Can a patient with a history of TEVAR, impaired liver function, and migraines safely use the Jadelle (levonorgestrel) implant for contraception?

Jadelle Contraceptive Implant for a Patient with Migraines with Visual Aura, TEVAR, and Abnormal LFTs

The Jadelle (levonorgestrel) implant is contraindicated in this patient due to her history of migraines with visual aura, which significantly increases her risk of stroke.

Risk Assessment

Migraine with Visual Aura

• Migraine with visual aura is a major contraindication for estrogen-containing contraceptives due to increased stroke risk 1
• While Jadelle is a progestin-only method that doesn't contain estrogen, the patient's migraine with visual aura represents a significant neurological condition that requires careful consideration

TEVAR History

• Patient underwent thoracic endovascular aortic repair (TEVAR) in 2013 for blunt thoracic aortic injury
• No follow-up since 2015 and recent CT was requested to check for endoleak/complications
• This vascular history further increases concerns about thrombotic risk

Abnormal Liver Function Tests

• Patient has documented abnormal LFTs from 2022 (ALP 165, GGT 99, ALT 59)
• The American Association for the Study of Liver Disease (AASLD) guidance indicates that progestin-only contraception can be acceptable in compensated liver disease but requires caution with decompensated liver disease 1
• Without knowing the cause of her abnormal LFTs, this represents an additional concern

Contraceptive Options Analysis

Progestin-Only Methods (Including Jadelle)

• Jadelle is a levonorgestrel-releasing implant approved for 5 years of continuous use 2
• Highly effective with failure rates <1% 1
• Does not contain estrogen, which avoids estrogen-associated thrombotic risks 1
• However, the patient's combination of risk factors (migraine with visual aura, vascular history with TEVAR, and abnormal LFTs) creates a concerning clinical picture

Intrauterine Device (IUD) Options

• Copper IUD (non-hormonal) would be the safest option for this patient:

  • No hormonal components that could affect migraine, vascular status, or liver function
  • Highly effective with failure rate of 0.8% 1
  • Effective for 10-12 years 1
  • No drug interactions or metabolic concerns

• Levonorgestrel IUD (hormonal) would be a second-line option:

  • Lower systemic hormone levels than implants 1
  • Highly effective with failure rate of 0.2% 1
  • Effective for 3-7 years depending on type 1

Management Recommendation

1. Do not proceed with Jadelle implant due to the combination of risk factors

2. Recommend copper IUD as first-line option due to:

   • Complete absence of hormones
   • No impact on migraine condition
   • No metabolic burden on the liver
   • No vascular/thrombotic concerns
   • Highly effective (>99%)
   • Long-acting (10+ years)

3. If patient strongly prefers a hormonal method, consider levonorgestrel IUD as a second choice, as it provides more localized hormone delivery with less systemic absorption

4. Address her other medical concerns:

   • Arrange follow-up for her TEVAR (overdue since 2015)
   • Complete the ordered LFTs and investigate cause of abnormalities
   • Consider neurological referral for management of worsening migraines with visual aura

Pitfalls and Caveats

• Despite the patient's preference for Jadelle, her medical history creates a concerning risk profile
• Long-acting reversible contraceptives (LARCs) are generally excellent choices for patients wanting to avoid pregnancy after completing their family 1
• The patient's concern about compliance with pills or injections is valid, but safety must be prioritized
• The copper IUD provides the best balance of effectiveness, safety, and long-term use for this specific patient's complex medical history