Levonorgestrel-Releasing Intrauterine Device (LNG-IUD) is the Safest and Most Effective Contraceptive Option
For this 32-year-old woman with coronary artery disease, prior myocardial infarction, atrial fibrillation on anticoagulation (Eliquis), and heavy menses, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the optimal contraceptive choice. This recommendation addresses both her cardiovascular contraindications to estrogen-containing contraceptives and provides therapeutic benefit for her heavy menstrual bleeding 1.
Why Combined Hormonal Contraceptives Are Absolutely Contraindicated
Combined hormonal contraceptives (pills, patches, rings) are classified as Category 4 (unacceptable health risk) for women with a history of cardiovascular disease, particularly those with prior myocardial infarction and those on anticoagulation 1, 2.
Estrogen-containing contraceptives significantly increase thromboembolism risk, with current combined oral contraceptive use conferring a relative risk of 1.6-1.9 for myocardial infarction and 1.7-1.9 for ischemic stroke 2.
Women with established cardiovascular disease face substantially elevated risks with combined hormonal methods, making them absolutely inappropriate for this patient 3.
Why LNG-IUD is the Best Choice
Superior Efficacy
The LNG-IUD achieves pregnancy rates of <1% per year, with failure rates of 0.2-0.8% per year, making it among the most effective reversible contraceptive methods available 1, 2.
Long-acting reversible contraceptives like the LNG-IUD have similar effectiveness in ideal use and "real-world" use, unlike oral contraceptives which have higher typical-use failure rates 2.
Cardiovascular Safety
The European Society of Cardiology specifically recommends the LNG-IUD as the safest contraceptive for women with cardiovascular disease 1.
The LNG-IUD contains only progestin (no estrogen), eliminating the thrombotic risk associated with combined hormonal methods 1, 2.
Progestin-only methods do not confer increased risk of venous or arterial thrombosis 3.
Therapeutic Benefit for Heavy Menses
The LNG-IUD provides significant reduction in menstrual blood loss, making it particularly advantageous for this patient's heavy menses 2.
This dual benefit addresses both contraceptive needs and menstrual management, which is especially important given her anticoagulation therapy that may exacerbate bleeding 1.
Safety with Anticoagulation
Antibiotic prophylaxis is not recommended at the time of IUD insertion or removal in anticoagulated patients, as the risk of pelvic infection is not increased 1.
The IUD can be safely inserted in women on anticoagulation like Eliquis 1.
Alternative Options (Less Preferred)
Progestin-Only Pills
Progestin-only pills are acceptable but significantly less optimal, with typical-use failure rates of 3-8% per year compared to <1% for the LNG-IUD 2, 1.
They require strict daily adherence, making them less reliable in real-world use 2.
They do not provide the therapeutic benefit for heavy menses that the LNG-IUD offers 2.
Copper IUD
The copper IUD has similar efficacy to the LNG-IUD (failure rates 0.2-0.8% per year) and is cardiovascularly safe 1, 2.
However, the copper IUD is contraindicated in this patient because it typically increases menstrual bleeding, which would worsen her existing heavy menses and is particularly problematic given her anticoagulation therapy 2, 4.
Depot Medroxyprogesterone Acetate (DMPA)
DMPA has typical-use failure rates of 3-8% per year, making it less effective than the LNG-IUD 2, 1.
DMPA may double the risk of venous thrombosis, though this risk is still lower than with combined hormonal contraceptives 3.
DMPA should be used cautiously in patients with heart failure, which may be a concern given her history of myocardial infarction 1.
Critical Pitfalls to Avoid
Never prescribe combined hormonal contraceptives (pills, patches, or vaginal rings) to this patient—this represents an unacceptable health risk given her cardiovascular history and anticoagulation 1, 2.
Do not assume that "low-dose" estrogen formulations are safe in this context—any estrogen-containing contraceptive is contraindicated 2, 3.
Avoid the copper IUD despite its excellent efficacy, as it will worsen her heavy menses 2.
Emergency Contraception Considerations
Should emergency contraception be needed, the copper IUD insertion within 5 days is the most effective method, preventing over 95% of pregnancies 1, 4.
Levonorgestrel emergency contraceptive pills (1.5 mg single dose) are safe for women on anticoagulation and have no cardiovascular contraindications 1, 2.