Transcript bleeding IUD

APPROACH TO CONTRACEPTION
IN WOMEN WITH SYSTEMIC
LUPUS ERYTHEMATOSUS
Dr Movahed
FACTORS TO CONSIDER

The choice of the optimal method of birth control for
women with SLE and/or APS depends upon multiple
factors:

patient values and preferences
efficacy and side effects of contraceptive methods
underlying disease activity
thromboembolic risk
medication interactions





In addition, any risk associated with a contraceptive
method must be weighed against the risk of unplanned
pregnancy for that particular patient.
CHOOSING A METHOD OF CONTRACEPTION

Reversible contraception options for women:

Barrier methods
IUDs
Contraceptive implants
Progestin-only
Estrogen-progestin hormonal contraceptives




LONG-ACTING REVERSIBLE
CONTRACEPTION

LARCs such as IUDs and contraceptive implants are
considered the most effective form of contraception and
are generally safe for women with SLE and APS.
INTRAUTERINE DEVICES

IUDs are safe and effective for most women with SLE and
aPLs, including adolescents and nulliparous women.

IUDs available in the United States release either copper or
the synthetic progestin LNg.

The copper-containing IUD may be used for at least 10 years
and may be associated with heavier menses and
dysmenorrhea.

The LNg-containing IUD which may remain in place for at
least three to five years and significantly reduces
dysmenorrhea and menstrual bleeding. Complete amenorrhea
occurs in up to 50 percent of patients by 24 months, which is a
significant benefit for patients who require long-term
anticoagulation.
INTRAUTERINE DEVICES

While data on IUD use in patients treated with immunosuppressive
medications are limited, no increased infection risk is found in HIV-infected
women.

Guidelines developed by professional organizations do not consider
immunosuppressive therapy a contraindication to IUD use.

Most experts agree that the minimal risk of infection with IUD use is
outweighed by the risks associated with unintended pregnancy in women
with active inflammatory disease on potentially teratogenic medications.

Thrombophilia does not preclude placement of an IUD. Caution is advised,
however, if patients have significant thrombocytopenia that would preclude
minor surgical procedures. In such cases, placement of any IUD should be
avoided until the count improves in order to minimize risk of bleeding
during the procedure.
CONTRACEPTIVE
IMPLANTS

Contraceptive implants are an alternative option to IUDs for
women with SLE or aPLs who want an effective LARC and
cannot take estrogen-containing preparations.

The implant most commonly used in the United States is a single
rod subdermal implant that is placed in the inner upper arm and
releases etonogestrel (a third-generation progestin) over a threeyear period. A LNg (a second-generation progestin) implant is
also available.

The risk for thromboembolism with progestin-only contraception
is low, third-generation progestins do have a slightly higher risk
of venous thromboembolism than do the second-generation
progestins.
CONTRACEPTIVE IMPLANTS

In addition, safety data on use of the etonogestrel implant
in patients with APS are not available.

Given the slightly greater risk of venous thrombosis
associated with third-generation progestins, and the lack
of data for use in aPL-positive patients, we prefer use of
the LNg-containing IUD over contraceptive implants in
aPL-positive women.

Progestin-only contraceptives are not associated with an
increased risk of SLE flare.
HORMONAL CONTRACEPTION

Hormonal contraception includes:

Estrogen-progestin preparations(eg, pill, patch, ring)

Progestin-only preparations (eg, pill, injection, IUD, implant).
ESTROGEN-PROGESTIN CONTRACEPTIVES

Estrogen-progestin contraceptives may be used in SLE
patients with stable low disease activity and documented
negative aPLs.

The data are also limited on the safety of estrogencontaining contraceptives in SLE patients with high
disease activity; thus, alternative methods such as the
progestin-only pill and IUDs are preferable in such
patients.
THROMBOEMBOLIC RISK AND ESTROGEN

Serious complications including venous thromboembolism,
stroke, and myocardial infarction.

The use of estrogen-progestin hormonal contraceptives is
contraindicated in women with aPL with or without SLE due to an
increased risk of thrombosis.

The safety of use in patients with fluctuating aPL titers or positive
aPL on anticoagulation is unknown and their use is not
recommended.

SLE patients without aPLs do not appear to be at increased risk
for thrombosis when taking oral hormonal contraceptives.
RISK OF LUPUS FLARE

Despite the common, long-held belief that estrogens
provoke lupus disease activity, estrogen-progestin
hormonal contraceptives are generally a safe form of
contraception for stable aPL-negative SLE patients with
mild-moderate disease activity.

A clinical trial evaluated the risk of flare associated with
the use of estrogen-progestin oral contraceptive
compared with a progestin-only oral contraceptive and a
copper IUD, and found no significant differences in
disease activity among the three groups
PROGESTIN-ONLY CONTRACEPTIVES

Progestin-only contraceptives present an alternative option for
SLE patients who cannot take estrogen-containing preparations.

This includes patients with active disease and those with positive
aPLs, as well as those with other general contraindications.

DMPA is more convenient than the pills, and has improved
efficacy due to its suppression of ovulation.

Progestin-only preparations are more likely to cause irregular,
“break-through” bleeding, and this is the most common cause of
discontinuation, but unpredictable bleeding is greatest within the
first three months of use and diminishes significantly with time
PROGESTIN-ONLY CONTRACEPTIVES

Also, DMPA, may cause reversible bone loss due to
inhibition of ovulation.

A history of fragility fracture, known osteoporosis, or
strong risk factors for osteoporosis (such as
corticosteroid
use)
are
generally
considered
contraindications to use of DMPA.

An additional disadvantage of DMPA in contrast to the
LNg IUD and subdermal system is that there may be a
delayed return to fertility. Thus, it is not recommended
for patients who plan pregnancy within the next year.
THROMBOEMBOLIC RISK AND PROGESTIN

The risk for thromboembolism with progestin-only
contraception is very low, and they are generally safe for most
SLE patients with or without positive aPLs.

Guidelines of the CDC:

Progestin-only contraceptives in woman with SLE and
positive (or unknown) aPL are categorized as a "3" (where the
risk of use may exceed the benefits).

By contrast, the ACOG guidelines for contraceptive use in
women with chronic medical conditions specifically suggest
that progestin-only contraceptives may be safer alternatives
than estrogen-progestin contraceptives for women with SLE
with aPL, active nephritis, and vascular disease
RISK OF LUPUS FLARE

Progestin-only contraceptives have not been observed to
increase risk of lupus flare.
BARRIER METHODS

Barrier methods of contraception, which include condoms,
diaphragms, and spermicides, have low rates of typical use
effectiveness.

Since highly effective methods are preferred to avoid
unintended pregnancy, barrier methods are not appropriate
first-line methods.

However, reliance on barrier methods may be necessary
during periods of acute illness, including acute thrombosis,
when other methods may be contraindicated, or as an interim
method until more effective methods can be safely instituted.

An additional consideration is that condoms are effective for
reducing the risk of transmission of sexually transmitted
diseases.
EMERGENCY CONTRACEPTION

Emergency contraception is an option for all patients
with SLE, including those with positive antiphospholipid
antibodies (aPLs).
SUMMARY AND
RECOMMENDATIONS
FOR PATIENTS WHO WANT TO USE A LONGACTING REVERSIBLE CONTRACEPTIVE
 The
levonorgestrel (LNg)-containing intrauterine
device (IUD) is a safe and effective option for most
patients with SLE and/or positive antiphospholipid
antibodies (aPLs).
FOR PATIENTS WHO WANT TO USE AN
ORAL HORMONAL CONTRACEPTIVE

The OCP may be used in patients with stable low disease activity and
documented negative aPLs.

In women with high disease activity; alternative methods such as
progestin-only contraceptives and IUDs are preferable.

The use of OCP are contraindicated in women with aPLs with or
without SLE, due to the increased risk for thrombosis.

The safety of OCP use in patients with fluctuating aPL titers or
positive aPL on anticoagulation is unknown and is not
recommended.
FOR SLE PATIENTS WHO DO NOT WANT TO USE
AN IUD AND HAVE HIGH DISEASE ACTIVITY, A
POSITIVE APL

We suggest progestin-only contraceptives such as the
progestin-only pill.

Barrier methods are the least effective contraceptive method,
and should be reserved for situations when hormone-containing
contraceptives or IUDs must be avoided.
RHEUMATOID ARTHRITIS AND
CONTRACEPTION

The data on the effect of oral contraceptives on RA
are conflicting:
 A case-control study that reviewed the records of
229 women with RA and 458 controls reported no
association between RA and the use of oral
contraceptives.
 Two other reports noted a decreased risk of RA
among current users of oral contraceptives, as well
as a lower risk among women who had used oral
contraceptives in the past.
 The Nurses’ Health Study found that the risk of RA
was not altered by a history of oral contraceptive
use but reported that a modest protective effect of
current users could not be excluded.
RHEUMATOID ARTHRITIS AND
CONTRACEPTION


In summary, data do not support the concept
that oral contraceptives protect against the
development of RA, at least among women who
have used these medications in the past.
The use of oral contraceptives appears neither to
worsen nor to improve disease activity.