Can I use a hormonal Intrauterine Device (IUD) and Oral Contraceptive Pills (OCPs) together?

Using Hormonal IUD and Oral Contraceptive Pills Together

Using a hormonal intrauterine device (IUD) and oral contraceptive pills (OCPs) together is generally unnecessary for contraception purposes, as each method alone provides excellent contraceptive efficacy, but may be appropriate in specific clinical scenarios for non-contraceptive benefits.

Understanding the Mechanisms of Action

Hormonal IUD

• Works primarily through local effects on the endometrium and cervical mucus
• May inhibit ovulation in approximately half of cycles, though this varies by individual 1
• Provides 99% contraceptive efficacy alone
• Typically causes irregular bleeding patterns initially, with decreased overall bleeding over time

Oral Contraceptive Pills

• Work primarily by inhibiting ovulation
• Also thicken cervical mucus and thin the endometrium
• Provide 91-99% contraceptive efficacy (depending on perfect vs. typical use)

Clinical Scenarios Where Combined Use May Be Appropriate

1. Patients taking mycophenolate mofetil/mycophenolic acid (MMF)

   • The American College of Rheumatology conditionally recommends that women with rheumatic and musculoskeletal diseases (RMD) taking MMF use either:
     • An IUD alone OR
     • Two other methods of contraception together 2
   • This is because MMF may reduce serum estrogen and progesterone levels, potentially reducing the efficacy of oral contraceptives

2. Management of heavy or irregular bleeding with IUD

   • Some patients with a hormonal IUD may experience breakthrough bleeding, especially in the first few months
   • Short-term use of OCPs can help manage this bleeding pattern until the IUD's effect stabilizes

3. Non-contraceptive benefits

   • OCPs may provide additional benefits not fully addressed by the IUD alone:
     • Acne management
     • Cycle control
     • Management of premenstrual symptoms

Important Considerations and Risks

1. Redundant contraception

   • Using both methods solely for pregnancy prevention is unnecessary, as each method alone is highly effective

2. Increased hormone exposure

   • Combined use means exposure to both systemic hormones (from OCPs) and local hormones (from IUD)
   • This may increase the risk of hormone-related side effects

3. Cost implications

   • Using two methods increases cost without proportional increase in contraceptive efficacy

4. Venous thromboembolism (VTE) risk

   • OCPs, particularly those containing estrogen, carry a small increased risk of VTE 3
   • The hormonal IUD does not significantly increase VTE risk due to minimal systemic hormone absorption

Special Populations

1. Patients with rheumatic and musculoskeletal diseases (RMD)

   • The American College of Rheumatology strongly recommends IUDs (copper or progestin) for women with RMD who are receiving immunosuppressive therapy 2
   • For patients taking MMF, combined methods may be appropriate as noted above

2. Patients at risk for osteoporosis

   • For women at increased risk for osteoporosis from glucocorticoid use or underlying disease, the American College of Rheumatology conditionally recommends against using depot medroxyprogesterone acetate (DMPA) as a long-term contraceptive 2
   • A hormonal IUD with OCPs may be preferable to DMPA in these patients

Decision-Making Algorithm

1. Assess primary goal of contraception

   • If contraception is the only goal → Choose either IUD or OCPs alone, not both
   • If additional benefits are needed → Consider if one method alone can address all needs

2. Consider medication interactions

   • If patient is taking MMF → Consider IUD alone or two methods together
   • If patient is on other medications that might reduce OCP efficacy → IUD may be preferable

3. Evaluate bleeding patterns and other symptoms

   • If patient has a hormonal IUD but experiences problematic bleeding → Short-term OCP use may help
   • If patient needs benefits that IUD alone doesn't provide (acne control, etc.) → Combined approach may be reasonable

4. Assess risk factors

   • If patient has risk factors for VTE → Avoid estrogen-containing OCPs
   • If patient has osteoporosis risk → Avoid DMPA, consider IUD with or without OCPs

In conclusion, while using both methods together is not necessary for contraception alone, there are specific clinical scenarios where the combination may be appropriate. The decision should be based on the patient's specific medical conditions, medication use, and need for non-contraceptive benefits.