Can contraceptives be used in patients who are anticoagulated (on anticoagulant therapy)?

From the Guidelines

Contraceptives can be used in patients who are anticoagulated, but the choice of method should be carefully considered to minimize the risk of thrombosis, with progestin-only methods or non-hormonal methods being preferred options. When considering contraceptive options for patients on anticoagulant therapy, it is crucial to weigh the risks and benefits of each method. According to the 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases 1, estrogen-containing contraceptives are contraindicated in patients with antiphospholipid antibodies due to the increased risk of thrombosis.

Key Considerations

• Estrogen-containing contraceptives increase the risk of venous thromboembolism (VTE) and are not recommended for patients on anticoagulants 1.
• Progestin-only methods, such as the progestin-only pill or the levonorgestrel intrauterine device (IUD), are considered safer options and do not increase the risk of VTE 1.
• The copper IUD is a highly effective alternative that does not increase the risk of VTE, but may increase menstrual bleeding and cramping for several months after insertion 1.
• Depot medroxyprogesterone acetate (DMPA) injections are not recommended due to concerns regarding thrombogenicity 1.

Recommendations

• Progestin-only methods, such as the progestin-only pill or the levonorgestrel IUD, are recommended for patients on anticoagulant therapy.
• Non-hormonal methods, such as the copper IUD or barrier methods, are also excellent choices with no interaction with anticoagulation therapy.
• Patients should be aware of the potential for increased menstrual bleeding with hormonal IUDs, which typically improves over time. By carefully selecting the most appropriate contraceptive method, patients on anticoagulant therapy can effectively manage their reproductive health while minimizing the risk of thrombosis.

From the FDA Drug Label

Oral contraceptives should not be used in women who currently have the following conditions: Thrombophlebitis or thromboembolic disorders The risk of thromboembolic disease associated with oral contraceptives is not related to length of use and disappears after pill use is stopped If feasible, oral contraceptives should be discontinued at least four weeks prior to and for two weeks after elective surgery of a type associated with an increase in risk of thromboembolism and during and following prolonged immobilization The risk of morbidity and mortality increases significantly in the presence of other underlying risk factors such as certain inherited thrombophilias, hypertension, hyperlipidemias, obesity, and diabetes

Contraindications and warnings for patients on anticoagulant therapy are not explicitly stated in the provided drug labels. However, the labels do mention that oral contraceptives should not be used in women with thrombophlebitis or thromboembolic disorders.

• The labels also state that the risk of thromboembolic disease associated with oral contraceptives is well established.
• Additionally, the labels advise that oral contraceptives should be discontinued at least four weeks prior to and for two weeks after elective surgery of a type associated with an increase in risk of thromboembolism.
• It is also mentioned that the risk of morbidity and mortality increases significantly in the presence of other underlying risk factors such as certain inherited thrombophilias, hypertension, hyperlipidemias, obesity, and diabetes. Based on this information, it can be inferred that patients who are anticoagulated may be at a higher risk of thromboembolic events when using oral contraceptives. Therefore, oral contraceptives should be used with caution in patients who are anticoagulated, and the decision to use them should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 2, 3.

From the Research

Contraceptives in Anticoagulated Patients

• The use of contraceptives in patients who are anticoagulated is a complex issue, and the choice of contraceptive method depends on various factors, including the type of anticoagulant therapy and the patient's medical history 4, 5.
• Progestin-only contraceptives (POCs) are generally considered safe for use in women with thrombophilia and/or a history of venous thromboembolism (VTE), as they do not increase the risk of thrombosis 4, 6.
• However, some studies suggest that depot medroxyprogesterone acetate (DMPA) may increase the risk of VTE, particularly in women with certain thrombogenic mutations or those who smoke 4.
• The levonorgestrel-releasing intrauterine system (LNG-IUS) is a safe and effective contraceptive option for women with thrombophilia and/or a history of VTE, and its use is not affected by oral anticoagulant therapy (OAT) 7.
• Combined hormonal contraceptives (CHCs) that contain estrogen are associated with an increased risk of VTE and are generally not recommended for women with thrombophilia and/or a history of VTE 8, 6.

Specific Contraceptive Methods

• Progestin-only pills (POPs) and implants are considered safe for use in women with thrombophilia and/or a history of VTE 4, 6.
• The LNG-IUS is a safe and effective contraceptive option for women with thrombophilia and/or a history of VTE, and its use is not affected by OAT 7.
• DMPA may increase the risk of VTE, particularly in women with certain thrombogenic mutations or those who smoke 4.
• CHCs that contain estrogen are associated with an increased risk of VTE and are generally not recommended for women with thrombophilia and/or a history of VTE 8, 6.

Clinical Considerations

• Women with thrombophilia and/or a history of VTE should be counseled on the risks and benefits of different contraceptive methods, and the choice of method should be individualized based on their medical history and other factors 5, 6.
• OAT does not modify the bleeding pattern associated with the LNG-IUS in women with thrombophilia and/or a history of VTE 7.
• The screening for thrombophilia is not indicated in every woman with the wish for contraception, but should be restricted to certain cases, such as women with a positive history for VTE or with close relatives suffering from VTE in younger than 50 years 6.