Can a woman with Factor V Leiden take progestin-only (progestin) birth control pills?

Progestin-Only Birth Control Pills for Women with Factor V Leiden

Women with Factor V Leiden can safely use progestin-only birth control pills as they do not increase the risk of venous thromboembolism. 1, 2

Safety Profile of Progestin-Only Pills in Thrombophilia

Progestin-only contraceptives are a safer alternative for women with thrombophilia compared to estrogen-containing methods:

• Studies show that venous thromboembolism (VTE) risk in women using progestin-only pills is not increased, with a relative risk of 0.90 (95% CI 0.57-1.45) 1
• The American College of Rheumatology strongly recommends progestin-only pills for women with thrombophilic conditions 1
• Progestin-only methods are widely accepted as lower-risk options for patients with contraindications to estrogen who still need effective contraception 1

Contraceptive Options for Women with Factor V Leiden

For women with Factor V Leiden, contraceptive options can be prioritized as follows:

1. First-line options (highest safety profile):

   • Levonorgestrel IUD (relative risk for VTE: 0.61) 1, 2
   • Copper IUD (no hormones, no VTE risk) 1, 2
   • Progestin-only pills 1, 2

2. Contraindicated options (avoid completely):

   • Any estrogen-containing contraceptives (combined oral contraceptives, patches, rings) 1, 2, 3

Important Considerations

• Effectiveness: Progestin-only pills have a perfect use failure rate of 0.5% in the first year, but are less effective than IUDs or implants 2
• Timing requirements: Must be taken at the same time each day, within a 3-hour window 2
• Pregnancy risk: The risk of pregnancy-related VTE in the general population is >10 times that seen with estrogen-progestin contraceptive use, making effective contraception important 1

Cautions and Monitoring

• Avoid depot medroxyprogesterone acetate (DMPA) injections as limited data suggest a higher VTE risk (RR 2.67) compared to other progestin-only methods 1
• While one case report described a pulmonary embolism in a Factor V Leiden carrier using a progestin IUD 4, this is inconsistent with larger studies showing no increased risk 1, 2
• The absolute risk of VTE in Factor V Leiden carriers using progestin-only methods remains very low compared to estrogen-containing methods 3

Clinical Decision Algorithm

1. Confirm Factor V Leiden status
2. Discuss contraceptive options, emphasizing:
   • Complete avoidance of estrogen-containing methods
   • Preference for IUDs (levonorgestrel or copper) due to higher effectiveness
   • Progestin-only pills as an acceptable alternative if IUDs are not desired
3. If choosing progestin-only pills:
   • Emphasize strict adherence to timing requirements
   • Consider backup contraception method (condoms) for additional protection

The evidence strongly supports that progestin-only pills are a safe contraceptive option for women with Factor V Leiden, though IUDs may offer better effectiveness with similar or better safety profiles.