Contraception for a 32-Year-Old Female with Atrial Fibrillation on Eliquis
For a 32-year-old woman with atrial fibrillation on apixaban (Eliquis), the levonorgestrel-releasing intrauterine device (LNG-IUD) or copper IUD are the most effective and safest contraceptive options, with the LNG-IUD being particularly advantageous due to its superior efficacy and reduction in menstrual blood loss.
Primary Recommendation: Long-Acting Reversible Contraceptives (LARCs)
Intrauterine devices represent the optimal choice for women with cardiovascular disease requiring anticoagulation. The European Society of Cardiology specifically identifies the levonorgestrel-releasing IUD as "the safest and most effective contraceptive that can be used in women with...cardiovascular disease" 1. These devices achieve pregnancy rates of <1% per year, placing them in the highest tier of contraceptive effectiveness 1.
Why IUDs Are Preferred
No thrombotic risk: Unlike estrogen-containing contraceptives, IUDs do not increase thromboembolism risk, which is critical for patients with atrial fibrillation already at elevated thrombotic risk 1.
Superior efficacy: Both copper and levonorgestrel IUDs have failure rates of 0.2-0.8% per year, making them among the most effective reversible contraceptive methods available 1, 2, 3.
No drug interactions: IUDs do not interfere with anticoagulation control, unlike estrogen-containing oral contraceptives which may upset anticoagulation management 1.
LNG-IUD vs. Copper IUD
The levonorgestrel-releasing IUD offers additional benefits over the copper IUD for this patient:
Reduced menstrual bleeding: The LNG-IUD reduces menstrual blood loss by 40-50% and induces amenorrhea in 35% of users after 2 years 1, 2. This is particularly valuable for a patient on anticoagulation who may experience heavier bleeding.
Equivalent efficacy: The LNG-IUD has a Pearl index of 0.1-0.2 per 100 woman-years, comparable to or better than copper IUDs 1, 4.
Duration: Provides effective contraception for 5 years 4.
The copper IUD remains an excellent alternative, particularly for women preferring hormone-free contraception, with efficacy lasting over 10 years and cumulative pregnancy rates of 3-5% 4, 5.
Contraindicated Methods
Combined estrogen-progestin contraceptives are absolutely contraindicated in this patient population:
The CDC Medical Eligibility Criteria classifies combined hormonal contraceptives as Category 4 (unacceptable health risk) for women with a history of deep venous thrombosis or pulmonary embolism on anticoagulation 1.
Estrogen-containing contraceptives significantly increase thromboembolism risk, which is particularly dangerous in patients with atrial fibrillation already at elevated stroke risk 1.
This includes oral contraceptive pills, transdermal patches, and vaginal rings 1.
Alternative Options (Less Preferred)
Progestin-Only Methods
Progestin-only pills and depot medroxyprogesterone acetate (DMPA) are acceptable but less optimal:
These methods are classified as Category 2 (advantages generally outweigh risks) for women with cardiovascular disease 1.
However, DMPA may cause fluid retention and should be used cautiously in patients with any degree of heart failure 1.
Progestin-only pills have higher typical-use failure rates (3-8% per year) compared to IUDs 1.
The subdermal progestin implant (etonogestrel) is highly effective (<1% failure rate) and represents another excellent LARC option 1.
Important Clinical Considerations
IUD Insertion in Anticoagulated Patients
Antibiotic prophylaxis is not recommended at the time of IUD insertion or removal, as the risk of pelvic infection is not increased 1.
IUD insertion can be performed safely in anticoagulated patients, though timing should be coordinated with her cardiologist if there are concerns about bleeding risk 2.
Perforation risk is low (0.6-16 per 1000 insertions) and is not significantly increased by anticoagulation 2.
Monitoring and Follow-Up
The most common reasons for IUD discontinuation are menstrual bleeding and dysmenorrhea with copper IUDs, which occur less frequently with LNG-IUDs 2, 3.
Expulsion occurs in 5-10% of cases within 5 years, with recurrence in approximately 30% 2.
After 5 years, approximately 50% of women continue using the copper IUD, indicating high long-term acceptability 3.
Emergency Contraception
Should unprotected intercourse occur, emergency contraception options include:
Copper IUD insertion within 5 days is the most effective emergency contraception method, preventing over 95% of pregnancies 1, 5.
Levonorgestrel emergency contraceptive pills (1.5 mg single dose) are safe and have no contraindications, including in women on anticoagulation 1.
Ulipristal acetate (30 mg) is more effective than levonorgestrel, especially when taken 3-5 days after intercourse 1, 6.