What are the best contraceptive options for individuals with autoimmune hepatitis?

Contraceptive Options for Individuals with Autoimmune Hepatitis

Long-acting reversible contraceptives (LARCs) such as intrauterine devices are the preferred contraceptive option for individuals with autoimmune hepatitis, as they avoid the potential hepatotoxic effects of estrogen-containing contraceptives. 1

First-Line Contraceptive Options

Recommended Options

• Intrauterine devices (IUDs)
  • Copper IUDs
  • Progestin-releasing IUDs
• Progestin-only methods
  • Implants
  • Progestin-only pills
  • Depot medroxyprogesterone acetate injections

Contraindicated Options

• Combined hormonal contraceptives (CHCs) containing estrogen should be avoided in:
  • Patients with decompensated cirrhosis 1
  • Patients with cholestatic jaundice 2
  • Patients with hepatic adenomas or carcinomas 2

Decision Algorithm Based on Disease Status

For Patients with Well-Controlled AIH (No Cirrhosis)

1. First choice: Long-acting reversible contraceptives (IUDs or implants)

   • Highest efficacy
   • No hepatic metabolism
   • Reduced compliance concerns

2. Second choice: Progestin-only methods

   • Pills
   • Injections

3. Third choice: Barrier methods

   • Condoms
   • Diaphragms
   • Should be combined with other methods for higher efficacy 1

For Patients with AIH and Cirrhosis

1. First choice: IUDs (copper preferred)

   • No hepatic metabolism
   • Highly effective

2. Second choice: Barrier methods

   • May be combined with progestin-only methods if no decompensation

3. Avoid: All estrogen-containing contraceptives 2

   • Contraindicated due to risk of cholestatic effects

Special Considerations

Pregnancy Planning

• Preconception counseling is essential for women with AIH 1
• Attempt to discontinue azathioprine before pregnancy if possible 1
• Disease should be in stable remission for at least a year before conception 3
• Poor disease control in the year prior to pregnancy is associated with worse outcomes 3

Risk of Flares

• AIH can flare during pregnancy (reported in 12-86% of cases) 1
• Higher risk of flares in the postpartum period 1
• Patients who experience flares during pregnancy are more likely to develop hepatic decompensation 3

Medication Considerations

• Azathioprine has FDA pregnancy category D rating 1
• Mycophenolate mofetil is contraindicated in pregnancy 1
• Effective contraception is particularly important for patients on teratogenic medications 1

Monitoring Recommendations

For Patients Using Combined Hormonal Contraceptives (if no contraindications)

• Check liver function tests and serum bile acids 4 weeks after starting therapy 1
• Discontinue if abnormalities develop

For All Patients with AIH on Contraception

• Regular monitoring of liver function tests every 3-6 months
• More frequent monitoring if any signs of disease flare

Important Caveats

• Women with advanced liver disease and portal hypertension are at risk for variceal hemorrhage during pregnancy and should be strongly advised to use effective contraception 1
• Substance use, which may be more prevalent in some liver disease patients, is associated with contraceptive non-compliance, making LARCs particularly beneficial 1
• Emergency contraception is generally safe for use in patients with chronic liver disease 1

By following these recommendations, individuals with autoimmune hepatitis can choose appropriate contraceptive methods that minimize risks while providing effective pregnancy prevention.