Approach to contraception in women with systemic lupus erythematosus
- Bonnie L Bermas, MD
Bonnie L Bermas, MD
- Professor of Medicine
- UT Southwestern Medical Center
- 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
- Courtney A Schreiber, MD, MPH
Courtney A Schreiber, MD, MPH
- Section Editor — Family Planning
- Associate Professor of Obstetrics and Gynecology
- Program Director, Fellowship in Family Planning
- Perelman School of Medicine
- University of Pennsylvania
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].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Schwarz EB, Manzi S. Risk of unintended pregnancy among women with systemic lupus erythematosus. Arthritis Rheum 2008; 59:863.
- Yazdany J, Trupin L, Kaiser R, et al. Contraceptive counseling and use among women with systemic lupus erythematosus: a gap in health care quality? Arthritis Care Res (Hoboken) 2011; 63:358.
- Britto MT, Rosenthal SL, Taylor J, Passo MH. Improving rheumatologists' screening for alcohol use and sexual activity. Arch Pediatr Adolesc Med 2000; 154:478.
- Quinzanos I, Davis L, Keniston A, et al. Application and feasibility of systemic lupus erythematosus reproductive health care quality indicators at a public urban rheumatology clinic. Lupus 2015; 24:203.
- Dalkilic E, Tufan AN, Oksuz MF, et al. Comparing female-based contraceptive methods in patients with systemic lupus erythematosus, rheumatoid arthritis and a healthy population. Int J Rheum Dis 2014; 17:653.
- Yazdany J, Panopalis P, Gillis JZ, et al. A quality indicator set for systemic lupus erythematosus. Arthritis Rheum 2009; 61:370.
- Fotherby K. Interactions with oral contraceptives. Am J Obstet Gynecol 1990; 163:2153.
- Sievers TM, Rossi SJ, Ghobrial RM, et al. Mycophenolate mofetil. Pharmacotherapy 1997; 17:1178.
- Sammaritano LR. Contraception in patients with systemic lupus erythematosus and antiphospholipid syndrome. Lupus 2014; 23:1242.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
- Hidalgo M, Bahamondes L, Perrotti M, et al. Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Contraception 2002; 65:129.
- Stringer EM, Kaseba C, Levy J, et al. A randomized trial of the intrauterine contraceptive device vs hormonal contraception in women who are infected with the human immunodeficiency virus. Am J Obstet Gynecol 2007; 197:144.e1.
- Browne H, Manipalviratn S, Armstrong A. Using an intrauterine device in immunocompromised women. Obstet Gynecol 2008; 112:667.
- Julkunen HA, Kaaja R, Friman C. Contraceptive practice in women with systemic lupus erythematosus. Br J Rheumatol 1993; 32:227.
- Sánchez-Guerrero J, Uribe AG, Jiménez-Santana L, et al. A trial of contraceptive methods in women with systemic lupus erythematosus. N Engl J Med 2005; 353:2539.
- Cravioto MD, Jiménez-Santana L, Mayorga J, Seuc AH. Side effects unrelated to disease activity and acceptability of highly effective contraceptive methods in women with systemic lupus erythematosus: a randomized, clinical trial. Contraception 2014; 90:147.
- Zerner J, Doil KL, Drewry J, Leeber DA. Intrauterine contraceptive device failures in renal transplant patients. J Reprod Med 1981; 26:99.
- Petri M, Kim MY, Kalunian KC, et al. Combined oral contraceptives in women with systemic lupus erythematosus. N Engl J Med 2005; 353:2550.
- van den Heuvel MW, van Bragt AJ, Alnabawy AK, Kaptein MC. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive. Contraception 2005; 72:168.
- van Hylckama Vlieg A, Helmerhorst FM, Vandenbroucke JP, et al. The venous thrombotic risk of oral contraceptives, effects of oestrogen dose and progestogen type: results of the MEGA case-control study. BMJ 2009; 339:b2921.
- Asherson RA, Harris EN, Hughes GR, Farquharson RG. Complications of oral contraceptives and antiphospholipid antibodies: reply to the letter by Bruneau et al. Arthritis Rheum 1988; 31:575.
- Bacci S, Urquiola G, del Médico P, et al. [Budd-Chiari syndrome, pulmonary thromboembolism, and deep venous thrombosis associated with "lupus anticoagulant" and recent use of oral contraceptives]. G E N 1990; 44:237.
- Chopra N, Koren S, Greer WL, et al. Factor V Leiden, prothrombin gene mutation, and thrombosis risk in patients with antiphospholipid antibodies. J Rheumatol 2002; 29:1683.
- Choojitarom K, Verasertniyom O, Totemchokchyakarn K, et al. Lupus nephritis and Raynaud's phenomenon are significant risk factors for vascular thrombosis in SLE patients with positive antiphospholipid antibodies. Clin Rheumatol 2008; 27:345.
- Urbanus RT, Siegerink B, Roest M, et al. Antiphospholipid antibodies and risk of myocardial infarction and ischaemic stroke in young women in the RATIO study: a case-control study. Lancet Neurol 2009; 8:998.
- Hubacher D, Lopez L, Steiner MJ, Dorflinger L. Menstrual pattern changes from levonorgestrel subdermal implants and DMPA: systematic review and evidence-based comparisons. Contraception 2009; 80:113.
- American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG Committee Opinion No. 415: Depot medroxyprogesterone acetate and bone effects. Obstet Gynecol 2008; 112:727.
- Pongsatha S, Ekmahachai M, Suntornlimsiri N, et al. Bone mineral density in women using the subdermal contraceptive implant Implanon for at least 2 years. Int J Gynaecol Obstet 2010; 109:223.
- Mantha S, Karp R, Raghavan V, et al. Assessing the risk of venous thromboembolic events in women taking progestin-only contraception: a meta-analysis. BMJ 2012; 345:e4944.
- World Health Organization. Reproductive Health. (2010). Medical eligibility criteria for contraceptive use. World Health Organization.
- ACOG Committee on Practice Bulletins-Gynecology. ACOG practice bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol 2006; 107:1453.
- Hennessy S, Berlin JA, Kinman JL, et al. Risk of venous thromboembolism from oral contraceptives containing gestodene and desogestrel versus levonorgestrel: a meta-analysis and formal sensitivity analysis. Contraception 2001; 64:125.
- Julkunen HA. Oral contraceptives in systemic lupus erythematosus: side-effects and influence on the activity of SLE. Scand J Rheumatol 1991; 20:427.
- Mintz G, Gutiérrez G, Delezé M, Rodríguez E. Contraception with progestagens in systemic lupus erythematosus. Contraception 1984; 30:29.
- Jungers P, Dougados M, Pélissier C, et al. Influence of oral contraceptive therapy on the activity of systemic lupus erythematosus. Arthritis Rheum 1982; 25:618.
- Chabbert-Buffet N, Amoura Z, Scarabin PY, et al. Pregnane progestin contraception in systemic lupus erythematosus: a longitudinal study of 187 patients. Contraception 2011; 83:229.
- 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
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS