What are the recommendations for oral contraception in patients with portal vein thrombosis?

Contraception Recommendations for Patients with Portal Vein Thrombosis

Combined estrogen-containing contraceptives are absolutely contraindicated in patients with portal vein thrombosis due to the significantly increased risk of recurrent thrombosis. 1

Recommended Contraceptive Options

First-line options:

1. Intrauterine Devices (IUDs)

   • Copper IUD: Highly effective, non-hormonal option with no thrombotic risk 1
   • Levonorgestrel IUD: Provides localized progestin action with minimal systemic effects 1

2. Progestin-only pill: Safe alternative with no significant increase in thrombotic risk 1, 2

Options to avoid:

• Combined estrogen-progestin contraceptives (pills, patches, vaginal rings): These increase thrombosis risk 3.5-fold compared to non-use 3 and are strongly contraindicated in patients with existing thrombosis 1
• Depot medroxyprogesterone acetate (DMPA): Not recommended due to potential thrombogenicity concerns 1

Evidence and Rationale

Thrombotic Risk

• Portal vein thrombosis represents a significant prothrombotic condition where additional thrombotic risk factors should be avoided 1
• Combined oral contraceptives significantly increase thrombotic risk:
  • Overall 3.5-fold increased risk compared to non-users 3
  • 22.1-fold increased odds of cerebral venous thrombosis 1
  • The combination of hormonal contraceptives with prothrombotic conditions dramatically increases thrombosis risk 1

Safety of Progestin-only Methods

• Progestin-only methods do not significantly increase thrombosis risk 2, 4
• The American College of Rheumatology strongly recommends IUDs (levonorgestrel or copper) or progestin-only pills for women with prothrombotic conditions 1
• Relative risk of VTE with progestin-only pill is 0.90 (95% CI 0.57-1.45) and with progestin IUD is 0.61 (95% CI 0.24-1.53) 1

Special Considerations

• For patients with portal hypertension (common in chronic portal vein thrombosis):
  • Increased risk of bleeding from esophageal varices 1
  • Splenomegaly may lead to decreased platelet counts 1
  • These factors further increase bleeding risks with anticoagulation 1
  • Copper IUDs may increase menstrual bleeding and cramping 1
  • Levonorgestrel IUDs may decrease menstrual symptoms, which is beneficial for patients on anticoagulation 1

Management Algorithm

1. Assess current thrombotic status:

   • Acute vs. chronic portal vein thrombosis
   • Presence of portal hypertension
   • Current anticoagulation therapy

2. Contraceptive recommendation:

   • First choice: Levonorgestrel IUD (especially if patient has heavy menstrual bleeding)
   • Second choice: Copper IUD (if patient prefers non-hormonal method)
   • Third choice: Progestin-only pill (if IUD is not acceptable)

3. Contraceptives to avoid:

   • All combined estrogen-containing contraceptives (pills, patches, rings)
   • Injectable DMPA

Clinical Pearls and Pitfalls

• Pitfall: Assuming all hormonal contraceptives carry the same thrombotic risk

  • Avoid by: Distinguishing between estrogen-containing methods (high risk) and progestin-only methods (low risk)

• Pitfall: Overlooking the interaction between anticoagulation and contraceptive choice

  • Avoid by: Considering that levonorgestrel IUDs may reduce menstrual bleeding in patients on anticoagulation

• Pitfall: Failing to recognize that portal vein thrombosis often coexists with other prothrombotic conditions

  • Avoid by: Screening for additional risk factors like myeloproliferative neoplasms (present in 21% of PVT cases) 1

• Pitfall: Assuming all progestin-only methods have the same safety profile

  • Avoid by: Recognizing that DMPA may have higher thrombotic risk than other progestin-only methods 1