Case Study - A difficult contraceptive dilemma to consider

A uterine malformation and a pituitary disorder raise important contraceptive issues, explains Dr Srishti Dutta.

Pituitary adenoma: elevated prolactin levels can be suppressed (Photograph: SPL)
Pituitary adenoma: elevated prolactin levels can be suppressed (Photograph: SPL)

The first time I saw Miss J was when she came to discuss contraception. She was 41, and keen to use a copper IUD, but told me that she had a history of uterine malformation and was attending the endocrinology clinic for a pituitary adenoma.

She was in a new relationship and her partner was using condoms. On vaginal examination there were two cervical ostia visible, and bimanual examination showed an anteverted, mobile and normal size uterus.

We agreed to screen for STI and review the results, by which time I would have had a chance to read her history and research the possible options.

A complex medical history
Her records confirmed she was found to have a bicornuate uterus when she was investigated for primary subfertility.

She had endoscopic resection of the uterine septum, which was followed by successful IVF. After the pregnancy, Miss J had presented with prolonged amenorrhoea. A pelvic ultrasound at the time was normal, but blood tests showed a raised prolactin of 2,178 nanograms/ml and a 1cm diameter pituitary adenoma was found on MRI.

She started cabergoline and had responded well with a reduction in size of the adenoma on scans over the next two years. She then opted for a trial without therapy for a year, but she developed galactorrhoea and raised prolactin levels of 1,259 nanograms/ml. She had a regular menstrual cycle.

Cabergoline was restarted and prolactin levels fell to normal within four months, with no galactorrhoea and continuing menstrual cycles. She was still taking cabergoline when I saw her.

The contraceptive options
When Miss J returned I felt in a much better position to discuss contraception with her.

I explained that the use of the combined pill is not contraindicated with pituitary adenomas or cabergoline treatment, but may not be the ideal choice as her menstrual cycle was one of the parameters being monitored to assess her response to treatment. It would alter her usual 22 to 23 day regular cycle and could cause post-pill amenorrhea, and so distort the clinical picture.

On balance we agreed that use of the copper coil would eliminate this hurdle, and this was the method favoured by her endocrinologist.

However, this raised another problem. Miss J had two cervical canals with a single uterine cavity, so although fitting a coil might not be straightforward, it should be effective within her now single uterine cavity.

The insertion of a copper IUD on day five of her next cycle proved uneventful and ultrasonography confirmed a single uterine cavity with normal endometrium and the IUD in situ.

Obtaining further information
The clinical effectiveness unit at the Faculty of Sexual and Reproductive Healthcare (FSRH) has received a number of queries concerning contraceptive choice for patients with pituitary adenomas and for bicornuate uterus.

The FSRH could find no evidence on the effect of hormonal contraception on prolactin or macroprolactin levels. Women with macroprolactinaemia are usually fertile and successful pregnancies are reported, so contraception is required to avoid unintended pregnancy.

Despite a lack of evidence, prescribing oral contraception is often considered contraindicated in women with hyperprolactinaemia. The use of hormonal methods of contraception is not contraindicated for those on treatment with cabergoline or bromocriptine.

In theory the effects of levonorgestrel released by the Mirena intrauterine system might not extend throughout a bicornuate uterus, and the summary of product characteristics lists uterine abnormality as a contraindication to insertion. Other methods of contraception may be more appropriate in these circumstances.

  • Dr Dutta is a salaried GP in Hertfordshire
Key Points
  • Patients with uterine abnormalities and endocrine problems who need contraception require specific attention.
  • Despite a lack of evidence, oral contraception is often not advised for women with hyperprolactinaemia.
  • The Mirena intrauterine system may not be appropriate for women with a bicornuate uterus.

 

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