Contraindications to Progesterone-Only Contraception
Progesterone-only contraception is contraindicated in patients with active deep vein thrombosis, pulmonary embolism, arterial thromboembolic disease, history of these conditions, known liver dysfunction or disease, undiagnosed abnormal genital bleeding, and known or suspected breast cancer. 1
Absolute Contraindications
- Known hypersensitivity to ingredients (including peanut oil allergy for some formulations) 1
- Undiagnosed abnormal genital bleeding 1
- Known, suspected, or history of breast cancer 1, 2
- Active deep vein thrombosis or pulmonary embolism 1
- History of deep vein thrombosis or pulmonary embolism 1
- Active arterial thromboembolic disease (stroke, myocardial infarction) 1
- History of arterial thromboembolic disease 1
- Known liver dysfunction or disease 1, 3
- Known or suspected pregnancy 1
- Positive antiphospholipid antibodies (specific to depot medroxyprogesterone acetate/DMPA) 4, 5
Relative Contraindications
Cardiovascular Conditions
- Severe thrombocytopenia (especially for DMPA due to increased bleeding risk) 4
- Systemic lupus erythematosus with positive antiphospholipid antibodies 4
- Moderate to severe cardiac impairment (New York Heart Association Class III or IV) 4
- History of ischemic heart disease (continuation of DMPA is Category 3) 4
- History of stroke (continuation of DMPA is Category 3) 4
- Cyanotic congenital heart disease 5, 6
- Fontan procedure history 5
- Pulmonary arterial hypertension 5
Bone Health Concerns
- Increased risk for osteoporosis (especially for long-term DMPA use) 4
- Chronic glucocorticoid use (especially for DMPA) 4
Thrombosis Risk Differences Among Progesterone-Only Methods
Different progesterone-only contraceptives carry varying thrombosis risks:
- DMPA (injectable): Associated with significantly higher VTE risk (RR 2.67,95% CI 1.29-5.53) compared to other progesterone-only methods 4, 5, 7
- Progestin-only pills: No significant increase in VTE risk (RR 0.90,95% CI 0.57-1.45) 4
- Levonorgestrel IUD: No significant increase in VTE risk (RR 0.61,95% CI 0.24-1.53) 4, 8
- Progestin implants: Limited data on VTE risk 4
Special Considerations for Specific Patient Populations
Patients with Systemic Lupus Erythematosus (SLE)
- For SLE patients with stable/low disease activity without antiphospholipid antibodies: All progesterone-only methods are appropriate 4
- For SLE patients with moderate/severe disease activity: Progesterone-only methods preferred over combined hormonal contraceptives 4
- For SLE patients with positive antiphospholipid antibodies: Avoid DMPA; consider progestin-only pills or IUDs 4
Patients with Antiphospholipid Antibodies
- Strongly avoid DMPA due to increased thrombosis risk 4, 5
- Recommend levonorgestrel IUD, copper IUD, or progestin-only pills 4
Patients with Congenital Heart Disease
- Avoid DMPA in patients with cyanotic heart disease, Fontan physiology, atrial fibrillation, or pulmonary hypertension 5, 6
- Consider levonorgestrel IUD or barrier methods 5, 6
Patients at Risk for Osteoporosis
- Avoid long-term DMPA use due to potential bone mineral density loss (up to 7.5% over 2 years) 4
- Consider alternative progesterone-only methods such as IUDs or pills 4
Clinical Pitfalls and Caveats
- The risk of thrombosis with progesterone-only methods is generally much lower than with combined hormonal contraceptives, but DMPA appears to be an exception 4, 5, 7
- Recent evidence suggests all hormonal contraceptives, including progesterone-only methods, may be associated with a slight increase in breast cancer risk (OR 1.26,95% CI 1.16-1.37 for oral progestin-only pills) 2
- Patients with liver disease should avoid all hormonal contraceptives during acute phases of illness 1, 3
- For patients requiring immunosuppressive therapy, IUDs (copper or progestin) remain highly effective options despite theoretical infection concerns 4
- Fluid retention may occur with progesterone-only methods, warranting careful observation in patients with cardiac or renal dysfunction 1