BRCA1 pos patient with Mirena wants to take OCP for ovarian CA protection

[medsurg2010]

Hello all,

I am currently on my OB rotation and an attending asked me to look up info because one of our patients who has a significant family hx of ovarian ca.

She is 24y/o G1P1 otherwise healthy, non-smoker. (sister died at age 25, maternal aunt died at 31, cousin died at 28 from stromal ovarian CA) and she is BRCA1 positive wants to take OCPs for ovarian CA protection but has a Mirena IUD for contraception.

I found this article in NEJM showing that OCPs decrease ovarian CA rates in BRCA1 positive patients:

http://content.nejm.org/cgi/content/abstract/339/7/424

But, I can find absolutely no literature on mirena/OCP interaction and I would be really appreciative if someone could point me in the right direction.

My initial thought would be that there is no interaction since the intrauterine devices do not cause elevated peripheral progesterone levels so there would likely be no interaction but that was my best guess. Thanks

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[Winged Scapula]

So she wants to take OCP AND keep the Mirena in?

Unfortunately, the study never controlled for the type of OCP taken so its hard to extrapolate to current formulations. My gyne and medical oncologists counsel my BRCA patients to stay away from ANY hormonal form of birth control. I've never asked for their data in doing so.

 

[maxheadroom]

Man, with that family history I'd be running to get my bilateral mastectomies and BSO.

 

[Winged Scapula]

Man, with that family history I'd be running to get my bilateral mastectomies and BSO.

Really. Although suprisingly I have some resistant patients who have "elected" to do nothing.

 

[THP]

Mirena IUD is not one of the absolute contraindications for OCPs. I don't even think that it is a relative one. Its usually not an issue we deal with though. However, an estrogen sensitive neoplasm is one of the absolute contraindications so I imagine you would want to be careful with the OCPs. I will admit in my 8 months of internship I haven't encountered this much. It always amazes me women who are done child bearing and don't want the prophylactic BSO if they have a family history of ovarian Ca.

 

[wvshootr]

It's very suitable to do this in this patient. Often two types of contraceptives are used for certain issues. OCPs are the only preventative prophylaxis that is effective in decreasing the risk of ovarian cancer. Ovarian cancers are not estrogen dependent. Patients who are BRCA carriers who are not wanting to conceive should be followed carefully as recommended, but I would absolutely encourage OCPs. No need in removing the Mirena, as it will just give double protection for contraception. The mirena can give measurable progesterone levels, but this is mostly a local effec to the uterus and tubes. There is data to suggest that a Mirena can inhibit ovulation as well.

Travis McCoy, MD FACOG

 

[Winged Scapula]

But what about the risk of breast cancer in BRCA1 - is she ignoring that?

There is very mixed data on whether not OCPs increase the risk of breast CA, especially in BRCA mutations.

If she were my patient, I'd encourage prophylactic breast surgery if she is not ready for oophorectomy and insists on using hormonal birth control (for whatever reason).

 

[wvshootr]

The breast cancer issue is one of debate, of course. Surgery vs surveillance is a tough one, though with the use of MRI likely surveilance may be the better choice in my opinion.

The initial patient in discussion had the very strong history in her family of ovarian cancer. Reproductive issues have to be factored into these decisions. The data on OCPs and breast cancer will likely never be sorted out as prospective studies won't ever be done, and other suitable analyses of patients are all underpowered to yield definititive answers concerning OCPs. Of note, patients on a low dose OCP, or on a Nuvaring, through inhibition of ovulation will likely experience a Lower exposure to estrogen over time (AUC) than if she were allowed to ovulate naturally. Thus one could theorize that this could both lower estrogen exposure and provide some ovarian protection.


Travis McCoy

 

[Winged Scapula]

The breast cancer issue is one of debate, of course. Surgery vs surveillance is a tough one, though with the use of MRI likely surveilance may be the better choice in my opinion.

I offer my patients surgery, surveillance and/or chemoprevention with a SERM.

I order a LOT of MRIs but am losing faith in them (or at least the radiologists reading them). I have done prophylactic surgery on patients with "clean" MRIs only to find 1 cm DCIS or a 7 mm invasive cancer. I have seen them vastly underestimate the size of a primary (2 cm vs the 8 cm seen on path) and of course, overestimate the size of a tumor. I'm not sure I'm remaining as comfortable with surveillance anymore.

The initial patient in discussion had the very strong history in her family of ovarian cancer. Reproductive issues have to be factored into these decisions.

Obviously, but people with a family history of Ovarian CA who are BRCA positive for some reason think they are immune to other cancers which are carried on the gene. I understand why she is worried about her ovarian cancer risk but was wondering if she has ignored the very real fact that she also has a risk, and a HIGHER risk of breast cancer than ovarian cancer.

The data on OCPs and breast cancer will likely never be sorted out as prospective studies won't ever be done, and other suitable analyses of patients are all underpowered to yield definititive answers concerning OCPs. Of note, patients on a low dose OCP, or on a Nuvaring, through inhibition of ovulation will likely experience a Lower exposure to estrogen over time (AUC) than if she were allowed to ovulate naturally. Thus one could theorize that this could both lower estrogen exposure and provide some ovarian protection.

You are right...a real RCT will never be done in this country. And I understand that the OCP *may* lower her estrogen exposure over the natural state. Seems to me the best thing she could do would be to have all the children she wants NOW, and have surgery with that family history and being BRCA positive. These patients make me nervous - I have several who are doing the same thing and I worry about the day we find something (or not). But that is a surgeons perspective, eh?

 

[maxheadroom]

I saw a 31 y/o WF in consult the other day. STRONG family h/o breast ca (paternal grandmother died in her late 30s, father died in 50s) and just got BRCA-2 positive results. She has two kids under 3 and says that she and her husband aren't planning any others. She was having a hard time accepting the fact that she really needed to consider prophylactic mastectomies and BSO (she was seeing us for a consult regarding recon). She was pretty distraught. Fortunately, her mom and husband were both with her and very supportive.

 

[luvOB]

why does she still want to keep the mirena? why not just OCP's? is she worried about forgetting to take the pill or does she also have menorrhagia?

i guess i'm wondering what the added benefit is and if this is something commonly done? have not heard of this management before...