Contraindications and Precautions for Progesterone-Only Contraception

Absolute Contraindications

• The American College of Rheumatology recommends avoiding progesterone-only contraception in patients with positive antiphospholipid antibodies, especially depot medroxyprogesterone acetate (DMPA), due to increased thrombosis risk 1, 2, 3

Relative Contraindications

Cardiovascular Conditions

• The Centers for Disease Control and Prevention (CDC) recommend caution when using DMPA in patients with severe thrombocytopenia, systemic lupus erythematosus with positive antiphospholipid antibodies, moderate to severe cardiac impairment, history of ischemic heart disease, or history of stroke, as these conditions may increase the risk of adverse cardiovascular events 4, 5
• The CDC also recommends avoiding DMPA in patients with cyanotic congenital heart disease, Fontan procedure history, or pulmonary arterial hypertension, due to increased risk of thrombosis 3

Bone Health Concerns

• The American College of Rheumatology recommends avoiding long-term DMPA use in patients at risk for osteoporosis, as it may lead to bone mineral density loss (up to 7.5% over 2 years) 6, 7

Special Considerations for Specific Patient Populations

Patients with Systemic Lupus Erythematosus (SLE)

• The American College of Rheumatology recommends using progesterone-only methods with caution in SLE patients, especially those with positive antiphospholipid antibodies, and avoiding DMPA due to increased thrombosis risk 5, 8, 9

Patients with Antiphospholipid Antibodies

• The American College of Rheumatology strongly recommends avoiding DMPA in patients with antiphospholipid antibodies due to increased thrombosis risk, and instead recommends using levonorgestrel IUD, copper IUD, or progestin-only pills 1, 2

Patients at Risk for Osteoporosis

• The American College of Rheumatology recommends avoiding long-term DMPA use in patients at risk for osteoporosis, and instead recommends using alternative progesterone-only methods such as IUDs or pills 6, 7

Clinical Pitfalls and Caveats

• The CDC recommends being aware of the potential increased risk of thrombosis with DMPA compared to other progesterone-only methods (RR 2.67, 95% CI 1.29-5.53) 1, 2
• The American College of Rheumatology recommends considering the use of IUDs (copper or progestin) in patients requiring immunosuppressive therapy, despite theoretical infection concerns 6, 7