When using combined hormonal contraceptives (CHC), what degree of hyperlipidemia and non-alcoholic fatty liver disease (NAFLD) warrant a treatment change to progesterone-only contraceptives?

Contraception Recommendations for Women with Hyperlipidemia and NAFLD

Women with significant hyperlipidemia (total cholesterol ≥240 mg/dL) or advanced NAFLD should switch from combined hormonal contraceptives to progestin-only methods to reduce cardiovascular risk.

Hyperlipidemia Considerations

Risk Assessment and Recommendations

• Severity thresholds warranting switch to progestin-only methods:

  • Total cholesterol ≥240 mg/dL
  • Presence of multiple cardiovascular risk factors alongside hyperlipidemia
  • Evidence of atherosclerotic disease

• Evidence on hyperlipidemia risk:

  • Women with hypercholesterolemia using combined hormonal contraceptives (CHCs) have a dramatically increased risk of myocardial infarction (adjusted OR 24.7,95% CI 5.6-108.5) compared to women with neither risk factor 1
  • CHCs in women with dyslipidemia increase myocardial infarction risk (OR 25,95% CI 6-109) 2
  • Women with dyslipidemia using CHCs have increased risk for transient ischemic attacks or cerebrovascular accidents (RR 1.76,95% CI 1.51-2.06) 1

Monitoring Recommendations

• For women with mild-to-moderate hyperlipidemia (total cholesterol <240 mg/dL) who choose to continue CHCs:
  • Monitor lipid profiles every 3-6 months
  • Assess for additional cardiovascular risk factors
  • Consider switch to progestin-only methods if lipid levels worsen

NAFLD Considerations

Risk Assessment and Recommendations

• Severity thresholds warranting switch to progestin-only methods:

  • Evidence of advanced fibrosis or cirrhosis
  • Elevated liver enzymes >2-3 times upper limit of normal
  • Presence of metabolic syndrome alongside NAFLD

• Evidence on NAFLD risk:

  • CHCs should be avoided in women with decompensated cirrhosis due to concerns of impaired estrogen metabolism 3
  • Women with NAFLD require careful review of metabolic profiles before using CHCs 3
  • Transdermal estrogen may be beneficial for NAFLD progression compared to oral administration 4

Contraceptive Options for Women with Hyperlipidemia and NAFLD

Recommended Options (in order of preference):

1. Intrauterine Devices (IUDs):

   • Copper IUDs (hormone-free) - failure rate <1%, effective for up to 10 years 3
   • Levonorgestrel IUDs - failure rate <1%, effective for 3-5 years 3

2. Progestin-only Methods:

   • Implants - lowest failure rate (0.05%), effective for up to 3 years 3
   • Depot medroxyprogesterone acetate (DMPA) - typical failure rate ~6%, administered every 12 weeks 3
   • Progestin-only pills - failure rate ~9%, requires strict adherence to timing 3

Cautions and Considerations:

• For DMPA: Be aware of potential black box warning for decreased bone density (normalizes after cessation) 3
• For progestin-only pills: Requires strict adherence to timing of daily dosing 3
• For women with compensated liver disease: Low-dose CHCs or progestin-only methods may be acceptable 5

Special Considerations

• Women with NAFLD and prior gestational diabetes should be particularly cautious with progestin-only contraceptives, as recent evidence suggests they may increase NAFLD risk (adjusted OR 4.28,95% CI 1.55-11.85) 6

• Screening for hyperlipidemia before initiating hormonal contraceptives is not routinely necessary due to low prevalence of undiagnosed disease in women of reproductive age 3

• For women with both hyperlipidemia and NAFLD, prioritize cardiovascular risk assessment, as NAFLD is associated with increased cardiovascular mortality 7

• The U.S. Medical Eligibility Criteria (MEC) classifies CHC use in women with certain hyperlipidemias as category 2/3 (depending on type and severity of hyperlipidemia and presence of other cardiovascular risk factors) 3

Remember that while contraceptive decisions should consider these recommendations, pregnancy itself carries significant risks that must be weighed against contraceptive risks when making clinical decisions.