Approach to contraception in women with systemic lupus erythematosus
- Bonnie L Bermas, MD
Bonnie L Bermas, MD
- Associate Professor of Medicine
- Harvard Medical School
- Lisa R Sammaritano, MD
Lisa R Sammaritano, MD
- Associate Professor of Medicine
- Weill Medical College of Cornell University
- Section Editors
- David S Pisetsky, MD, PhD
David S Pisetsky, MD, PhD
- Section Editor — Lupus
- Professor of Medicine and Immunology
- Duke University Medical Center
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Family planning is an important clinical consideration in women with systemic lupus erythematosus (SLE), given that the peak incidence of this disorder is in women of reproductive age and approximately 50 percent of pregnancies in the United States are unplanned. Pregnancies in SLE patients during periods of high disease activity (particularly nephritis) or with significant disease-related damage (such as pulmonary hypertension and cardiovascular disease) are associated with high maternal morbidity and mortality and poor fetal outcomes. Furthermore, many of the medications used for the management of SLE and antiphospholipid syndrome (APS), such as mycophenolate mofetil, cyclophosphamide, methotrexate, and warfarin, are contraindicated during pregnancy. (See "Pregnancy in women with systemic lupus erythematosus".)
Contraceptive choice varies for patients with SLE and APS, and depends upon clinical history including the presence or absence of antiphospholipid antibodies (aPL); current disease activity; the patient's age, reproductive history, and desires; and religious and cultural factors.
Recommendations for individualizing the contraceptive decision for patients with SLE and/or APS will be discussed here. Rheumatologists and gynecologists each have specific expertise to contribute toward making the final decision with the patient. An overview of contraception as well as more detailed information regarding the various contraceptive methods can be found in separate topics. (See "Contraceptive counseling and selection" and "Intrauterine contraception: Devices, candidates, and selection" and "Overview of the use of estrogen-progestin contraceptives" and "Risks and side effects associated with estrogen-progestin contraceptives" and "Progestin-only pills (POPs) for contraception" and "Etonogestrel contraceptive implant" and "Transdermal contraceptive patch".)
Despite the risks of unplanned pregnancy in the setting of systemic lupus erythematosus (SLE), many women with SLE do not adequately use effective birth control. Survey studies examining the likelihood of unintended pregnancy and the use of effective contraception in reproductive-aged sexually active women with SLE have found that almost one-quarter have inconsistent or no use of contraception [1,2]. In one of the studies, over one-half of the women using contraception were depending solely on less effective barrier methods . Women on teratogenic medications were no more likely than others to use effective contraception.
The inconsistent use of contraception in SLE patients may partly reflect limited screening, counseling, and gynecology referral by rheumatology clinicians. One prospective study of 178 adolescent from a rheumatology practice evaluated clinician performance of behavioral screening, including screening for sexual activity, and demonstrated low rates of screening by rheumatologists (12.4 percent) . The major reported barrier to addressing contraception was limited time during the clinic visit. Other factors identified by rheumatologists included logistical issues, their discomfort with the subject area, and ambivalence about their role in behavior screening. Other studies have found that approximately one-half of adult reproductive-aged women with SLE do not receive documented contraceptive counseling [4,5].
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- FACTORS TO CONSIDER
- Efficacy of contraception
- Disease activity
- Thromboembolic risk
- Medication interactions
- CHOOSING A METHOD OF CONTRACEPTION
- Our overall approach
- Contraceptive options
- - Long-acting reversible contraception
- Intrauterine devices
- Contraceptive implants
- - Hormonal contraception
- Estrogen-progestin contraceptives
- - Thromboembolic risk and estrogen
- - Risk of lupus flare
- Progestin-only contraceptives
- - Thromboembolic risk and progestin
- - Risk of lupus flare
- Barrier methods
- - Emergency contraception
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS