TEALE FENNING

stewartdisu · Joined: 24 Jun 2007 Posts: 20

Are Progesterone only pills safe following an erpoc for a molar pregnancy while being monitored with declining Hcg levels

Any ideas Nick?

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

stewartdisu · Joined: 24 Jun 2007 Posts: 20

Thats good clarifiaction
Iucd can be offered as well

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

POP's -- may be used

the caution came from the fact that older hcg assays measured alpha as well as beta fraction of hcg, the alpha fraction is non specific to trophoblasts and has cross reactivity to LH, FSH, TSH etc,
COCP or POP alter endogenous gonadotrophins and hence would give incorrect assay results.
with the advent of specific beta sub unit assays for hcg, the above problem has been solved and hence POP are now ok.

COCPs contraindicated till hcg returns to normal -- as the oestrogen causes increased persistant trophoblastic activity and hence increased risk if persistant mole / invasive mole / recurrent mole with next pregnancy event, also increased need for chemotherapy.

IUCD -- contraindicated till hcg back to normal, the rationale behind this is -- persistant mole / invasive mole present with irregular bleed / spotting. the IUCD - copper or mirena both may cause the same symptoms, and it will be difficult to know which is the cause mole / iucd.
hence avoided.

hope the rationale behind the above helps you remember it.

raj
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

http://www.clinicalanswers.nhs.uk/index.cfm?question=4014

Is there any evidence as to the safety of the use of progesterone only methods of contraception in women who have a past history of a molar pregnancy? 26/Sep/06

Answer:The Faculty of Family Planning and Reproductive Health Care (FFPRHC) answered a question concerning contraception in patients with recent gestational trophoblastic disease in 2003. They concluded:

“Hydatidiform mole is a form of gestational trophoblastic disease, which is a rare condition with an incidence of 1.54 per 1000 live births in the UK. Of patients with hydatidiform mole, 20% develop a trophoblastic malignancy and after a complete mole develops, uterine invasion occurs in 15% of patients and metastasis occurs in 4%.

Guidelines from the RCOG on the management of trophoblastic disease advise that combined oral contraceptives (COCs) can be used by women with gestational trophoblastic disease when serum human chorionic gonadotrophin (hCG) levels are normal since use before this time may increase the need for treatment. Guidelines from the RCOG and from Canada both recommend that women with gestational trophoblastic disease should be advised to avoid pregnancy until serum hCG levels have been normal for six months. The Canadian guidelines suggest pregnancy should be avoided for one year following chemotherapy for gestational trophoblastic tumour. Both guidelines agree that these women can safely use COC.

1)The WHO Medical Eligibility Criteria for Contraceptive Use (WHMECC) suggest women with either benign or malignant gestational trophoblastic disease can use the COC, progestogen-only pill (POP), depot medroxyprogesterone acetate (DMPA) or the implant (Norplant) (WHO Category 1-unrestricted use).
2)WHOMEC classifies the insertion of either a copper intrauterine device (IUD) or the levonorgestrel intrauterine system (LNG-IUS) as WHO Category 3 (risks outweigh the benefits) for women with benign gestational trophoblastic disease.
3)WHOMEC advises that women with malignant gestational trophoblastic disease should not have either an IUD or the LNG-IUS inserted because there is an increased risk of perforation from treatment of this condition[/b].” [1]

We searched the TRIP and Medline databases but found no additional information on the suitability of progesterone only methods of contraception for women with a history of molar pregnancy.

Furthermore, in August 2006, the FFPRHC stated:

“The FFPRHC CEU are currently in the process of developing a UK version of the World Health Organization Medical Eligibility Criteria for Contraceptive Use (WHOMEC). UKMEC will be published shortly on the FFPRHC website www.ffprhc.org.uk.” This information has not appeared on the FFPRHC site yet. [2]

References
1. FFPRHC. For women with recent gestational trophoblastic disease (hydatidiform mole), which methods of contraception can be safely used? 2003 (http://www.ffprhc.org.uk/admin/uploads/No274.pdf)
2. FFPRHC. For women with gestational trophoblastic neoplasia, can hormonal contraception be used safely? August 2006. (http://www.ffprhc.org.uk/admin/uploads/No1736.pdf).

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

http://www.ffprhc.org.uk/admin/uploads/No1736.pdf

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

Infact, both the COC and the POP can cause altered gonadotropin secretion. However that may not be the main concern in the case of either COC or POP and their use in molar pregnancy. Actually oral contraceptives decrease LH

The main argument/concern against using both forms of Oral Contraception (COC and POP) molar pregnancy is that they both may affect bhcg regression and may lead to increased risk of persistent trophoblastic neoplasia.

Previous experimental studies in humans and animals suggest that it is biologically plausible for sex hormones to have a role in trophoblastic proliferation and, although in vitro studies have reported inhibitory or no effect in trophoblastic cells replication and hCG secretion.

There are many recent studies and systematic reviews which have suggested that oral contraception is safe post molar pregancy.
Ref:Influence of oral contraceptives in the development of post-molar trophoblastic neoplasia--a systematic review.Gynecol Oncol. 2006 Mar;100(3):579-85. Epub 2005 Nov 17
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16297971&ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

But for exam purpose better to stick to the RCOG guideline which for some interesting reason choses not to mention about POPs but only mentions about COCs(that is to avoid until HCG returns to normal. )

stewartdisu · Joined: 24 Jun 2007 Posts: 20

So practically and the purpose of the exam
Avoid intercourse or use barrier methods till the HCG surveillance reaches less than 20iu/l or uring hcg negativity.

Nick Raine-Fenning · Posted: Wed Aug 01, 2007 12:41 am Post subject: Re: Hmole