for STI protection.

• Emergency contraception: the copper T 380A within 5 days; if oral treatment only is available, levonorgestrel 1.5 mg within 120 hours, which may be used once after counselling.

• Sterilisation: tubal occlusion or vasectomy for the partner once fertility goals are settled.

• Hormonal methods: not used while cancer is current or within 5 years.

Fertility planning. Discuss fertility preservation before gonadotoxic therapy; pregnancy after breast cancer is possible after an interval chosen with the oncologist, commonly 2 years or more.

Switching. If a hormonal method is in use at diagnosis, stop it and insert a copper device, using condoms for 7 days.

Follow up. Review at oncology visits for method, bleeding and pregnancy intention.

Pregnancy during treatment. Decisions on stopping teratogenic therapy are made with the oncologist; refer urgently for counselling and options.

Bleeding on tamoxifen. Evaluate persistent or postmenopausal bleeding with ultrasound and endometrial sampling.

Infection after insertion. Treat pelvic infection with antibiotics and remove the device if no improvement within a few days.

Red flags. New breast lump, bone pain, jaundice, severe headache, postmenopausal bleeding.

Referral and escalation. Refer any breast mass, suspected recurrence, pregnancy, and unexplained bleeding to oncology and gynaecology.