Hardman
Use of hormonal contraception after hydatidiform mole
SMR Hardman
Clinical Effectiveness Unit, Faculty of Sexual & Reproductive Healthcare, Edinburgh, UK
Linked article: This is a mini commentary on A Braga et al., pp. 1330–1335 in this issue. To view this article visit
http://dx.doi.org/10.1111/1471-0528.13617.
Published Online 5 October 2015.
Effective contraception is important
during monitoring of human chori-
onic gonadotrophin (hCG) levels
after uterine evacuation for hydatidi-
form mole (HM), to avoid confusion
between a rising hCG associated with
ongoing gestational trophoblastic
disease (GTD) and that resulting
from a new pregnancy. Contracep-
tion should be started as soon as
possible: conception can occur before
menses are re-established.
But how do women achieve effec-
tive contraception in the immediate
aftermath of molar pregnancy? Typi-
cally, condom use is associated with
an 18% contraceptive failure rate
over a year of use. Intrauterine con-
traception has been avoided in GTD
because of concerns about possible
increased risk of bleeding and uter-
ine perforation.
Hormonal contraception (HC) is
effective: the progestogen-only implant
has a typical use failure rate of only
0.05% over a year, oral contraception
9% and injectables 6%. On discontinu-
ation of HC (except injectables), there
is a rapid return to fertility – impor-
tant to many women after an episode
of GTD. However, guidelines regarding
use of HC during follow up of HM
have been inconsistent.
Royal College of Obstericians and
Gynaecologists guidance (Green Top
Guideline 38, London: RCOG;
1336
March 2010) recommended that
HC be avoided until hCG levels
normalised because of concern that
use of combined HC after molar
pregnancy might increase the risk
of gestational trophoblastic neopla-
sia.
However, a systematic review by
Gaffield et al. (Contraception 2009;80
:363–71) found no evidence of an
effect of combined HC on the course
of GTD after HM. On this basis, the
2009 World Health Organization
Medical Eligibility Criteria for Con-
traceptive Use recommended that
there should be no restriction on use
of HC while hCG levels are elevated
in GTD. In line with this, the Faculty
of Sexual and Reproductive Health-
care (UK Medical Eligibility Criteria
for Contraceptive Use, London:
FSRH; 2009) and Centers for Disease
Control (US Medical Eligibility Cri-
teria for Contraceptive Use, Atlanta:
CDC; 2010) advise that HC can
safely be used while hCG remains
elevated.
In the current retrospective data-
base study, Braga et al. find no
association between use of HC
started while hCG levels are still
raised after uterine evacuation for
complete HM and time to hCG
regression, development of gesta-
tional trophoblastic neoplasia or
FIGO risk score.
ª 2015 Royal College of Obstetricians and Gynaecologists
The study includes 2423 women
with complete HM. However, only
154 used HC (100 combined oral
contraception, 43 progestogen-only
pill, 11 progestogen-only injectable).
Because numbers of women using
each contraceptive were small, meth-
ods are considered together as ‘hor-
monal contraception’. The study is
not powered to detect different
effects of individual HC methods on
GTD outcomes. Progestogen-only
implants and non-oral combined
contraceptives are not considered.
Contraceptive method was not
randomised. Prescribing might have
been influenced by plateaued or ris-
ing hCG levels or by bleeding prob-
lems in the weeks following uterine
evacuation so there is a potential
prescribing bias.
Despite its limitations, this study
adds to the weight of evidence that
suggests HC can safely be used after
molar pregnancy before hCG levels
normalise. Clinicians caring for
women with a diagnosis of molar
pregnancy should not forget about
contraception and can advise women
that the limited evidence is that HC is
safe to start.
Disclosure of interests
None declared. Completed disclosure
of interests form available to view
online as supporting information. &