Contraception for Women with Lupus and History of Pulmonary Embolism
A levonorgestrel intrauterine device (IUD) is the optimal contraceptive choice for a woman with SLE and prior pulmonary embolism, as it provides highly effective contraception without increasing thrombotic risk and offers the additional benefit of reducing menstrual bleeding in patients requiring anticoagulation. 1, 2
Primary Recommendation: Levonorgestrel IUD
The levonorgestrel IUD is strongly recommended by the American College of Rheumatology as the preferred contraceptive method for SLE patients, particularly when benefits of reduced menstrual bleeding outweigh potential risks 2. This is especially relevant for your patient who likely requires ongoing anticoagulation following her PE 1, 2.
Key advantages specific to this patient:
- Pregnancy prevention rates <1% per year with no increased thrombosis risk 2
- Reduces excessive menstrual bleeding, which is critical for patients on anticoagulation therapy 1, 2
- Does not require daily adherence, ideal for patients on complex medication regimens 2
- Safe regardless of antiphospholipid antibody status 2
Alternative Safe Options
Copper IUD
- Can be used in any SLE patient without hormonal concerns 1
- Equally effective for contraception without thrombotic risk 2
- Does not provide menstrual bleeding reduction benefit 1
Progestin-Only Pills
- Suitable for SLE patients with positive antiphospholipid antibodies 1, 3
- Lower efficacy than IUDs due to adherence requirements 2
- Safe thrombotic profile in SLE patients 1, 4
Absolute Contraindications for This Patient
Combined Estrogen-Progestin Contraceptives (Pills, Patches, Vaginal Rings)
These are absolutely contraindicated in your patient due to her history of PE. 1, 5 The EULAR guidelines explicitly state that combined hormones should be discouraged in women with thrombotic history, and in young women with arterial events and positive lupus anticoagulant, combined pills increased arterial event risk compared to non-users 1.
Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera)
Avoid DMPA in this patient for two critical reasons:
- Increased thrombosis risk compared to other progestin-only methods (RR 2.67) 3, 6
- The American College of Rheumatology specifically recommends avoiding DMPA in patients with positive antiphospholipid antibodies due to increased thrombosis risk 3
- Additional concern for bone mineral density loss (up to 7.5% over 2 years), particularly problematic if patient requires corticosteroids 3, 7
Essential Clinical Considerations
Antiphospholipid Antibody Testing
Before finalizing contraceptive choice, ensure this patient has been tested for antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies, anti-beta-2-glycoprotein I). 2, 5 This significantly impacts contraceptive recommendations, though the levonorgestrel IUD remains safe regardless of aPL status 2.
Disease Activity Assessment
- For SLE patients with moderate to severe disease activity, progestin-only methods like levonorgestrel IUDs are strongly recommended over combined contraceptives 2
- Even in stable/inactive SLE, the history of PE makes estrogen-containing contraceptives inappropriate 1, 5
Common Pitfalls to Avoid
Do not prescribe combined estrogen-progestin contraceptives based solely on "stable lupus" – the prior PE history is an independent absolute contraindication regardless of current SLE activity 1, 5.
Do not use transdermal estrogen-progestin patches – these have higher estrogen exposure and should be avoided in rheumatic diseases 5.
Do not assume all progestin-only methods are equivalent – DMPA carries higher thrombotic risk than other progestin-only options 3, 6.