Flare risks in AHP depend on hormonal birth control type, study finds
Another factor is the patient's specific type of porphyria
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Hormonal birth control may increase the risk of disease flares in people with acute hepatic porphyria (AHP), but the risk depends on the type of birth control used, as well as the individual’s specific type of porphyria, according to a new study.
Findings specifically suggest that birth control pills containing both estrogen and progesterone are associated with the highest risk of disease flares. By contrast, the risk is lower with pills that only contain progesterone, certain intrauterine devices (IUDs), and hormone therapies used to relieve symptoms of menopause.
“Tolerability of hormonal treatments in AHP is highly variable and influenced by both therapy type and porphyria subtype. … These findings support a personalised, carefully monitored approach to hormonal management in AHP and underscore the need for prospective studies to refine clinical guidelines and optimise patient safety,” researchers wrote in the study, “Tolerability of hormonal treatments in acute hepatic porphyria patients,” which was published in Internal Medicine Journal.
Options for managing reproductive health in AHP can be few
AHP encompasses several types of porphyria characterized by sudden attacks of symptoms. These disease flares may be triggered by changes in hormone levels, particularly levels of the so-called female hormones estrogen and progesterone.
Many contraceptive treatments, such as birth control pills, contain estrogen and/or progesterone. These medications are commonly used to prevent pregnancy and also to help manage hormone-related health problems such as heavy menstrual bleeding or symptoms from menopause.
A study done in the early 2000s showed that oral birth control pills can trigger disease flares in many women with a form of AHP called acute intermittent porphyria (AIP). Based largely on this study, it’s generally recommended that women with all forms of AHP should avoid using hormonal birth control.
But there are many different types of hormonal birth control medications, not to mention other types of AHP. The blanket recommendation against all forms of hormonal contraception can leave women with AHP few options to manage their reproductive health.
Flares most common in patients who used COCP
In this study, a trio of scientists in Australia conducted a survey aimed at getting a more nuanced understanding of the risks of different types of hormonal therapies in women with different forms of AHP.
The survey was answered by 12 people with AIP, 12 with variegate porphyria (VP), and six with hereditary coproporphyria (HCP). Most of the survey respondents reported having used at least one type of hormone therapy, most commonly birth control pills containing both estrogen and progesterone, sometimes called COCP (short for combined oral contraceptive pill). Other types of hormonal therapies reported included IUDs that release the hormone levonorgestrel, progesterone-only pills, implants using the hormone etonogestrel, and hormonal therapies for menopause symptoms.
Since some individuals had tried more than one hormone therapy, a total of 33 exposures were reported across all the survey respondents. Roughly 30% of these exposures led to a disease flare, though rates varied notably by therapy type and porphyria type.
Specifically, data showed that flares were most common in patients who used COCP. Across all types of AHP, patients taking COCP reported higher flare rates and worse tolerability than with any other type of hormonal treatment. IUDs using levonorgestrel led to flares in two exposures, one in a patient with AIP and one in a patient with HCP, whereas two AIP patients and one VP patient did not experience flares with this same type of IUD.
These findings underscore the clinical importance of defining safe and effective options for contraception, fertility management and menopausal symptom control in [people with AHP]3.
Other types of hormonal treatment — namely progesterone-only pills, implants, or menopausal therapies — were not reported to trigger flares by any of the patients who tried them, and were generally reported as well-tolerated.
“COCPs appear to confer the greatest risk of triggering acute attacks, particularly in individuals with HCP, whereas progesterone-only methods, levonorgestrel-releasing IUDs and [menopausal hormone therapies] demonstrate more favourable tolerability profiles,” the researchers wrote.
The researchers stressed that these data are limited to a small number of patients — for example, only one patient in the survey had used an implant — so it’s not possible to draw any sweeping conclusions. Still, they said these data may help women with AHP and their doctors make informed decisions about reproductive healthcare options.
“These findings underscore the clinical importance of defining safe and effective options for contraception, fertility management and menopausal symptom control in [people with AHP],” the scientists concluded.
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