What contraception methods are suitable for patients with End-Stage Renal Disease (ESRD)?

Contraception in End-Stage Renal Disease

For women with ESRD, progestin-only methods (pills, injections, implants) and intrauterine devices (both levonorgestrel and copper) are the safest and most appropriate contraceptive options, while estrogen-containing contraceptives should be avoided due to thromboembolism risk. 1

Recommended Contraceptive Methods

First-Line Options

Levonorgestrel-releasing intrauterine devices (IUDs) are the preferred hormonal contraceptive for ESRD patients because they provide highly effective contraception with minimal systemic hormone exposure (only 4-13% of the exposure seen with combined oral contraceptives). 2, 3

• Copper (non-hormonal) IUDs are equally safe and highly effective, making them an excellent alternative for patients who prefer to avoid hormones entirely. 2, 1

• Progestin-only pills are generally safe in ESRD, though they have higher failure rates than IUDs and may cause irregular bleeding. 1

• Subdermal progestin implants (like etonogestrel) are highly effective with failure rates <1% per year and are appropriate for ESRD patients. 2

• Barrier methods (condoms, diaphragms) carry no medical risks and provide protection against sexually transmitted infections, though they have higher failure rates (18-28% per year with typical use). 2, 1

Methods to Use With Caution

Depot medroxyprogesterone acetate (DMPA) injections should be used cautiously or avoided in ESRD patients because this formulation can cause significant fluid retention, which is particularly problematic in patients already struggling with volume management on dialysis. 2, 3

• The European Society of Cardiology specifically warns that monthly injectable forms of medroxyprogesterone are inappropriate for patients with fluid overload concerns. 3

• If DMPA is used, patients require close monitoring for weight gain, edema, and signs of volume overload. 3

Contraindicated Methods

Estrogen-containing contraceptives (combined oral contraceptives, patches, vaginal rings) are contraindicated in ESRD due to substantially increased thromboembolism risk in this population. 2, 1

• ESRD patients already have elevated baseline thrombotic risk from uremia, endothelial dysfunction, and often concurrent anticoagulation needs for dialysis access. 1

• The transdermal estrogen patch results in even greater estrogen exposure than oral formulations and should be specifically avoided. 2

• Low-dose estrogen formulations (≤20 mcg ethinyl estradiol) may be considered only in early-stage CKD without proteinuria, but are not appropriate once patients reach ESRD. 1

Permanent Sterilization Considerations

Tubal ligation or hysteroscopic sterilization (Essure) may be considered for ESRD patients desiring permanent contraception, though surgical risks must be carefully weighed. 2, 3

• Hysteroscopic sterilization may be preferable to laparoscopic tubal ligation because it avoids general anesthesia and abdominal insufflation. 2, 3

• Vasectomy of a male partner is often the safest permanent option when the female partner has ESRD, though this requires frank discussion about the woman's prognosis. 2

Emergency Contraception

Levonorgestrel emergency contraception ("morning-after pill") is not contraindicated in ESRD, though acute fluid retention is a potential risk that should be discussed. 2

• The benefits of preventing unplanned pregnancy generally outweigh the temporary risk of fluid retention in ESRD patients. 2

Special Clinical Considerations

All women with ESRD of childbearing age require contraceptive counseling because while fertility is reduced in ESRD, pregnancy remains possible and carries extremely high maternal and fetal risks. 4, 1, 5

• Pregnancy in women on conventional hemodialysis (15-24 hours/week) has live birth rates of only 50-87%, with high rates of prematurity, low birth weight, and maternal complications. 2

• Unplanned pregnancy in ESRD patients taking teratogenic medications (such as renin-angiotensin system inhibitors or immunosuppressants in transplant recipients) poses additional serious risks. 2

The intrauterine device infection risk in ESRD remains controversial, but most experts consider IUDs appropriate with individualized assessment, particularly given the high efficacy and low systemic effects. 2, 1

• Patients on peritoneal dialysis require special consideration regarding IUD placement due to theoretical concerns about ascending infection, though evidence of increased risk is limited. 1

Contraceptive counseling should occur early and be revisited regularly, including discussion of failure rates, the specific risks of pregnancy in ESRD, and the patient's values and preferences. 2