Maybe, Baby? Birth Control After Cancer

by Marloe EschOctober 3, 2019View more posts from Marloe Esch

Since cancer, I’ve been trying to be better about living in the moment.  You know — seizing the day, taking more chances, throwing caution to the wind…   But there are still a few situations in which preparation and planning should be the golden rule, and one of them is contraception.  Making smart, thoughtful choices about birth control is an important part of taking responsibility for your sexual health, regardless of cancer status.

Studies show that during and after treatment for cancer, we young survivors consistently underestimate our ability to get pregnant or cause pregnancy for our partners. We are also less likely than our cancer-free peers to use highly effective birth control methods. And this isn’t without consequences; cancer survivors are three times more likely to experience an unintended pregnancy than the general population.

Wait, I thought cancer treatment causes infertility?

So…it’s complicated. During or after certain treatments for cancer, your fertility may be reduced temporarily or permanently, or you may experience complete infertility temporarily or permanently, or your ability to have children may not be compromised at all at any point in your treatment. What gives?

The degree to which your fertility is impaired, and for how long, is individualized and depends on a number of things. Factors like your age, the type of cancer you have, and the specific type, dosing, and number of treatments can all play a role. Also, the negative effects of radiation or chemo on fertility often happen gradually, which means that pregnancy could happen during active treatment. An exception, of course, would be if you had both of your ovaries or your uterus removed surgically, or both testicles.  These types of surgeries cause immediate and permanent infertility.

How will I know if I need to use birth control?

It’s not always easy to tell if you can get pregnant or get your sexual partner pregnant. Both men and women can potentially maintain or regain their ability to have children after going through cancer treatments.  For some women, pregnancy is still possible even if they aren’t getting a period or if their periods are irregular. Talking with your provider can help you better understand your need for contraception.

What if my partner and I want to become pregnant?

It is important to avoid pregnancy while undergoing cancer treatments and for a certain time after.  Both radiation therapy and certain anticancer medicines can adversely affect a developing embryo or fetus, and becoming pregnant at this time may require you to make a decision between the most effective treatment for your cancer or compromising the health of your pregnancy.

Some women are diagnosed with cancer when they are already pregnant. In this case, a woman’s healthcare team will help her make an informed decision about treatment. Certain treatments are safe during pregnancy, especially in the second or third trimester.

Chemotherapy or radiation can also damage the DNA in egg or sperm cells, which may increase the risk for birth defects or miscarriage temporarily.  However, it is worth noting that overall, studies have not shown an increased incidence of birth defects in children conceived by survivors after treatment for cancer.

If you wish to have children after treatment, ask your provider how long you should wait before attempting to conceive. Your provider may recommend waiting anywhere from six months to three years after the end of your treatments.  During this time, use an effective birth control method.

What birth control options are available for cancer survivors?

Your medical history, the type of cancer you have, and your treatment plan may affect what birth control options are available to you. Other important considerations include whether the method is reversible or permanent, long-acting (which is typically more effective) or short-acting, how easy it is to acquire and to use, and whether it provides protection against sexually transmitted infections (STIs). Some methods require a prescription or a clinic appointment to access, while others are available over-the-counter. Ideally, you will work with your provider to find a method that is safe for your circumstances, highly effective and easy to use.

The National Comprehensive Cancer Network (NCCN) recommends long acting, reversible contraceptives for women with a history of cancer (as long as there are no contraindications) because they are the most effective at preventing pregnancy.  The only non-permanent option available for men is the male condom, a barrier method that is effective when used correctly and with every sexual encounter.

Combining the use of two compatible methods at the same time (such as pairing condoms with another type of birth control, for example) is called the “dual method” approach.  This is a good way to increase protection against pregnancy.  It’s also a good idea to talk with your partner about your plan birth control before you’re in the heat of the moment to make sure you’re both on the same page.

Barrier Methods

Barrier methods work by preventing sperm from fertilizing an egg. These include the female and male condoms, as well as the diaphragm, cervical cap, cervical sponge, and spermicides. The effectiveness of each depends on how consistently and accurately the method is used. You can easily pair a barrier method with the use of hormonal birth control or an IUD for extra protection. Condoms are the only method available that also help protect against transmitting STIs.

Hormonal Methods

Hormonal methods prevent pregnancy by stopping ovulation, changing cervical mucous characteristics and altering the uterine lining.

Combination (estrogen + progestin) hormonal options include oral pills taken daily, a transdermal patch placed on your skin that is changed weekly, or an intravaginal ring that is replaced weekly.

Some hormonal methods do not contain estrogen. Short-acting progestin-only options include a daily pill (the “mini pill”) or an injection given every 3 months.  Long-acting methods include an implantable rod (Nexplanon) inserted under the skin of your arm, and a hormonal (LNg) IUD.

Hormonal methods can be very effective when used correctly, but they are not right for everyone.  For example, if you were diagnosed with a hormone-sensitive cancer or are less than 6 months out from treatment, your provider may recommend avoiding hormonal options.  Other potential contraindications may include a history of radiation to your chest, a risk for blood clots, a diagnosis of osteoporosis (weak bones) or impaired liver function, or if you are a smoker over the age of 35. Talk with your provider to determine if hormonal birth control is safe for you.

Intrauterine Device (IUD) Methods

An IUD is a small T-shaped wire or plastic device that sits inside your uterus to prevent pregnancy. In addition to the hormonal (progestin-only, or LNg) IUD mentioned above, there is a non-hormonal (copper) IUD option. Both are very effective types of long-acting, reversible birth control.

The Society of Family Planning’s guidelines on cancer and contraception indicate that women who are immunosuppressed can safely use an IUD for birth control. Evidence for this recommendation is based on the results of studies looking at other immunocompromised populations, which have not shown an increased risk for infection with IUD use. Unfortunately, studies have not focused specifically on women being treated for cancer.

If you have an IUD in place at the time of your diagnosis, you may be able to leave it in place throughout treatment. However, insertion of an IUD during treatment or when your immune system is not working properly may be contraindicated. Your provider may also have concerns about insertion or use of an IUD if you have low platelet counts.

Natural Methods

Natural methods do not use a device or medication to prevent pregnancy.

Withdrawal (or the “pull-out” method) is when a penis is pulled out of a vagina before ejaculating, thus preventing sperm from coming in contact with an egg.

Fertility awareness-based methods (FAMs) include using a calendar to track your menstrual cycle and monitoring for signs that are associated with ovulation, such as changes in cervical secretions and body temperature. FAMs work by helping you determine which days you are most likely to get pregnant, so that you can abstain from intercourse (or use another method) during that time-frame.

Failure rates for natural methods are fairly high because they can be difficult to use. Pairing a natural method with another form of birth control improves effectiveness.

Permanent Methods

Non-reversible surgical procedures are available for both men and women that can permanently prevent pregnancy.

But this stuff is so hard to talk about!

If your oncology provider addressed birth control with you before beginning treatment, yay! But if not, you’re not alone. Even though healthcare professionals agree that providing timely, accurate and complete information on fertility and safer sex and contraception is an essential aspect of cancer care, these topics often get left out of the conversation.

Don’t be afraid to bring up birth control at your next appointment.  Your provider can help you understand your risk of pregnancy and what options may be right for you. If you still have questions, ask to be referred to a specialist such as a gynecologist or urologist, or to someone with expertise in reproductive medicine or fertility issues.

You can learn more about contraception and cancer at the resources listed below.  Other trusted online resources include Center for Disease Control and Prevention and Planned Parenthood.

In conclusion…

Cancer can change our view on what it means to live life to the fullest.  It can also change how we plan for the future. Careful consideration and consistent use of birth control allows you to choose if and when a pregnancy should occur, which means that you can seize all of the days ahead of you, in all the ways that you want to.  Carpe Diem!

Resources:

  • Britton, L. E. (2017). Unintended pregnancy. Clinical Journal of Oncology Nursing 21(2): 189-196.
  • Green, Laci. (2018) Sex Plus. New York, NY, HarperCollins Publishers.
  • Katz, Anne. (2014) This Should Not Be Happening: Young Adults with Cancer. Hygeia Media, Pittsburg PA.
  • Katz, Anne. Meeting the Need for Psychosocial Care in Young Adults with Cancer. Pittsburgh, PA, Oncology Nursing Society, 2015.
  • Kelvin, J.F., Steed, R., Jarrett, J. (2014). Discussing safe sexual practices during cancer treatment. Clinical Journal of Oncology Nursing 18(4): 449-453
  • Memorial Sloan Kettering Cancer Center, Sexual Health and Intimacy, accessed 7/8/19.
  • National Comprehensive Cancer Network Guidelines: Survivorship.  www.nccn.org, accessed 7/8/19
  • National Comprehensive Cancer Network Guidelines: AYA Oncology.  www.nccn.org, accessed 7/8/19.
  • Patel, A., Schwarz, B. (2012). Cancer and Contraception. Contraception 86(3): 191-198.
  • Schover, Leslie R. (1997).  Sexuality and Fertility After Cancer. John Wiley & Sons, Inc.
  • UpToDate: Comparison of Effectiveness of Contraceptive Methods, accessed 7/8/19.

 

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