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Guideline Summary
Guideline Title
Noncontraceptive uses of hormonal contraceptives.
Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Noncontraceptive uses of hormonal contraceptives. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Jan. 13 p. (ACOG practice bulletin; no. 110).  [160 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Menstrual cycle irregularity
  • Menorrhagia
  • Dysmenorrhea
  • Premenstrual syndrome
  • Menstrual migraines
  • Risk factors for endometrial cancer, ovarian cancer, or colorectal cancer
  • Acne
  • Hirsutism
  • Osteoporosis
  • Leiomyomas
  • Endometriosis
Guideline Category
Assessment of Therapeutic Effectiveness
Prevention
Treatment
Clinical Specialty
Dermatology
Family Practice
Internal Medicine
Obstetrics and Gynecology
Oncology
Preventive Medicine
Intended Users
Physicians
Guideline Objective(s)

To describe noncontraceptive uses for hormonal contraceptives and examine the evidence evaluating the effectiveness of contraceptives for these applications

Target Population

Women at risk for or with conditions that might benefit from noncontraceptive use of hormonal contraceptive drugs

Interventions and Practices Considered

Use of hormonal contraceptives

  • Estrogen therapy
  • Progestin therapy
  • Combination therapy (monophasic and triphasic)
Major Outcomes Considered
  • Incidence and intensity of pain
  • Quality of life
  • Incidence of endometrial, ovarian, or colorectal cancer; leiomyomas; or ovarian cysts
  • Incidence of bone fractures
  • Treatment side effects
  • Periodicity of menstrual cycle and ovulation
  • Frequency and degree of menstrual bleeding
  • Frequency and degree of migraine headaches

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1995 and November 2007. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Rating Scheme for the Strength of the Recommendations

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A—Recommendations are based on good and consistent scientific evidence.

Level B—Recommendations are based on limited or inconsistent scientific evidence.

Level C—Recommendations are based primarily on consensus and expert opinion.

Cost Analysis

A formal cost analysis was not performed; however, the cost-effectiveness for the management of menorrhagia was reviewed. Markov modeling has been used to estimate the cost-effectiveness of different approaches to management of menorrhagia in women desiring contraception. In the absence of a pathological cause, the use of a combined oral contraceptive (OC) for menorrhagia was the most cost-effective approach in the first year only. In women who responded initially to a combined OC, it was more cost-effective to switch to a levonorgestrel device than to continue with combined OCs. In women who failed to respond to combined OCs, the levonorgestrel intrauterine system was the most cost-effective approach followed by surgery if the levonorgestrel intrauterine system also failed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician–gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

Recommendations

Major Recommendations

The grades of evidence (I–III) and levels of recommendations (A–C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

  • Combined oral contraceptives (OCs) should not be used to treat existing functional ovarian cysts.
  • Use of combined hormonal contraception has been shown to decrease the risk of endometrial and ovarian cancer.
  • Combined OCs have been shown to regulate and reduce menstrual bleeding, treat dysmenorrhea, reduce premenstrual dysphoric disorder symptoms, and ameliorate acne.
  • Continuous combined hormonal contraception, depot medroxyprogesterone acetate (DMPA), and the levonorgestrel intrauterine system may be considered for long-term menstrual suppression.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

  • Based on the limited data available, it appears overall that combined OCs do not increase the risk of development of uterine leiomyomas.
  • Hormonal contraception should be considered for the treatment of menorrhagia in women who may desire further pregnancies.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A—Recommendations are based on good and consistent scientific evidence.

Level B—Recommendations are based on limited or inconsistent scientific evidence.

Level C—Recommendations are based primarily on consensus and expert opinion.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Potential Noncontraceptive Benefits of Hormonal Contraception

  • Menstrual cycle regularity
  • Treatment of menorrhagia
  • Treatment of dysmenorrhea
  • Inducing amenorrhea for lifestyle considerations
  • Treatment of premenstrual syndrome
  • Prevention of menstrual migraines
  • Decrease in risk of endometrial cancer, ovarian cancer, and colorectal cancer
  • Treatment of acne or hirsutism
  • Improved bone mineral density
  • Treatment of bleeding due to leiomyomas
  • Treatment of pelvic pain due to endometriosis
Potential Harms

Potential side effects of hormonal contraceptive use (e.g., cerebrovascular events)

Qualifying Statements

Qualifying Statements

The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

Implementation of the Guideline

Description of Implementation Strategy

Proposed Performance Measure

Percentage of women using hormonal contraception for symptomatic relief of menorrhagia or dysmenorrhea or both who have no contraindications and wish to preserve reproductive function

Implementation Tools
Audit Criteria/Indicators
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American College of Obstetricians and Gynecologists (ACOG). Noncontraceptive uses of hormonal contraceptives. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Jan. 13 p. (ACOG practice bulletin; no. 110).  [160 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Jan
Guideline Developer(s)
American College of Obstetricians and Gynecologists - Medical Specialty Society
Source(s) of Funding

American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins

Composition of Group That Authored the Guideline

American College of Obstetricians and Gynecologists (ACOG) committees are created or abolished and their overall function defined by the Executive Board. Appointments are made for one year, with the understanding that such appointment may be continued for a total of three years. The majority of committee members are Fellows, but Junior Fellows also are eligible for appointment. Some committees may have representatives from other organizations when this is particularly appropriate to committee activities. The president elect appoints committee members annually.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: None available

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org.

The ACOG Bookstore is available online at the ACOG Web site External Web Site Policy.

Availability of Companion Documents

Proposed performance measures are included in the original guideline document.

Patient Resources

The following is available:

  • Hormonal birth control. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2007. Available from the ACOG Web site External Web Site Policy. Copies are also available in Spanish External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on June 7, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

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