Progesterone-Only Pills Are Acceptable for Patients with Thrombocytosis
Yes, a patient with high platelets can take progesterone-only pills (POPs), as they are considered acceptable contraception in myeloproliferative neoplasms causing thrombocytosis. 1
Guideline-Based Recommendation
The ESMO Clinical Practice Guidelines for myeloproliferative neoplasms (which commonly cause thrombocytosis) explicitly state that progesterone-only preparations are acceptable for oral contraception, while combined oral contraceptives (containing both estrogen and progesterone) are not recommended. 1 This represents the most direct guideline evidence addressing your specific question.
Key Distinction: Estrogen vs. Progesterone Risk
- The major thrombosis risk with hormonal contraception comes from estrogen, not progesterone 1
- Combined oral contraceptives are contraindicated due to estrogen's prothrombotic effects 1
- Progesterone-only methods carry minimal thrombotic risk in this population 2, 3
Clinical Context and Caveats
When to Exercise Additional Caution
While POPs are generally acceptable, consider additional risk stratification if the patient has:
- Prior thrombotic events (venous or arterial) - this elevates risk regardless of contraceptive choice 1
- Platelet count >1500 × 10⁹/L - defined as high-risk in MPN guidelines 1
- Positive antiphospholipid antibodies - avoid depot medroxyprogesterone acetate (DMPA) specifically, but POPs remain acceptable 4, 5
- Previous hemorrhage attributed to the MPN - though this relates more to disease management than contraceptive choice 1
Important Pitfall: Not All Progestin Methods Are Equal
Do not prescribe depot medroxyprogesterone acetate (DMPA/Depo-Provera) if the patient has additional thrombotic risk factors, as this specific progestin formulation carries elevated VTE risk (RR 2.67,95% CI 1.29-5.53) compared to other progestin-only methods. 4, 5, 6 POPs and levonorgestrel IUDs are safer alternatives. 4, 5
Alternative Progestin-Only Options
If POPs are not suitable due to adherence concerns (must be taken at the same time daily), consider: 4
- Levonorgestrel intrauterine device (LNG-IUD) - extremely low-risk and acceptable 1
- Etonogestrel implant - no increased VTE risk demonstrated 6, 2
- Barrier methods - if hormonal contraception is declined 1
Counseling Points
- Discuss the necessity of taking POPs at the same time every day for efficacy 4
- Counsel about thrombosis warning signs (leg swelling, chest pain, neurological symptoms) given underlying thrombocytosis 1
- Consider thromboprophylaxis if short-term hormonal manipulation is required (e.g., fertility treatment) 1
- Monitor platelet counts as part of routine MPN management, not specifically due to POP use 1
Evidence Quality Note
The ESMO guideline acknowledges that evidence for hormonal therapy in MPN is poor (Level V evidence), but the recommendation for progesterone-only preparations being acceptable represents expert consensus based on the known thrombotic mechanisms. 1 Research evidence confirms that POPs do not increase VTE risk in general populations or high-risk groups. 6, 2, 7