Contraception with Progesterone-Only Methods

Absolute Contraindications

The American College of Rheumatology recommends avoiding DMPA entirely in patients with positive antiphospholipid antibodies due to significantly increased thrombosis risk (RR 2.67, 95% CI 1.29-5.53) 1
The FDA labels progesterone-only pills as contraindicated in known or suspected breast carcinoma 2
The FDA labels progesterone-only pills as contraindicated in hypersensitivity to any component 2
The FDA labels progesterone-only pills as contraindicated in benign or malignant liver tumors 2
The FDA labels progesterone-only pills as contraindicated in acute liver disease 3

The American College of Cardiology notes that estrogen-containing contraceptives are absolutely contraindicated in patients with congenital heart disease and pulmonary arterial hypertension, while progesterone-only preparations may be considered 4, 5
The American College of Cardiology recommends levonorgestrel, barrier methods, or tubal ligation for women with cyanotic CHD and PAH 3
The ACC/AHA guidelines note that progesterone-only contraceptives should be used with extreme caution in patients with cyanosis related to intracardiac shunt 6
The ACC/AHA guidelines note that progesterone-only contraceptives should be used with extreme caution in patients with prior Fontan procedure 6
The ACC/AHA guidelines note that progesterone-only contraceptives should be used with extreme caution in patients with severe pulmonary arterial hypertension 2
The ACC/AHA guidelines note that progesterone-only contraceptives should be used with extreme caution in patients with Eisenmenger physiology 4
Medroxyprogesterone, progesterone-only pills, and levonorgestrel may cause fluid retention and should be used with caution in patients with heart failure 6, 3

The American College of Rheumatology recommends using progesterone-only methods with caution in patients with systemic lupus erythematosus, especially if positive antiphospholipid antibodies are present 2
The American College of Rheumatology recommends avoiding DMPA due to increased thrombosis risk in patients with systemic lupus erythematosus 1, 2
The American College of Rheumatology recommends levonorgestrel IUD or progestin-only pills as preferred alternatives in patients with systemic lupus erythematosus 1, 2
Long-term DMPA use should be avoided in patients at risk for osteoporosis, as it causes bone mineral density loss up to 7.5% over 2 years 2
Alternative progesterone-only methods (IUDs or pills) are recommended instead of DMPA for patients at risk for osteoporosis 2
IUDs (copper or progestin) are strongly recommended for patients on immunosuppressive therapy despite theoretical infection concerns 1, 2
Studies in HIV-positive women and solid organ transplant patients show no increased infection risk with IUD use 1

The American College of Obstetricians and Gynecologists recommends discussing the necessity of taking pills at the same time every day with patients before prescribing progesterone-only pills 2

The U.S. Medical Eligibility Criteria assigns Category 1 (no restriction) to progestin-only pills for virtually all hematologic conditions, including various anemias and coagulopathies, as stated by the Centers for Disease Control and Prevention (CDC) 7, 8
Alpha-thalassemia 1 carrier status does not appear in contraceptive eligibility criteria and poses no restriction to progestin-only pill use, according to the CDC 7, 8
The American College of Obstetricians and Gynecologists (ACOG) recommends progestin-only methods when combined hormonal contraceptives are contraindicated due to their lack of estrogen-related thrombotic risk 9, 10

Ensure pregnancy is excluded with urine or serum hCG before starting the mini pill, as recommended by the CDC 8
The CDC recommends that the mini pill can be initiated "anytime" if you're reasonably certain the patient isn't pregnant, and it may actually improve symptoms if endometriosis is confirmed 8
Plan to adjust therapy based on biopsy results: if benign (endometrial hyperplasia, endometriosis), continue the mini pill; if malignancy, discontinue immediately, as stated by the FDA and CDC 8, 11