Contraception for Women with Lupus and History of Pulmonary Embolism

Primary Recommendation: Levonorgestrel IUD

The American College of Rheumatology recommends a levonorgestrel intrauterine device (IUD) as the optimal contraceptive choice for women with Systemic Lupus Erythematosus (SLE) and a history of pulmonary embolism, due to its high efficacy and lack of increased thrombotic risk, as well as its benefit in reducing menstrual bleeding in patients requiring anticoagulation 1, 2
The levonorgestrel IUD has a pregnancy prevention rate of less than 1% per year, with no increased risk of thrombosis, making it a safe option for women with a history of pulmonary embolism 2
The device reduces excessive menstrual bleeding, which is critical for patients on anticoagulation therapy, and does not require daily adherence, making it ideal for patients on complex medication regimens 1, 2
The levonorgestrel IUD is safe for use regardless of antiphospholipid antibody status 2

The American College of Rheumatology suggests that a copper IUD can be used in SLE patients without hormonal concerns, as it is equally effective for contraception without increasing thrombotic risk 1, 2
Progestin-only pills are suitable for SLE patients with positive antiphospholipid antibodies, although they have a lower efficacy than IUDs due to adherence requirements, and have a safe thrombotic profile in SLE patients 1, 3

The European League Against Rheumatism (EULAR) guidelines state that combined estrogen-progestin contraceptives are absolutely contraindicated in women with a history of pulmonary embolism, due to the increased risk of thrombosis 1, 4
The American College of Rheumatology recommends avoiding Depot Medroxyprogesterone Acetate (DMPA) in patients with positive antiphospholipid antibodies, due to the increased risk of thrombosis, and also due to concerns about bone mineral density loss 3

Antiphospholipid antibody testing should be performed before finalizing contraceptive choice, as it significantly impacts recommendations, although the levonorgestrel IUD remains safe regardless of antiphospholipid antibody status 2, 4
For SLE patients with moderate to severe disease activity, progestin-only methods like levonorgestrel IUDs are strongly recommended over combined contraceptives, and even in stable/inactive SLE, a history of pulmonary embolism makes estrogen-containing contraceptives inappropriate 1, 2, 4

The European League Against Rheumatism recommends levonorgestrel intrauterine device (IUD) as the optimal contraceptive choice for women with Systemic Lupus Erythematosus (SLE), offering high efficacy and no increased thrombotic risk 5

The American College of Rheumatology suggests that levonorgestrel IUD is universally safe and recommended as first-line contraception for all SLE patients, with no contraindications based on antiphospholipid antibody status, disease activity, or thrombotic history 5
The European League Against Rheumatism recommends that combined estrogen-progestin contraceptives can be considered only in SLE patients with stable/inactive disease and negative antiphospholipid antibodies 5
The American College of Rheumatology states that combined estrogen-progestin contraceptives are absolutely contraindicated in SLE patients with positive antiphospholipid antibodies or a history of thromboembolism due to significantly increased thrombosis risk 5

The European League Against Rheumatism recommends that disease activity assessment should guide selection of contraceptive methods, with higher activity favoring progestin-only or IUD methods 5
The American College of Rheumatology suggests that thrombotic risk stratification, including history of venous or arterial events, is mandatory for SLE patients before selecting a contraceptive method 5