What contraception options are suitable for a patient with a history of Venous Thromboembolism (VTE)?

Contraception Options for Patients with History of Venous Thromboembolism (VTE)

For patients with a history of VTE, progestin-only contraceptive methods (particularly progestin-only pills or intrauterine devices) are strongly recommended as they do not significantly increase thrombosis risk, while combined hormonal contraceptives are contraindicated due to their substantial thrombotic risk.

Safe Contraceptive Options for VTE Patients

First-Line Options:

1. Intrauterine Devices (IUDs)

   • Levonorgestrel IUD: Highly effective with no increased VTE risk (relative risk 0.61,95% CI 0.24-1.53) 1
   • Copper IUD: Highly effective non-hormonal option with no thrombotic risk 1
   • Both options are considered safe and effective for patients with history of VTE

2. Progestin-Only Pills (POPs)

   • No increased risk of VTE (relative risk 0.90,95% CI 0.57-1.45) 1, 2
   • More favorable cardiovascular safety profile than combined hormonal methods 2
   • Requires consistent daily administration at the same time for optimal effectiveness

Options to Avoid:

1. Combined Hormonal Contraceptives (CHCs)

   • Strongly contraindicated in patients with history of VTE 1
   • Includes combined oral contraceptives, patches, and vaginal rings
   • Increases VTE risk 3-6 fold depending on the formulation 3, 4

2. Depot Medroxyprogesterone Acetate (DMPA)

   • Limited data suggest potentially higher VTE risk than other progestin-only methods 1
   • The American College of Rheumatology does not recommend DMPA for patients with positive antiphospholipid antibodies due to concern regarding thrombogenicity 1

Clinical Decision-Making Algorithm

1. Assess thrombotic risk factors:

   • Type of previous VTE (provoked vs. unprovoked)
   • Presence of thrombophilias (Factor V Leiden, Prothrombin mutation, etc.)
   • Additional cardiovascular risk factors
   • Current anticoagulation status

2. Choose appropriate contraception:

   • If patient desires highest efficacy with minimal intervention: → Recommend IUD (levonorgestrel or copper)

   • If patient prefers a non-invasive method: → Recommend progestin-only pills

   • If patient is currently on anticoagulation therapy: → Consider levonorgestrel IUD which may help reduce menstrual bleeding often worsened by anticoagulants 5

Important Considerations

Bleeding Management

• Progestin IUDs may decrease menstrual bleeding and cramping, providing additional benefit for patients on anticoagulation therapy 1
• Copper IUDs may initially increase menstrual bleeding and cramping for several months after insertion 1

Efficacy Considerations

• Typical use failure rate of progestin-only pills is approximately 6% (perfect use 0.2%) 2
• IUDs have lower typical use failure rates than oral contraceptives

Timing Considerations

• If transitioning from combined hormonal contraceptives while on anticoagulants, they should be discontinued before anticoagulant therapy is stopped, preferably after the second-last menstrual cycle of the intended anticoagulant treatment period 5

Common Pitfalls to Avoid

1. Assuming all hormonal contraceptives carry the same risk

   • Combined hormonal contraceptives significantly increase VTE risk
   • Progestin-only methods generally do not significantly increase VTE risk

2. Overlooking the benefits of contraception in VTE patients

   • Pregnancy itself carries a higher VTE risk than most contraceptive methods
   • Effective contraception is crucial for women on teratogenic medications like warfarin

3. Failing to consider the impact on menstrual bleeding

   • Patients on anticoagulation may experience heavier menstrual bleeding
   • Levonorgestrel IUD can help manage this side effect while providing effective contraception

4. Neglecting patient preferences and adherence factors

   • The most effective contraception is one that the patient will use consistently
   • Consider discussing multiple options that balance safety and patient preference

By following these recommendations, healthcare providers can help patients with a history of VTE select safe and effective contraceptive options that minimize thrombotic risk while meeting their reproductive health needs.