Contraception in Endometriosis and PCOS

Endometriosis and polycystic ovary syndrome are common gynaecological conditions in which contraceptives serve both as pregnancy prevention and as treatment. In endometriosis the aims are pain control and suppression of disease progression; in polycystic ovary syndrome the aims are cycle regulation, endometrial protection, control of hyperandrogenism and attention to metabolic risk.

Endometriosis. Cyclical or chronic pelvic pain, dysmenorrhoea, dyspareunia, dyschezia, dysuria and subfertility. Diagnosis may be clinical, with ultrasound or laparoscopy where available.

Polycystic ovary syndrome. Irregular or absent ovulation, clinical or biochemical hyperandrogenism (hirsutism, acne, alopecia) and polycystic ovarian morphology, with other causes excluded.

Assessment. Pain pattern and severity, bleeding pattern, hirsutism and acne, BMI, blood pressure, glucose and lipids, family history of diabetes, smoking, migraine, thrombosis risk, fertility intention, and mood. Exclude pregnancy, thyroid disease, hyperprolactinaemia and non-classical congenital adrenal hyperplasia where relevant.

Endometrial protection. In polycystic ovary syndrome with fewer than 3 or 4 withdrawal bleeds each year, long-term unopposed oestrogen raises endometrial hyperplasia and cancer risk, so a progestin is needed.

Effectiveness. First-year pregnancies per 100 women with typical use: implants 0.05, intrauterine devices 0.2 to 0.8, injectables 3, combined pills 8.

Eligibility.

Method comparison. In endometriosis, the levonorgestrel device, implants, DMPA and continuous combined pills give pain control; the copper device is not used for pain. In polycystic ovary syndrome, combined pills are first-line for cycle control, acne and hirsutism in eligible patients, and the levonorgestrel device provides endometrial protection without oestrogen.

Metabolic risk. Polycystic ovary syndrome is associated with insulin resistance and obesity; eligibility follows the diabetes and obesity categories. Combined pills have a small effect on lipids and glucose and are acceptable in most patients.

Interactions. Antiseizure medicines, rifampicin and efavirenz lower pill and implant effect and favour an intrauterine device or DMPA.

Special groups. Adolescents with severe dysmenorrhoea are treated early. Patients planning pregnancy need fertility counselling; polycystic ovary syndrome does not prevent pregnancy.

Regimen lines.

• Levonorgestrel 52 mg device: 5 years; insertion within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks, up to 4 weeks late; backup 7 days if started after day 7 of bleeding.

• Combined pill with ethinylestradiol 30 micrograms and levonorgestrel 150 micrograms: cyclical (21 days then a 7-day break) or continuous or extended (active tablets daily for 63 or more days, then a 7-day break); backup 7 days if started after day 5 of bleeding; the usual combined pill missed-pill rules apply.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• Analgesia for dysmenorrhoea: ibuprofen 400 mg orally every 6 to 8 hours with food, or mefenamic acid 500 mg three times daily during menses.

Surgery and referral. Laparoscopic excision or ablation is used for persistent pain, endometriomas or infertility, with contraception or suppression continued afterwards.

Follow up. Review pain scores, bleeding, hirsutism, weight, glucose, blood pressure and satisfaction at 3 months, then yearly.

Breakthrough bleeding on continuous regimens. Common in the first 3 to 6 months; exclude pregnancy and infection, allow a 4-day hormone-free break if bleeding persists, and continue.

Ovarian cyst or endometrioma. Functional cysts resolve; persistent or complex cysts need ultrasound review and specialist referral.

Thrombosis and cardiovascular risk. Stop combined methods for leg swelling, chest pain, migraine with aura or uncontrolled hypertension.

Endometrial hyperplasia. Abnormal or persistent bleeding in polycystic ovary syndrome with long amenorrhoea needs endometrial assessment.

Red flags. Acute severe pelvic pain, ruptured or torted cyst, heavy bleeding with anaemia, rapid virilisation.

Referral and escalation. Refer refractory pain, endometriomas, suspected endometrial hyperplasia, rapidly progressive hirsutism, and infertility to gynaecology and endocrinology.