Contraception After DVT: Switch to Progestin-Only Methods
This patient must immediately discontinue her combined hormonal contraceptive (which contains estrogen) and switch to a progestin-only contraceptive method, as estrogen-containing contraceptives are absolutely contraindicated in anyone with a history of venous thromboembolism. 1
Why Estrogen-Containing Birth Control Must Be Stopped
Combined hormonal contraceptives (pills, patches, or vaginal rings containing estrogen) induce a hypercoagulable state and significantly increase VTE risk—this is primarily driven by the estrogenic component 2. Women with a history of DVT who are not receiving anticoagulation therapy have an absolute contraindication to combined hormonal contraceptives 2. Even though this patient is currently anticoagulated on apixaban, the estrogen must be discontinued before she completes her anticoagulation course.
Safe Contraceptive Options
Progestin-Only Methods (All Safe Options)
The following progestin-only contraceptives do not increase thrombotic risk and are appropriate for women with prior VTE 1, 3:
- Progestin-only pills (POPs): No association with increased VTE risk 3
- Etonogestrel implant (Nexplanon): No increased VTE risk 3
- Levonorgestrel intrauterine device (Mirena, Kyleena, Skyla, Liletta): No increased VTE risk and offers the additional benefit of reducing menstrual bleeding, which is particularly advantageous while on anticoagulation 1, 3
Special Consideration for DMPA
Depot medroxyprogesterone acetate (Depo-Provera) should be avoided in this patient. While most progestin-only methods are safe, limited evidence suggests DMPA may double the risk of VTE 3, 4. Given that safer alternatives exist, DMPA is not the optimal choice for someone with established thrombosis.
Long-Acting Reversible Contraception (LARC) Advantages
The levonorgestrel IUD is particularly advantageous for this patient because:
- It provides highly effective contraception without thrombotic risk
- It reduces menstrual bleeding, which helps minimize bleeding complications while she remains on apixaban 1
- It requires no daily adherence
- It remains safe and effective long-term, even after anticoagulation is discontinued
Timing of Contraceptive Switch
The switch from combined hormonal contraception to progestin-only methods should occur immediately—there is no need to wait. The patient can start a progestin-only method right away while continuing apixaban 1. If switching to an IUD, she can have it placed at any time, ideally coordinating with her menstrual cycle for ease of insertion, but this is not mandatory.
Critical Pitfall to Avoid
Do not allow this patient to resume combined hormonal contraceptives after completing anticoagulation therapy. The history of provoked or unprovoked DVT creates a permanent contraindication to estrogen-containing contraceptives, even after the acute event has resolved and anticoagulation has been discontinued 2, 1.
Non-Hormonal Alternatives
If the patient prefers to avoid all hormonal methods, the copper IUD (Paragard) is another excellent option with no thrombotic risk and high efficacy. Barrier methods (condoms, diaphragm) are also safe but less effective for pregnancy prevention.