What is an effective birth control option for patients with Factor V (Coagulation Factor Five) Leiden deficiency?

From the Guidelines

For patients with Factor V Leiden, the most effective and safest birth control options are progestin-only contraceptives, such as the progestin-only pill, hormonal IUDs like Mirena, Kyleena, or Skyla, or the copper IUD, as they do not increase the risk of blood clots, according to the 2020 American College of Rheumatology guideline 1. When considering birth control options for patients with Factor V Leiden, it is essential to prioritize methods that do not increase the risk of thrombosis. The 2020 American College of Rheumatology guideline recommends against combined estrogen-progestin contraceptives due to the increased risk of thromboembolism 1.

• Progestin-only contraceptives, such as the progestin-only pill or hormonal IUDs, are recommended as they are widely accepted as a lower-risk option in patients for whom estrogens are contraindicated but who still need effective contraception 1.
• The copper IUD is also a highly effective alternative that does not increase the risk of VTE, but it may increase menstrual bleeding and cramping for several months after insertion 1.
• Barrier methods, such as condoms, diaphragms, and cervical caps, are safe alternatives but have lower effectiveness rates with typical use. It is crucial to weigh the risks and benefits of each birth control option and consider the patient's specific medical history, clotting risk factors, and contraceptive needs when determining the most appropriate option, as suggested by the American College of Medical Genetics consensus statement on Factor V Leiden mutation testing 1.

From the Research

Effective Birth Control Options for Patients with Factor V Leiden

• Patients with factor V Leiden are at an increased risk of venous thromboembolism (VTE) when using oral contraceptives, with a more than 30-fold increase in relative risk reported in some studies 2.
• The risk of VTE is higher for women with the factor V Leiden mutation who use third-generation oral contraceptives compared to second-generation oral contraceptives 3.
• Hormone replacement therapy (HRT) also increases the risk of VTE in women with factor V Leiden, with an estimated absolute incidence of VTE of 15.4 per 1000 per year compared to 2.0 per 1000 per year in women without the mutation who are taking a placebo 4.
• The interaction between combined hormonal contraception (CHC) use and presence of factor V Leiden on VTE risk is statistically significant, with a higher interaction for drospirenone and cyproterone acetate users compared to first or second generation CHC users 5.

Considerations for Birth Control Options

• Women with factor V Leiden should be aware of the increased risk of VTE associated with oral contraceptive use and discuss alternative birth control options with their healthcare provider.
• The choice of birth control method should be individualized based on the woman's medical history, family history, and personal preferences.
• Further studies are needed to assess the cost-effectiveness of biological thrombophilia screening (FVL) when prescribing CHC 5.

Key Findings

• The risk of VTE is increased in women with factor V Leiden who use oral contraceptives, especially third-generation oral contraceptives 2, 3, 5.
• HRT also increases the risk of VTE in women with factor V Leiden 4.
• The interaction between CHC use and presence of factor V Leiden on VTE risk differs by progestin type, with a higher interaction for drospirenone and cyproterone acetate users 5.