Combined hormonal oral contraceptives (CHC) have been around since the 1960’s. Concerns about the estrogen component in them and whether they impair bone formation in teenage girls has risen especially since this is the age that bone formation is so crucial.
Researchers conducted a meta-analysis (examined data from several independent studies on the same subject) to compare changes in bone density determined by duel-energy x-ray absorptiometry (DEXA) in healthy adolescent users and nonusers of estrogen-progestin CHC. There were 9 studies that involved a total of 1535 adolescents aged 12-19 years. Pooled analysis showed that the use of estrogen-progestin CHC was associated with significantly lower bone density at 24 months.

So even though findings confirm concerns that combined birth control pills negatively effect bone density in adolescents, I’m not sure we can blame it all on the estrogen component. The dose of hormone that may cause this effect wasn’t clear in the study. Even though the American Academy of Pediatrics are endorsing long-acting reversible contraceptive (LARC) options as being safer and effective, we need to remember that at least one progestin only option (Depo-provera) has been studied and was related to lower bone density. The contraceptive implant known as Nexplanon is also a synthetic progesterone. Both of these progestins are systemically absorbed which is why they are so effective in preventing pregnancy, but do they also effect bone density?

I believe it is still unclear which contraceptive method is best in reference to protecting bone health. We need to consider the costs and benefits of all of these methods. For instance, injectable contraceptives and implants provide effective longterm birth control yet do not involve a daily regimen. So for a women who may not remember or be able to take a pill at the same time daily, an oral birth control pill would not be the choice for her and would increase her risk of an unintended pregnancy. A LARC would be best for this particular patient but I would screen her for other risk factors for bone loss. This includes checking a Vitamin D level, evaluate her calcium and mineral intake as well as her gut health (to make sure she has healthy absorption), and increase weight bearing and strength training exercises.

Screening teens for bone health is always a good idea, but is essential for girls that desire ANY hormonal contraceptive. This will determine a baseline which then can be monitored yearly.

Lopez LM, Grimes DA, Schulz KF, Curtis KM; Chen M. Hormonal contraceptives and bone health in women. Cochrane.org.2014 June.
Goshtasebi A et al. Adolescent use of combined hormonal contraception and peak bone mineral density accrual: A meta-analysis of international prospective controlled studies. Clin Endocrinol (Oxf) 2019 Jan 7; [e-pub].

Breast feeding has documented benefits for both mother and baby (NEJM JW Women’s Health Jul 9 2014; [e-pub] and Am J Obstet Gynecol 2014; 211: 424.el). So when women are choosing birth control methods, it’s important to know the options regarding the effects of hormonal contraception on breast feeding performance, as well as ease of use and safety. The best time to talk about contraceptive options with your practitioner is during your pregnancy.

The CDC has recently updated the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC), which provides guidelines on the safety of available birth control choices for women with specific health conditions. Updates for breast feeding women were included based on risk for venous thromboembolism (VTE) and postpartum days. For instance, using combined oral birth control pills is not recommended within 21 days of delivery (rated category 4) due to the excess risk of VTE. It’s best to wait beyond 12 weeks postpartum to reduce the mother’s risk for blood clots. On the other hand, all progestin-only contraceptive methods are rated category 1 (low risk/no restrictions) or category 2 (advantages of the method generally outweigh its theoretical or proven risks) for breast-feeding women.

Here are some of the best options for breastfeeding moms:

1. Lactational Amenorrhea- This offers an effective temporary method of contraception (until menses return or milk substitutes are introduced). When women do not menstruate, they (usually) do not ovulate and cannot get pregnant. Some women will choose an additional method of contraception even while breast feeding exclusively to make sure they are protected from pregnancy…which I think is a good idea.

2. IUDs- There are several types of IUD’s which are safe and very effective. Some contain copper and others contain a hormone known as progestin, which is a synthetic progesterone. They can be used for many years and all can be removed as soon as you are ready to get pregnant again. An IUD can be placed in the uterus within 10 minutes of placental delivery which is very convenient, but risk for expulsion is higher when inserted this early. Many women prefer to wait until their 6-week follow-up appointment.

3. Implant, Shot, and Progestin-Only Pill- All 3 of these methods use the synthetic hormone Progestin. You can use any of these methods immediately after delivery. The implant is the most effective birth control available; even more effective than sterilization!!. Pregnancy can be achieved after removal of the implant. The Depo shot is also very effective as long as you are able to get the injection (given in the arm or buttocks) every 3 months. The progestin-only pill is least effective than the implant or shot mainly because there is more room for human error. The pill needs to be taken the same time everyday, which can be difficult when you have a baby to care for. A new option for women outside the U.S. is a progestin-only vaginal ring that is effective for about 1 year.

4. Emergency Contraception (EC)-This contraception is used only if your regular method of birth control has failed (forgotten pill, broken condom). If you are 17 years or older, you can get EC pills (Levonorgestrel) at the pharmacy without a prescription. Take them within 3 days of unprotected sex. A prescription-only EC pill, ulipristal acetate can be used up to 5 days after unprotected sex. Ulipristal is more effective than nonprescription EC. Small amounts of ulipristal has been found in breast milk so pumping and discarding breast milk is advised for 24 hours after taking ulipristal EC.
The most effective EC is having a copper IUD placed within 5 days after unprotected sex. This also provides you with a continuing and effective birth control method.

There are many safe and effective contraceptives choices after childbirth and when breastfeeding. Talk to your practitioner before having your baby to discuss your preferences when the time comes.

References: Chen, M, Schwarz, E. New guidance on contraception while breast-feeding, JWatch.org October 2016. p.77.
Curtis KM et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep 2016 Jul 29;65:1.

Screening for breast cancer seems like a good idea and mammograms are the gold standard for screening. The main risk factors for breast cancer are age and gender which unfortunately, we have little control over. With the incidence of breast cancer being 1 in 8 in a women’s lifetime, why would women not want to screen for cancer before any symptoms appear? Well, screening has some drawbacks, so consider some of the benefits and possible harms.

Lets first look at the benefits:
1. If your mammogram is normal and shows no signs of cancer, then that can be reassuring.
2. Most if not all insurance companies will cover the cost of a mammogram.
3. If the screening test shows signs of pre-cancer or early cancer, treatment may be shorter and simpler and prognosis is much better.

The downside of screening:
1. False positive result: This is when the findings suggest that you could have an early cancer when you really don’t. This can lead to further testing such as more breast images or a biopsy. As you can imagine, this leads to anxiety, inconvenience, discomfort and the expense of extra testing even though you don’t have cancer.
2. False negative result: This is when a mammogram misses a cancer that is actually present. This gives you a false reassurance that everything is OK.
3. Overdiagnosis: This occurs when a cancer is present, but it is one that does not interfere with the length or quality of your life. Not all cancers cause death or illness even though we may think the worst. In fact, some cancers would have never been found during your lifetime if you hadn’t had the screening test. This is known as an “indolent” cancer. Even oncologists cannot tell the difference between an indolent cancer and one that will progress. Therefore the cancer will probably be treated (unnecessarily) with surgery, radiation or medication. On the other hand…if the cancer found is a “real” cancer (one that would grow and perhaps spread), then early diagnosis with a mammogram would allow the patient to avoid more extensive treatment, such as chemotherapy, and it may have prevented her from dying of breast cancer.
The issue of overdiagnosis is confusing for both women and clinicians. So how often does overdiagnosis occur? Unfortunately, it cannot be directly measured because the incidence of cancer varies widely with geographic region and race/ethnicity of the study population and methods of research used.

This issue complicates the decision on whether to have a screening test at all. So what to do? Ask yourself these questions…
1. Is this cancer preventable (or easier to treat successfully) if it’s found by screening?
2. Do I have a higher then average chance of developing this type of cancer? For example, those with a family history of breast or ovarian cancer or those who have a genetic mutation will have a higher risk of developing breast cancer. It makes sense for these women to follow screening recommendations given by their practitioner.
3. Will finding this type of cancer early make a difference in how well treatment works?
4. How do I personally feel about being screened?

Consult with your doctor or practitioner on what they specifically recommend for you.

Reference: Kaunitz, A. Understanding Overdiagnosis as a Consequence of Cancer Screening. NEJM Journal Watch: Women’s Health September 2018 Vol. 23 No. 9; 68-70.

Mammograms continue to be the gold standard for breast cancer screening. How often to do these tests for average risk women is debatable depending on the health organization that you follow or discuss with your health practitioner. This site can be helpful https://ww5.komen.org/BreastCancer/BreastCancerScreeningforWomenatAverageRisk.html.

Many facilities also now offer a breast Tomosynthesis test along with your mammogram, which does make the screening more sensitive to finding breast cancer lesions. This 3-D mammogram may find up to 47% more cancers in women with dense breasts according to a Norway study in 2012. But be aware that it delivers twice as much radiation than traditional mammograms and the breast is compressed for about 48 seconds compared with about 20 seconds for a standard exam. Ouch!!

The question many women are asking is if they should get a breast MRI or when that would be indicated. Investigators performed an observational study in which they used > 2 million images from 6 breast cancer surveillance consortium registries to evaluate biopsy and pathology results after screening mammography and compared that with breast MRI. They looked at women with and without personal histories of breast cancer.

Results showed more high-risk benign (non-cancer) lesions involving biopsies with breast MRI than with mammogram regardless of personal history of breast cancer. Overall, biopsy rates were fivefold higher for MRI than mammography.

Recommendations are that women should not undergo routine breast MRI for cancer surveillance unless they meet certain criteria which includes:

1. Strong family history of breast cancer
2. Oncogenic hereditary mutation
3. Extremely dense breasts
4. High-risk lesions such as lobular carcinoma in situ

Of course, discuss recommendations with your practitioner to determine the best screening for you.

Reference: Buist DSM et al. Breast biopsy intensity and findings following breast cancer screening in women with and without a personal history of breast cancer. JAMA Intern Med 2018 Feb 12; [e-pub]. (https://doi.org/10.1001/jamainternmed.2017.8549).