What are the recommended contraceptive options for a 25-year-old female with a seizure disorder taking topiramate (anticonvulsant) who smokes 1 pack of cigarettes daily?

Recommended Contraceptive Options

For this 25-year-old woman with seizure disorder on topiramate who smokes heavily, long-acting reversible contraceptives (LARCs)—specifically the levonorgestrel IUD, copper IUD, or etonogestrel implant—are the optimal choices, as combined hormonal contraceptives are contraindicated due to smoking and have reduced efficacy with topiramate. 1

Why Combined Hormonal Contraceptives Should Be Avoided

Smoking Risk

• Combined hormonal contraceptives (pills, patches, rings) are absolutely contraindicated in women over age 35 who smoke any amount, and carry increased thrombotic risk in younger women who smoke heavily (≥1 pack/day). 1
• At age 25 with heavy smoking (1 pack daily), combined methods pose unacceptable cardiovascular risks that outweigh benefits. 1

Drug-Drug Interaction with Topiramate

• Topiramate is classified as a Category 3 medication (risks usually outweigh advantages) for combined hormonal contraceptives due to enzyme-inducing properties that reduce contraceptive efficacy. 1
• Topiramate at doses of 200-800 mg/day decreases ethinyl estradiol exposure by 18-30%, significantly increasing contraceptive failure risk. 2, 3
• Even at lower doses (50-200 mg/day), topiramate can cause breakthrough bleeding and decreased contraceptive efficacy. 2, 4

Optimal Contraceptive Choices

First-Line: Long-Acting Reversible Contraceptives (LARCs)

Levonorgestrel IUD (Mirena, Liletta, Kyleena, Skyla)

• Category 1 (no restriction) for use with topiramate—no drug interaction exists. 1
• Failure rate <1% annually, comparable to sterilization. 1
• Duration: 3-8 years depending on formulation. 1
• Additional benefit: reduces menstrual bleeding and dysmenorrhea. 1

Copper IUD (Paragard)

• Category 1 (no restriction) for use with topiramate—completely hormone-free, eliminating all drug interaction concerns. 1
• Failure rate <1% annually. 1
• Duration: up to 10-12 years. 1
• Ideal for women who prefer non-hormonal contraception. 1

Etonogestrel Implant (Nexplanon)

• Category 1 (no restriction) for use with topiramate. 1
• Failure rate <1% annually. 1
• Duration: 3 years. 1
• Single-rod subdermal placement in upper arm. 1

Second-Line: Progestin-Only Methods

Progestin-Only Pills (POPs)

• Category 1 for use with topiramate—no significant drug interaction. 1, 5
• Requires strict daily adherence (must be taken at same time daily). 2
• Less effective than LARCs due to user-dependent compliance. 1
• Backup contraception needed for 2 days if started >5 days after menses. 1

Depot Medroxyprogesterone Acetate (DMPA) Injection

• Category 1 for use with topiramate, though some guidelines recommend shortening injection interval from 12 to 10 weeks when used with enzyme-inducing AEDs. 1, 3
• Administered every 10-12 weeks. 3
• Backup contraception needed for 7 days if started >7 days after menses. 1

Critical Counseling Points

Teratogenicity Concerns

• Topiramate is FDA pregnancy category D with documented teratogenic effects, including increased risk of oral clefts and other congenital malformations. 1, 4
• Given that approximately 50% of pregnancies are unintended, highly effective contraception is essential. 4
• Women of childbearing potential on topiramate should receive 4 mg folic acid daily (higher than standard 0.4-1 mg dose) starting at least one month before any planned conception. 1

Contraceptive Failure Recognition

• Any woman using combined hormonal contraceptives with topiramate should be counseled to report breakthrough bleeding immediately, as this may signal contraceptive failure. 2, 4
• Unscheduled bleeding warrants pregnancy testing. 6

Documentation Requirements

• Pregnancy planning or contraception plans should be documented at least annually for all women of childbearing age taking topiramate. 4
• Only 7% of women receive adequate contraception counseling when prescribed teratogenic AEDs—this represents a critical care gap. 4

Common Pitfalls to Avoid

• Do not prescribe standard-dose combined oral contraceptives (<50 mcg ethinyl estradiol) with topiramate—if combined methods are absolutely necessary despite smoking, preparations with ≥50 mcg ethinyl estradiol are required, though this remains suboptimal. 3
• Levonorgestrel implants (not IUDs) are contraindicated with enzyme-inducing AEDs due to documented contraceptive failures. 3
• Do not assume contraception is unnecessary—many women with epilepsy incorrectly believe they have reduced fertility. 4
• Avoid naltrexone-bupropion for weight management in this patient—it is contraindicated in seizure disorders. 1

Practical Implementation

Immediate next steps:

• Initiate LARC placement (levonorgestrel IUD, copper IUD, or implant) at any time if reasonably certain patient is not pregnant. 1
• Backup contraception not needed with copper IUD; needed for 7 days with levonorgestrel IUD if placed >7 days after menses started. 1
• Prescribe 4 mg folic acid daily given topiramate use. 1
• Provide smoking cessation counseling and resources. 1
• Document contraception plan in medical record. 4