What birth control method is suitable for a female patient of childbearing age with bipolar symptoms?

Birth Control Selection for Women with Bipolar Disorder

For women with bipolar disorder, long-acting reversible contraceptives (LARCs)—specifically the etonogestrel implant (Nexplanon) or levonorgestrel IUD (Mirena)—are the optimal first-line choices, as they provide the highest contraceptive efficacy (>99%) without drug interactions with mood stabilizers and without worsening psychiatric symptoms. 1, 2

Why LARCs Are Superior for This Population

Contraceptive Efficacy Is Critical

• Women with bipolar disorder face substantial risks if pregnancy occurs while on mood stabilizers, particularly valproate (highest teratogenic risk) and lithium (greatest concern during breastfeeding) 3
• Nexplanon has a failure rate of only 0.05% with typical use, and Mirena has a 0.2% failure rate—far superior to combined oral contraceptives (9% typical use failure) 1
• The high efficacy of LARCs is essential because unintended pregnancy in bipolar disorder requires difficult decisions about continuing teratogenic medications versus risking psychiatric decompensation 4, 5

No Drug Interactions with Mood Stabilizers

• Unlike combined oral contraceptives, which can have reduced effectiveness with certain anticonvulsants (carbamazepine, topiramate) commonly used for bipolar disorder, LARCs are not affected by these drug interactions 6, 7
• Lithium, valproate, and other mood stabilizers do not reduce LARC effectiveness 6

Psychiatric Safety Profile

• Limited but reassuring evidence shows that depot medroxyprogesterone acetate (DMPA), IUDs, and sterilization did not increase psychiatric hospitalizations among women with bipolar disorder 2
• One study found that oral contraceptives did not significantly worsen mood cycling in women with bipolar disorder 2
• Progestin-only methods (like Nexplanon and Mirena) avoid estrogen, which theoretically could affect mood, though evidence is mixed 2

Specific LARC Recommendations

First Choice: Etonogestrel Implant (Nexplanon)

• Provides 3 years of highly effective contraception with 99.95% efficacy 1
• Particularly advantageous for women who cannot use estrogen-containing methods 1
• No requirement for patient follow-up to maintain effectiveness 1
• Ideal for women on multiple psychiatric medications where adherence to daily pills may be challenging 1

Second Choice: Levonorgestrel IUD (Mirena)

• Provides 5-7 years of contraception with 99.8% efficacy 1
• Additional benefit of significantly reduced menstrual bleeding, which may help women experiencing menstrual-related mood symptoms 1
• Continuation rates exceed 80% at one year 1

Methods to Avoid or Use with Caution

Combined Oral Contraceptives: Not Ideal but Acceptable

• If a woman strongly prefers oral contraceptives, low-dose monophasic formulations (30-35 μg ethinyl estradiol with levonorgestrel or norgestimate) are Category 1 (no restrictions) per CDC guidelines 7
• However, the 9% typical use failure rate makes them suboptimal given the high stakes of unintended pregnancy in bipolar disorder 1
• Certain mood-altering drugs like lithium might alter cycle regularity or fertility signs, requiring careful evaluation 6

Fertility Awareness-Based Methods: Contraindicated

• These methods have 24% typical use failure rates and are inappropriate for women where pregnancy poses significant risks 1
• Mood stabilizers like lithium can alter cycle regularity, making symptom-based and calendar-based methods unreliable 6
• The CDC specifically notes that drugs affecting cycle regularity require either caution or delay in using these methods 6

Critical Counseling Points

Pre-Conception Planning Is Essential

• Pre-conception counseling should be an integral part of managing bipolar disorder in women of childbearing age 4
• Discuss the risks of taking mood stabilizers during pregnancy versus the risks of untreated bipolar disorder 4, 5
• The postpartum period carries extremely high risk for bipolar relapse, making highly effective contraception crucial for spacing pregnancies 5, 8, 3

Dual Protection Considerations

• LARCs provide no STI protection; condoms should be used concurrently if STI risk exists 6
• Consistent condom use reduces STI risk including HIV 6

Common Pitfalls to Avoid

• Do not assume oral contraceptives are adequate for women with bipolar disorder—the combination of typical use failure rates and potential medication non-adherence creates unacceptable pregnancy risk 1, 4
• Do not delay contraceptive counseling until a woman requests it; initiate discussions proactively 4
• Do not overlook that pregnancy neither protects against nor exacerbates bipolar disorder, but the postpartum period dramatically increases relapse risk 8
• Screen for anticonvulsant mood stabilizers (carbamazepine, topiramate) before prescribing combined hormonal methods, as these reduce contraceptive efficacy 6, 7

Implementation Strategy

1. Offer LARC methods as first-line options, presenting them before less effective methods 1
2. Use the U.S. Medical Eligibility Criteria to ensure the chosen method is appropriate for any comorbid conditions 1
3. Emphasize that LARCs are easily reversible when pregnancy is desired, allowing for planned conception with psychiatric medication optimization 1
4. Consider immediate postpartum LARC placement to prevent short-interval pregnancy and allow adequate interpregnancy interval 1