What birth control options are available for patients with contraindications to estrogen-containing methods, such as history of blood clots, stroke, or breast cancer?

Birth Control Options for Patients with Contraindications to Estrogen-Containing Methods

For patients with contraindications to estrogen-containing contraceptives such as history of blood clots, stroke, or breast cancer, progestin-only contraceptive methods are the most appropriate and safest options.

Progestin-Only Contraceptive Options

Long-Acting Reversible Contraceptives (LARCs)

1. Progestin-only Intrauterine Devices (IUDs)

   • Levonorgestrel IUD (Mirena, Kyleena, Skyla, etc.)

   • 99% effective with failure rate <1% 1

   • Duration: 3-7 years depending on type
   • Benefits: Decreased menstrual bleeding (helpful for patients on anticoagulation) 1
   • No increased risk of thrombosis 2

2. Progestin Implant (Nexplanon)

   • 99% effective with failure rate <1% 1

   • Duration: 3 years
   • No increased risk of thrombosis 2, 3

3. Injectable Progestin (Depo-Provera)

   • 99.7% effective with perfect use, 97% with typical use 4
   • Duration: Injection every 3 months (13 weeks)
   • Caution: Some studies suggest a possible slight increase in VTE risk, though evidence is limited 2
   • Contraindicated in patients with active thrombophlebitis or thromboembolic disorders 4

4. Progestin-Only Pills (Mini-Pills)

   • 99.5% effective with perfect use, 91% with typical use 1
   • Must be taken at same time daily (within 3-hour window)
   • No increased risk of thrombosis when used for contraception 2
   • Contraindicated in known/suspected breast cancer 5

Contraindications to Estrogen-Containing Methods

Estrogen-containing contraceptives (combined oral contraceptives, patch, ring) are contraindicated (Category 4) in patients with:

1. History of Thrombosis

   • Deep vein thrombosis (DVT) or pulmonary embolism (PE) 6, 1
   • Cerebrovascular accident (stroke) 6
   • Current or history of ischemic heart disease 6

2. Thrombogenic Conditions

   • Known thrombogenic mutations 6, 1
   • Positive antiphospholipid antibodies 1
   • Active cancer 1

3. Breast Cancer

   • Current or history of breast cancer 6, 5

4. Other High-Risk Conditions

   • Migraine with aura 6
   • Age ≥35 years who smoke ≥15 cigarettes/day 6, 1
   • Uncontrolled hypertension 6, 1
   • Complicated valvular heart disease 6

Risk Assessment for Different Patient Populations

Patients with History of Blood Clots

• Best options: Progestin IUD, progestin implant
• Acceptable options: Progestin-only pills
• Use with caution: Injectable progestin (DMPA) - some studies suggest slight increased risk 2
• Avoid: All estrogen-containing methods (combined pills, patch, ring) 6

Patients with History of Stroke

• Best options: Progestin IUD, progestin implant
• Acceptable options: Progestin-only pills (RR 1.02,95% CI 0.72-1.44 for stroke risk) 6
• Avoid: All estrogen-containing methods (RR 1.7,95% CI 1.5-1.9 for ischemic stroke) 6

Patients with History of Breast Cancer

• Best options: Non-hormonal methods (copper IUD)
• Avoid: All hormonal methods including progestin-only methods 5

Non-Hormonal Contraceptive Options

For patients who cannot use any hormonal methods (including those with breast cancer):

1. Copper IUD

   • 99% effective

   • Duration: Up to 10 years
   • No hormones, no increased thrombosis risk
   • May increase menstrual bleeding

2. Barrier Methods

   • Condoms (male/female): 82-87% effective with typical use 6
   • Diaphragm: 88% effective with typical use 6
   • Should be combined with spermicide for better effectiveness

Important Considerations

• Pregnancy risk: The risk of thrombosis during pregnancy (30 per 100,000 pregnancies) is higher than the risk with most contraceptive methods 6
• Effectiveness: LARCs (IUDs, implants) have the highest effectiveness rates and require minimal user compliance 1
• Monitoring: No special monitoring is required for progestin-only methods 1
• Emergency contraception: Progestin-only emergency contraception is safe for women with contraindications to estrogen 1

Common Pitfalls to Avoid

1. Assuming all hormonal methods carry the same risk: Progestin-only methods do not significantly increase thrombosis risk, unlike estrogen-containing methods 2, 3

2. Overestimating risks in younger patients: For women <35 without other risk factors, the absolute risk of thrombosis with estrogen-containing methods is very low 1

3. Inadequate counseling about effectiveness: Progestin-only pills require strict adherence to timing; LARCs may be better for patients who might struggle with daily pill-taking 1

4. Failing to consider non-contraceptive benefits: Progestin IUDs can reduce heavy menstrual bleeding, which may benefit patients on anticoagulation therapy 1