What contraceptive options are suitable for a patient with a history of provoked Deep Vein Thrombosis (DVT) who is currently taking Xarelto (rivaroxaban) for anticoagulation and was previously on Xulane (ethinyl estradiol and norelgestromin)?

Contraceptive Options After Provoked DVT on Anticoagulation

For a patient with provoked DVT currently on rivaroxaban, progestin-only contraceptives (implants, IUDs, or pills) are the safest options and should be used instead of any estrogen-containing methods. 1, 2

Why Estrogen-Containing Contraceptives Are Contraindicated

Xulane (ethinyl estradiol/norelgestromin patch) must be permanently discontinued due to the following risks:

• The transdermal patch increases VTE risk 5-8 fold compared to non-users (OR 5.10-7.9) 3, 4, 5
• All combined hormonal contraceptives (CHCs) containing ethinyl estradiol increase VTE risk 2-4 fold, with the patch conferring among the highest risks 6, 4
• Even with concurrent anticoagulation, estrogen-containing contraceptives are potentially harmful in patients with prior thrombotic events 7
• The American Heart Association specifically identifies prior thrombotic events as a contraindication to estrogen-containing contraceptives 7

Recommended Safe Contraceptive Options

First-Line: Progestin-Only Methods

Subdermal etonogestrel implant (Nexplanon):

• Does not induce a prothrombotic state and carries no increased VTE risk 8
• Highly effective (>99%) with no estrogen component 6
• The absence of estrogen eliminates the mechanism that increases thrombotic risk (decreased antithrombin III and protein S) 8

Levonorgestrel IUD (Mirena, Skyla, Kyleena):

• No increased VTE risk demonstrated in multiple studies 4, 5
• Highly effective (>99%) 6
• Provides local rather than systemic hormone effects

Progestin-only pills (norethindrone, drospirenone):

• No association with VTE risk in large studies 4, 9
• Effectiveness 90% with typical use, requiring strict daily adherence 6

Second-Line: Non-Hormonal Methods

Copper IUD:

• No hormonal VTE risk
• Highly effective (>99%) 6

Barrier methods (condoms, diaphragm):

• No VTE risk but lower effectiveness (87-88%) 6

Critical Management Principles

Regarding anticoagulation duration:

• For provoked DVT, anticoagulation for 3 months is sufficient if the provoking factor has resolved 1, 2
• Extended anticoagulation beyond 3 months is not required for provoked VTE 1, 2
• The annual recurrence risk after completing 3 months of anticoagulation for provoked DVT is less than 1% 10

If considering any future estrogen use (NOT recommended):

• Women must discontinue hormonal therapy before stopping anticoagulation 1
• If estrogen therapy were continued for a strong clinical indication, anticoagulation must continue for the entire duration of hormone use 1
• However, given the history of DVT, this approach is not advisable and progestin-only methods should be prioritized 7

Common Pitfalls to Avoid

Do not assume transdermal estrogen is safer than oral:

• While transdermal estradiol (used for menopause) has lower VTE risk than oral estrogen, the contraceptive patch (Xulane) contains ethinyl estradiol and norelgestromin, which carries one of the highest VTE risks among all contraceptives 6, 4, 11
• The patch data should not be confused with menopausal transdermal estradiol formulations 10

Do not use depot medroxyprogesterone (Depo-Provera) as first choice:

• While progestin-only, it shows a 3.6-fold increased VTE risk in some studies 5
• Implants and IUDs are safer progestin-only alternatives 8, 4

Do not restart any combined hormonal contraceptive:

• Even low-dose formulations (≤20 μg ethinyl estradiol) increase VTE risk 6, 4
• The patient's prior use of Xulane was likely the provoking factor for the DVT 1, 12