From the Guidelines
For a female patient with active Systemic Lupus Erythematosus (SLE) and anti-phospholipid antibodies who is starting mycophenolate mofetil (MMF) and does not wish to have more children, the most appropriate long-term contraceptive method would be a levonorgestrel intrauterine device (IUD). This option provides highly effective contraception (>99%) without increasing the risk of thrombosis, which is particularly important given the patient's anti-phospholipid antibodies that already predispose her to clotting 1. The levonorgestrel IUD works primarily through local effects on the endometrium and cervical mucus, with minimal systemic hormone absorption. This is crucial because estrogen-containing contraceptives are contraindicated in patients with anti-phospholipid antibodies due to the significantly increased risk of thromboembolism 1. Additionally, reliable contraception is essential while taking MMF, which is a teratogenic medication (FDA pregnancy category D) that can cause serious birth defects. The IUD can remain in place for 3-7 years depending on the specific product (Mirena, Liletta, Kyleena, or Skyla), providing long-term protection without daily compliance concerns. Some key points to consider in this decision include:
- The patient's anti-phospholipid antibodies, which increase her risk of thrombosis and contraindicate the use of estrogen-containing contraceptives 1.
- The need for reliable contraception while taking MMF, a teratogenic medication 1.
- The effectiveness and safety of the levonorgestrel IUD in patients with SLE and anti-phospholipid antibodies 1. For patients who cannot use an IUD, other progestin-only methods like the subdermal implant (Nexplanon) could be considered as alternatives, though the IUD generally remains the preferred option in this clinical scenario. It is also important to note that the American College of Rheumatology recommends discussing use of emergency contraception with all patients, including those with SLE or positive aPL, because risks of emergency contraception are low compared to those of unplanned pregnancy 1. In terms of specific guidance, the 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases recommends the use of IUDs or progestin-only pills in women with positive aPL 1. Overall, the levonorgestrel IUD is the most appropriate long-term contraceptive method for this patient due to its high effectiveness, safety, and minimal impact on thrombosis risk.
From the FDA Drug Label
Females of reproductive potential taking mycophenolate mofetil must receive contraceptive counseling and use acceptable contraception (see Table 8 for acceptable contraception methods) Patients must use acceptable birth control during entire mycophenolate mofetil therapy, and for 6 weeks after stopping mycophenolate mofetil, unless the patient chooses abstinence (she chooses to avoid heterosexual intercourse completely) Patients should be aware that mycophenolate mofetil reduces blood levels of the hormones in the oral contraceptive pill and could theoretically reduce its effectiveness e Intrauterine devices (IUDs) Tubal sterilization Patient’s partner had a vasectomy OR Option 2 Hormone Methods choose 1 Barrier Methods choose 1 Choose One Hormone MethodANDOne Barrier Method Estrogen and Progesterone Oral contraceptive pill Transdermal patch Vaginal ring Progesterone-Only Injection Implant AND Diaphragm with spermicide Cervical cap with spermicide Contraceptive sponge Male condom Female condom OR Option 3 Barrier Methods choose 1 Barrier Methods choose 1 Choose One Barrier Method from Each Column (must choose two methods) Diaphragm with spermicide Cervical cap with spermicide Contraceptive sponge AND Male condom Female condom
The most appropriate long-term method of contraception for this patient is Tubal ligation 2, as the patient does not wish to have more children and this method is listed as an acceptable form of contraception. Other acceptable options include Intrauterine devices (IUDs) and Patient’s partner had a vasectomy. However, considering the patient's desire for a long-term solution and no future children, Tubal ligation is the most suitable choice.
From the Research
Contraception Options for SLE Patients
The patient's condition, active Systemic Lupus Erythematosus (SLE) with anti-phospholipid antibodies, and the initiation of mycophenolate mofetil (MMF) treatment, require careful consideration of contraception options. The following points summarize the key considerations:
- Estrogen-containing oral contraceptives are contraindicated in patients with positive antiphospholipid antibodies (aPL) due to the increased risk of thrombosis 3, 4.
- Progesterone-only oral contraceptives may be used, but they can cause side effects and do not seem to be the most preferred option for long-term contraception in this patient population 3, 4.
- Barrier methods are available but may not be the most effective long-term solution for a patient who does not wish to have more children 3.
- Intra-uterine contraceptive devices (IUDs), specifically the levonorgestrel IUD, are considered a good alternative for patients with anti-phospholipid syndrome (APS) and can decrease menstrual blood loss 3.
- Tubal ligation is a permanent method of contraception that may be suitable for a patient who does not wish to have more children and is undergoing evaluation for treatment with MMF, which is teratogenic 5.
Recommended Contraception Method
Given the patient's condition and treatment plan, the most appropriate long-term method of contraception would be:
- Tubal ligation, as it is a permanent method that eliminates the risk of unplanned pregnancy and is suitable for a patient who does not wish to have more children 5. Alternatively, an intra-uterine contraceptive device (IUD) could be considered, but it may not be as permanent as tubal ligation and may require more maintenance 3.