Progesterone-Only Contraceptives: Patient Suitability Assessment
Progesterone-only contraceptives can be given to most patients, but are absolutely contraindicated in those with positive antiphospholipid antibodies (especially depot medroxyprogesterone acetate/DMPA), current pregnancy, known breast cancer, undiagnosed vaginal bleeding, hypersensitivity to components, or liver tumors/acute liver disease. 1, 2
Absolute Contraindications (Do Not Prescribe)
The FDA labels progesterone-only pills as contraindicated in: 2
- Known or suspected pregnancy
- Known or suspected breast carcinoma
- Undiagnosed abnormal genital bleeding
- Hypersensitivity to any component
- Benign or malignant liver tumors
- Acute liver disease
For patients with positive antiphospholipid antibodies, avoid DMPA entirely due to significantly increased thrombosis risk (RR 2.67,95% CI 1.29-5.53). 3, 1 Instead, the American College of Rheumatology strongly recommends levonorgestrel IUD, copper IUD, or progestin-only pills as safer alternatives. 3, 1
High-Risk Cardiovascular Conditions Requiring Caution
Avoid estrogen-containing contraceptives but progesterone-only preparations may be considered in patients with: 3
Congenital Heart Disease with Pulmonary Arterial Hypertension
- Estrogen-containing contraceptives are absolutely contraindicated 3
- Progesterone-only preparations may be considered, though they increase thrombosis risk 3
- Levonorgestrel, barrier methods, or tubal ligation are recommended for women with cyanotic CHD and PAH 3
Other High-Risk Cardiac Conditions
The ACC/AHA guidelines note progesterone-only contraceptives should be used with extreme caution in: 3
- Cyanosis related to intracardiac shunt
- Prior Fontan procedure
- Severe pulmonary arterial hypertension
- Eisenmenger physiology
Critical caveat: Medroxyprogesterone, progesterone-only pills, and levonorgestrel may cause fluid retention and should be used with caution in patients with heart failure. 3
Relative Contraindications Requiring Risk-Benefit Discussion
Systemic Lupus Erythematosus (SLE)
- Use progesterone-only methods with caution, especially if positive antiphospholipid antibodies present 1
- Avoid DMPA due to increased thrombosis risk 3, 1
- Levonorgestrel IUD or progestin-only pills are preferred alternatives 3, 1
Osteoporosis Risk
Avoid long-term DMPA use in patients at risk for osteoporosis, as it causes bone mineral density loss up to 7.5% over 2 years. 1 Alternative progesterone-only methods (IUDs or pills) are recommended instead. 1
Immunosuppressive Therapy
- IUDs (copper or progestin) are strongly recommended despite theoretical infection concerns 3, 1
- Studies in HIV-positive women and solid organ transplant patients show no increased infection risk 3
Practical Prescribing Considerations
Patient Counseling Requirements
Before prescribing, discuss: 2
- Necessity of taking pills at the same time every day
- Need for backup contraception (condoms/spermicides) for 48 hours if pill taken ≥3 hours late
- Expected menstrual irregularities (most common complaint with all progesterone-only methods) 4
- Breakthrough bleeding affects ~40% of users; 25% discontinue for this reason 5
Managing Breakthrough Bleeding
Adding 5 mg norethindrone acetate significantly reduces bleeding frequency and quantity in women experiencing vaginal bleeding on progesterone-only pills. 5 This intervention shows significant improvement at 2,4, and 6 weeks without increased side effects. 5
Common Pitfalls to Avoid
Do not assume all progesterone-only methods have equivalent thrombosis risk. DMPA carries higher VTE risk (RR 2.67) compared to progestin-only pills (RR 0.90) or levonorgestrel IUD (RR 0.61). 3
Do not prescribe progesterone-only pills without emphasizing strict timing adherence. The typical failure rate is 5% (vs. 0.5% with perfect use) due to late or omitted pills. 2
Do not overlook drug interactions. Rifampin, barbiturates, phenytoin, carbamazepine, and St. John's Wort reduce effectiveness by inducing hepatic enzymes. 2