Response to the Letter by Alireza A., et al

I would like to thank Dr Alireza for bringing up rare and/or controversial areas of oral contraceptive (OC) use, which fell outside the scope of my article on the practical approach to OC use in women with polycystic ovary syndrome (PCOS) (1).

The approach to the patient article is a concise, patient-focused review addressing the role and mechanism of action of OCs as well as contraindications and safety issues specifically in the management of PCOS (1). Accordingly, a brief overview of OC use in the general population was given as background, and readers were referred for further information to the evidence-based guidelines developed and regularly updated by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) (2, 3). The most recent version of the WHO guidelines was released in August 2015 and is available at the WHO website (4).

From the points raised by Dr. Alireza, no data have been reported so far evaluating any association between PCOS and sickle cell disease, HIV infection, inflammatory bowel disease (IBD), or angioedema. Also, the limited available data do not allow the determination of any link between PCOS and cervical cancer (5). As the author noted, there are some studies in the general population suggesting that the relative risk of cervical cancer may increase with long-term use of OCs with apparently no remaining risk after exposure (6). However, as indicated in the Approach to the Patient paper, any screening, including pelvic and genital examination, and cervical cytology are not routinely recommended because they do not contribute substantially to the safety of OCs in PCOS or non-PCOS women (1, 4).

Sexually transmitted infections (STIs) and sickle cell anemia are among those conditions that expose a woman to unacceptable health risk as a result of unintended pregnancy. Therefore, the use of low-dose oral contraception is warranted for both conditions where there is no restriction of OC use for STI, and advantages generally outweigh the theoretical or proven risk in sickle cell anemia. In fact, screening and treatment of anemia or STI including HIV are not required to establish eligibility for or continuation of contraception (4).

IBD and hereditary angioedema are not included in international guidelines for OC use. There appears to be no association between OC use and IBD (7). However, as pointed out by Dr. Alireza, hereditary angioedema, a rare disorder affecting two out of 100 000 individuals in the general population, might be exacerbated by exogenous estrogen use (8).

Abbreviations

 
• IBD

  inflammatory bowel disease

 
• OC

  oral contraceptive

 
• PCOS

  polycystic ovary syndrome

 
• STI

  sexually transmitted infection.

References