Written by Marissa Ghant MD, Mark Pearlman MD, Justine Wu MD, MPH

Annually, 1 in 6 new breast cancer (BC) diagnoses occur in reproductive-aged individuals.¹ Those at risk for unplanned pregnancy should receive contraceptive counseling. Per the Society of Family Planning/Society of Gynecologic Oncology Guidelines² non-hormonal methods should be first line methods, emergency contraception (including levonorgestrel-containing) is always safe, and shared decision making within cancer context is essential. 

High-quality data regarding exogenous hormone use after BC are limited. Based on relevant studies,^3,4 and biologic plausibility,⁵ most agree with the U.S. Medical Eligibility Criteria (US MEC) classification of hormonal contraceptive use (including progestin only) within 5 years of cancer diagnosis as Category 4 (unacceptable health risk).⁶ 

For those in remission and beyond 5 years from diagnosis, the US MEC classifies hormonal contraception Category 3 (theoretical risks usually outweigh advantages) without mention of hormone receptor (HR) status.^5,6 We advise against assumptions that hormonal contraception does not elevate recurrence risk in HR negative BC. Our opinion differs slightly from SFP/SGO Guidelines, which recommend “avoiding or minimizing hormone exposure” in HR positive BC and “shared decision making” for those with HR negative BC.¹ Our rationale is based upon:1) a lack of safety data about hormonal contraception use among HR negative BC survivors; 2) data from two RCTs suggesting that menopausal hormone therapy (MHT) was associated with higher recurrence risk among HR negative survivors, albeit lower than that for HR positive survivors on MHT.^2,3 

Some may want hormonal contraception to treat uterine bleeding or pain unresponsive to non-hormonal treatment. In these select cases, we advise person-centered counseling in collaboration with oncology. These discussions should be revisited as clinical status and priorities evolve.  

Although BC recurrence risk declines over time, hormone exposure can increase this risk, especially in HR positive BC.⁴ Among those who completed 5 years of adjuvant hormonal therapy, the cumulative recurrence risk is 10%-41% nearly 20 years later.⁷ Thus, some experts advise lifelong avoidance of hormonal contraception.

All hormonal contraception should be avoided for at least five years after BC diagnosis. Afterwards, hormonal contraception use requires shared decision-making in collaboration with the oncology team.

RHAP Resources:

Your Birth Control Choices Fact Sheet

Medical Eligibility Criteria for Initiating Contraception

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Sources:

1. U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on 2021 submission data (1999–2019). U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute. Published June 2022. https://www.cdc.gov/cancer/dataviz

2. Batur P, Brant A, McCourt C, Schwarz EB, Beasley A, Atrio J, Gershon D, Nero NA; Clinical Affairs Committee. Society of Family Planning clinical recommendation: Contraceptive considerations for individuals with cancer and cancer survivors. Part 2—Breast, ovarian, uterine, and cervical cancer. Contraception. 2025;136:110529. doi:10.1016/j.contraception.2025.110529

3. Holmberg L, Anderson H; HABITS Steering and Data Monitoring Committees. HABITS (hormonal replacement therapy after breast cancer—is it safe?), a randomised comparison: trial stopped. Lancet. 2004;363(9407):453-455. doi:10.1016/S0140-6736(04)15493-7

4. Holmberg L, Iversen OE, Rudenstam CM, Hammar M, Kumpulainen E, Jaskiewicz J, Jassem J, Dobaczewska D, Fjosne HE, Peralta O, Arriagada R, Holmqvist M, Maenpaa J, Forbes JF; HABITS Study Group. Increased risk of recurrence after hormone replacement therapy in breast cancer survivors. J Natl Cancer Inst. 2008;100(7):475-482. doi:10.1093/jnci/djn058

5. Pearlman MD. Exogenous Hormones and Breast Cancer Risk: Contraception, Menopausal Hormone Therapy, and Breast Cancer Survivors. Clin Obstet Gynecol. 2022;65(3):510-523. doi:10.1097/GRF.0000000000000718

6. CDC. Appendix D: Classifications for Combined Hormonal Contraceptives. cdc.gov. Published November 19, 2024. https://www.cdc.gov/contraception/hcp/usmec/combined-hormonal-contraceptives.html

7. Pan H, Gray R, Braybrooke J, et al. 20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years. N Engl J Med. 2017;377(19):1836-1846. doi:10.1056/NEJMoa1701830

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