Is Mirena (levonorgestrel) safe for patients with rheumatoid arthritis (RA)?

Mirena (Levonorgestrel IUD) Safety in Rheumatoid Arthritis Patients

The Mirena (levonorgestrel) intrauterine device is safe and recommended for patients with rheumatoid arthritis, as it provides highly effective contraception without increasing disease activity or thrombotic risk. 1

Safety Profile of Mirena in RA

The American College of Rheumatology's 2020 guidelines for reproductive health in rheumatic diseases specifically address contraceptive options for patients with rheumatic conditions:

• Progestin IUDs like Mirena are considered "safe in all women with rheumatic and musculoskeletal disease" with a failure rate of <1% 1
• Mirena may provide the additional benefit of decreasing menstrual bleeding, which can be particularly helpful for patients on anticoagulation therapy 1
• Unlike combined hormonal contraceptives, progestin-only methods like Mirena do not increase thrombotic risk 2

Decision Algorithm for Contraception in RA

Step 1: Assess for Antiphospholipid Antibodies (aPL)

• If aPL positive: Mirena (or other IUD) is preferred over other contraceptive options 1
• If aPL negative: All contraceptive options can be considered, with IUDs still being highly recommended 1

Step 2: Assess Disease Activity

• For patients with low, moderate, or high disease activity: Mirena is appropriate and safe 1
• For patients on immunosuppressive therapy: Mirena is strongly recommended due to its high efficacy 1

Step 3: Consider Bone Health

• If patient is at risk for osteoporosis (common in RA patients on glucocorticoids): Mirena is preferred over depot medroxyprogesterone acetate (DMPA), which can decrease bone mineral density 1

Advantages of Mirena for RA Patients

1. No Impact on Disease Activity: Unlike some contraceptive methods, Mirena has not been shown to worsen RA symptoms 3

2. No Thrombotic Risk: Progestin-only methods like Mirena show no increased thrombosis risk (RR 0.61,95% CI 0.24-1.53) 2

3. Highly Effective: >99% effective, which is crucial for RA patients who may be taking teratogenic medications like methotrexate or leflunomide 1

4. Reduced Menstrual Bleeding: Can help manage menorrhagia, which may benefit patients with anemia or those on anticoagulation 1

5. Minimal Systemic Absorption: Primarily works locally in the uterus with minimal systemic effects 1

Special Considerations

• Immunosuppression: Despite theoretical concerns about infection risk during IUD insertion in immunosuppressed patients, studies in other immunocompromised populations show no increased risk 1

• Medication Interactions: Unlike oral contraceptives, Mirena is not affected by medications that might reduce contraceptive efficacy 1

• Long-term Use: Provides contraception for up to 5-7 years, reducing the need for frequent medical visits 1

Common Pitfalls to Avoid

• Avoiding IUDs due to unfounded infection concerns: Studies show no increased infection risk in immunosuppressed patients 1

• Choosing combined hormonal contraceptives: These should be avoided in RA patients with positive aPL or high disease activity 1, 2

• Selecting DMPA for patients on glucocorticoids: This can worsen bone mineral density loss, already a concern with long-term steroid use 1

In conclusion, Mirena represents one of the safest and most effective contraceptive options for women with rheumatoid arthritis, regardless of disease activity level, and should be considered a first-line option for these patients.