Use of Hormonal Contraceptives Is Associated With Decreased Incidence of Anterior Cruciate Ligament Injuries Requiring Reconstruction in Female Patients

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PURPOSE: To investigate associations between hormonal contraceptive use and female patients who had sustained an anterior cruciate ligament (ACL) injury requiring reconstruction. METHODS: Deidentified data collected from female patients aged 15 to 35 years between 2011 and 2024 were obtained from the Colorado Health Data Compass database. The study patients were separated into female patients who sustained an ACL injury that was treated by arthroscopic ACL reconstruction and female patients without a history of ACL injury. Among these groups, non-contraceptive users, total hormonal systemic contraceptive users (including oral contraceptive pills [OCPs], implants, rings, injections, and patches), and OCP users (including formulations of norethindrone [NE] only, drospirenone plus ethinyl estradiol (EE), NE plus EE, and norgestimate plus EE) were included in the analysis. RESULTS: The 2,120,628 female patients in the systemic hormonal contraceptive use group had a lower incidence of ACL injury (0.079%; 95% confidence interval [CI], 0.075%-0.083%) than the 12,766,138 female patients in the non-contraceptive use group (0.12%; 95% CI, 0.118%-0.121%). In addition, the 745,062 female patients in the OCP use group had a lower ACL injury incidence (0.088%; 95% CI, 0.081%-0.095%), suggesting an association between contraceptive use and ACL injury. When data were stratified by 5-year age intervals, the 15- to 19-year-old group showed no difference in the ACL injury incidence between the OCP use group (0.101%; 95% CI, 0.081%-0.125%) and the non-contraceptive use group (0.118%; 95% CI, 0.114%-0.122%), whereas all other age groups showed a lower ACL injury incidence in the OCP use group. All age groups in the systemic hormonal contraceptive use group had a lower ACL injury incidence than the non-contraceptive use group. Additionally, different contraceptive formulations showed a similar injury incidence, with a lower proportion of ACL injuries in NE-only users (0.03%) compared with norgestimate-EE users (0.093%), NE-EE users (0.099%), and drospirenone-EE users (0.096%). CONCLUSIONS: Systemic hormonal contraceptive use is associated with a lower incidence of ACL injury requiring ACL reconstruction compared with no contraceptive use in female patients aged 15 to 35 years, with a stronger association with progestin-only OCPs. Female patients aged 15 to 19 years showed no difference in the association with the ACL injury incidence between OCP use and no contraceptive use. LEVEL OF EVIDENCE: Level III, prognostic retrospective comparative study.

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