Alternatives to Hormonal Contraceptives

The results of a large Danish prospective cohort study (1.8 million women followed for an average of 10.9 years) published recently in The New England Journal of Medicine indicate that even low-estrogen oral contraceptives and progestin-only intrauterine devices are associated with an increased risk of breast cancer.  The risk was 20% higher in current or recent users of any hormonal contraceptive, compared to nonusers, and the longer the use, the higher the risk. The absolute difference in risk was small: 13 breast cancers per 100,000 person-years. No increased risk was found among women who had previously used hormonal contraception for less than 5 years (LS Mørch et al. Contemporary hormonal contraception and the risk of breast cancer. N Engl J Med 2017; 377:2228).

News of this study may lead some women to ask if they should keep using their hormonal contraceptive. Our most recent article on contraceptives may be helpful in answering their questions on this subject (Choice of contraceptives. Med Lett Drugs Ther 2015; 57:127). It points out, for one thing, that taking combination oral contraceptives has some non-contraceptive benefits. Women who take them have a reduced risk of both epithelial ovarian and endometrial cancer. This benefit is detectable within one year of use and appears to persist for years after discontinuation. Other benefits include a reduction in dysfunctional uterine bleeding and dysmenorrhea, a lower incidence of ectopic pregnancy and benign breast disease, and an increase in hemoglobin concentrations. Many women also benefit from the convenience of menstrual regularity. All combination oral contraceptives increase sex hormone binding globulin and decrease free testosterone concentrations, which can lead to improvements in hirsutism and acne. Combination oral contraceptives are also often used off-label to treat polycystic ovary syndrome.

Despite the small increase in breast cancer risk and the noncontraceptive benefits, women currently using hormonal contraceptives may ask what their alternatives are. For women currently using a hormonal intrauterine device who want to continue using an IUD, but without the hormones, there is only one choice: the copper-containing ParaGard T 380A is the only nonhormonal IUD currently available in the US. It has a failure rate of less than 1% and remains effective for 10 years, but may cause heavier bleeding and more dysmenorrhea than hormonal IUDs.

For women who choose to stop using oral contraceptives and do not want to switch to an IUD, there are several nonhormonal alternatives, but none as effective and convenient as taking a pill. Use of a diaphragm with spermicide has the advantages of low cost and possibly a lower risk of cervical cancer, but with typical use it has an annual failure rate of 12%. Male condoms protect against sexually transmitted diseases, but they typically have a failure rate of 18% per year, which can be reduced to 2% with perfect use. The sponge is sold without a prescription, require no fitting, and provide 24 hours of protection, but it has an even higher failure rate, and if a woman forgets to remove it, they can develop toxic shock syndrome. Spermicide alone has an 18% failure rate even with perfect use.

The bottom line on alternatives is that the only highly effective, nonhormonal, reversible contraceptive is the copper IUD. With perfect use, male condoms are almost as effective, and they offer the advantage of protection against sexually transmitted disease.

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  1. Mark Mailhot, MD says:

    I read your article on alternatives to hormonal contraceptives and could not help noting the omission of Natural Family Planning (NFP). NFP is a safe, non-hormonal method of either planning or avoiding pregnancy that has been shown in studies to be as effective as hormonal methods. There are various different NFP techniques, including the Billings, Creighton and Symptothermal Methods. More than the “Rhythm” or Calendar method, these techniques are based on recognizable symptoms and signs that occur during the menstrual cycle. If you are not familiar with NFP I urge you to look into this safe and healthy alternative.

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