Contraception Guidelines

Safety and Efficacy

• Progestin-only contraceptives are recommended for women with contraindications to estrogen, such as those with thrombophilia, positive antiphospholipid antibodies, or high risk of venous thromboembolism, due to their safety and efficacy in providing effective contraception without increasing thrombosis risk, as supported by the American College of Rheumatology and with a strength of evidence level of high 1, 2
• Progestin-only pills or LNG-IUS do not increase the risk of venous thromboembolism (VTE) in women with contraindications to estrogen, with a relative risk (RR) of 1.02 (95% CI 0.72-1.44) for stroke risk, as reported by the British Medical Journal 1, 3
• The baseline risk of VTE in non-pregnant, non-OCP users is 1-5 per 10,000 woman-years, while users of combined OCPs have a VTE risk of 3-9 per 10,000 woman-years, which is still lower than the risk during pregnancy (5-20/10,000 woman-years), according to the Centers for Disease Control and Prevention and the American Heart Association 4, 5, 6

Mechanism and Effectiveness

• Progestin-only contraceptives primarily work by thickening cervical mucus, not consistently inhibiting ovulation, with a typical use failure rate higher than other progestin-only methods due to strict adherence requirements, as reported by the British Medical Journal 7
• The effectiveness of different contraceptive methods is as follows:

• Barrier methods, such as condoms (male/female) and the diaphragm, are also available, with effectiveness of 82-87% and 88%, respectively, as noted by the Centers for Disease Control and Prevention 12

Administration and Adherence

• Progestin-only pills must be taken at the same time daily for maximum effectiveness, and missed pills can significantly reduce effectiveness, with a recommendation to take one pill as soon as possible and continue taking pills daily at the same time, and use backup contraception until 2 days after the missed pill, as advised by the Centers for Disease Control and Prevention 7, 12
• Higher typical use failure rates are seen with progestin-only pills compared to long-acting methods due to strict adherence requirements, with a recommendation to discuss long-acting reversible contraceptives (LARCs) like IUDs or implants as more effective options that require less user compliance, as recommended by the American College of Obstetricians and Gynecologists 7, 10

Specific Concerns and Recommendations

• The American College of Rheumatology recommends against the use of DMPA in women with positive antiphospholipid antibodies due to thrombosis concerns, with a relative risk (RR) of 2.67 (95% CI 1.29-5.53) for VTE risk, as reported by the American College of Rheumatology 1
• Cigarette smoking at age ≥35 years is a contraindication for combined hormonal contraceptives (Category 4) due to unacceptable cardiovascular risk, as stated by the Centers for Disease Control and Prevention, while the contraindication for cigarette smokers aged ≥35 years is specific to tobacco, not cannabis, as noted by the Centers for Disease Control and Prevention and the British Medical Journal 10, 7
• A history of cerebrovascular accident (stroke) and current or history of ischemic heart disease are significant factors that increase the risk of thrombosis, as reported by the Centers for Disease Control and Prevention and the American College of Cardiology, with a recommendation to avoid all estrogen-containing methods due to the increased risk of thrombosis (RR 1.7, 95% CI 1.5-1.9 for ischemic stroke), as recommended by the American College of Obstetricians and Gynecologists 6, 12, 3
• Known thrombogenic mutations and complicated valvular heart disease are conditions that increase the risk of thrombosis, as indicated by the Centers for Disease Control and Prevention, with a recommendation to prescribe progestin-only pills instead of combined oral contraceptives for patients with a history of deep venous thrombosis (DVT) or pulmonary embolism (PE), known thrombophilia, active cancer, hypertension, peripartum cardiomyopathy, valvular heart disease, or breastfeeding women, as recommended by the American College of Rheumatology 12, 10, 1

Monitoring and Follow-up

• Blood pressure should be checked at initiation and follow-up, with a scheduled follow-up within 1-3 months to assess for adverse effects, as recommended by the British Medical Journal 7
• Women should be educated on signs/symptoms of VTE (leg pain/swelling, chest pain, shortness of breath), as advised by the Centers for Disease Control and Prevention 7
• No routine follow-up visit is required for patients using progestin-only pills, but patients should be advised to return if they have concerns about side effects or want to change methods, as recommended by the Centers for Disease Control and Prevention 12

Special Considerations

• The relationship between oral contraceptives and cancer risk is as follows:

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• Emergency contraception is recommended for all patients, including those with SLE or positive aPL, as risks are low compared to unplanned pregnancy, according to the American College of Rheumatology, with a recommendation to use highly effective contraception, such as LARCs, for patients on immunosuppressive therapy, as noted by the American College of Rheumatology 1