Female service members deserve an individualized approach to hormonal contraception counseling

Abstract: We appreciate the participation of the authors1 in the much-needed discussion about hormonal contraception (HC) and medical readiness in military service members (SMs) in response to our manuscript.2 SMs deserve excellent, evidence-based clinical counseling about HC, requiring pro- viders to understand factors that are of particular relevance to SMs. This information may be especially helpful for civilian clinicians and/or those who do not specialize in gynecology. We agree that "reporting side effects as a collective may deter women from using hormonal methods entirely,”1 which is why we presented evidence for each type of HC separately to dissuade readers from assuming that all HCs have the same effect on weight, bone, psychological health, or performance. Regarding weight, our literature review identi ed a pattern of small and insigni cant weight gain (<2 kg) with oral combination (estrogenþprogestin) contraception, vaginal ring, and transdermal patch use, with more variable and some- times greater weight gain with progestin-only contraception (implants, intrauterine devices, and depot medroxyprogesterone acetate injections). We maintain the conclusion that weight may be a factor for some SMs deciding among HC types. There is physiological variability in re- sponses. For instance, although Burkman et al3 reported average body weight change within 5% in a trial comparing2 combined oral contraception formulations, one- fth of participants gained >5%, and 10% to 13% of participantslost >5% of their body weight. Such individual variability may in uence person-level HC decision-making. Although pregnancy prevention and menstrual suppression are important for many SMs, they may not always outweigh all other risks and benefits of HC use, as reasons for HC use are many. Not all SMs engage in heterosexual, sexually active relationships. Furthermore, providers can counsel about nonhormonal contraceptive options for SMs that aim to prevent pregnancy. Menstrual suppression is not desired universally, as some prefer to have regular menstrual bleeding as a signal of health.4,5 The in uence of each factor when making HC choices is inherently personal, and those pre- sented in the manuscript may be more or less important to each scenario. Overall, we agree that "it is important to consider any side effects from HC in the context of their occupation and an individualized approach is required,”1 especially given the variability in the evidence base, which may partially be due to inherent variability in physiological response to hormone manipulation. We hope the manuscript empowers SMs and their clinicians to make individualized, evidence-informed decisions, as the readiness of the female force depends on the readiness of each female SM.