What birth control method is recommended for a patient with SLE, pulmonary embolism, and sickle cell trait?

Recommended Contraception for Patient with SLE, Pulmonary Embolism, and Sickle Cell Trait

This patient should receive a levonorgestrel intrauterine device (IUD) as first-line contraception, given her history of pulmonary embolism, SLE, and current anticoagulation therapy. 1

Primary Recommendation: Levonorgestrel IUD

The levonorgestrel IUD is the optimal choice for this patient because it provides highly effective contraception (pregnancy rate <1% per year) without increasing thrombotic risk, and offers the critical benefit of reducing menstrual bleeding in a patient on Eliquis. 2, 1

Key Supporting Evidence

• The American College of Rheumatology strongly recommends IUDs (copper or progestin) for women with rheumatic and musculoskeletal diseases receiving immunosuppressive therapy, which applies to this patient on CellCept (mycophenolate). 2

• Progestin IUDs do not increase VTE risk (RR 0.61,95% CI 0.24-1.53), making them safe for patients with prior thrombotic events. 2

• The levonorgestrel IUD remains safe regardless of antiphospholipid antibody status, though aPL testing should still be performed to fully characterize this patient's thrombotic risk profile. 1, 3

Additional Benefits for This Specific Patient

• Reduced menstrual bleeding: Critical for a patient on anticoagulation (Eliquis) to minimize bleeding complications. 2, 1, 3

• No daily adherence required: Ideal for a patient already managing multiple medications (Plaquenil, CellCept, prednisone, lisinopril, Eliquis, atorvastatin, omeprazole). 1, 3

• Safe with immunosuppression: Despite theoretical infection concerns, IUD-associated infection risk is not increased in immunosuppressed patients, including those with HIV and solid organ transplants. 2

• Addresses mycophenolate concerns: Since this patient takes CellCept (mycophenolate), the ACR conditionally recommends using an IUD alone OR two other contraceptive methods together, as mycophenolate may reduce hormonal contraceptive efficacy. The IUD alone satisfies this requirement. 2

Alternative Safe Option: Copper IUD

A copper IUD is an equally acceptable alternative that provides highly effective contraception without any hormonal component and no increased VTE risk. 2, 1

Considerations

• The copper IUD may increase menstrual bleeding and cramping for several months after insertion, which is a significant disadvantage for a patient on anticoagulation. 2

• This option is preferable only if the patient has strong preferences against hormonal methods. 1

Less Preferred but Acceptable: Progestin-Only Pills

Progestin-only pills are a low-risk alternative if the patient is unable or unwilling to use an IUD, though they are less effective due to adherence requirements. 2, 1

Limitations

• Pregnancy rates are higher (3-8% per year) compared to IUDs due to the need for daily adherence. 2

• This patient's complex medication regimen makes daily adherence more challenging. 1

• VTE risk is not increased with progestin-only pills (RR 0.90,95% CI 0.57-1.45). 2

Absolute Contraindications for This Patient

Combined estrogen-progestin contraceptives are absolutely contraindicated due to this patient's history of pulmonary embolism. 1

Rationale

• Estrogen-containing contraceptives significantly increase VTE risk, with odds ratios ranging from 2.2 to 6.6 depending on progestin type. 2

• The patient's history of pulmonary embolism represents an absolute contraindication regardless of SLE disease activity or aPL status. 1

• Even low-dose estrogen formulations and transdermal patches are contraindicated. 2

Depot medroxyprogesterone acetate (DMPA/Depo-Provera) should be avoided in this patient for two reasons: 2, 1

• DMPA carries a higher VTE risk than other progestin-only contraceptives (RR 2.67,95% CI 1.29-5.53), similar to combined oral contraceptives. 2

• DMPA causes bone mineral density decline (up to 7.5% over 2 years), which is particularly concerning for a patient on chronic prednisone therapy who is already at increased osteoporosis risk. 2

Essential Clinical Actions Before IUD Placement

Test for antiphospholipid antibodies (anticardiolipin antibodies, anti-β2-glycoprotein I antibodies, and lupus anticoagulant) before finalizing contraceptive choice, as positive aPL status significantly impacts overall thrombotic risk stratification, though it does not change the recommendation for levonorgestrel IUD. 1, 3

Assess current SLE disease activity, as this patient appears to have stable disease based on her well-woman exam presentation, which supports the safety of any progestin-only method. 2, 3

Common Pitfalls to Avoid

• Do not prescribe combined estrogen-progestin contraceptives based solely on stable SLE disease activity without considering the pulmonary embolism history, which is an independent absolute contraindication. 1

• Do not use the etonogestrel subdermal implant as a first-line option, as VTE data for this newer progestin implant are inadequate to permit recommendations in high-risk patients. 2

• Do not delay contraception while awaiting aPL testing results, as the levonorgestrel IUD is safe regardless of aPL status and pregnancy risk in this patient would be substantially higher than any contraceptive risk. 2, 1

• Do not overlook the patient's recent chlamydia infection when counseling; emphasize that IUDs do not protect against sexually transmitted infections and recommend condom use for dual protection. 2