What are the considerations for contraception in females with rheumatic conditions?

Contraception Awareness and Considerations in Women with Rheumatic Conditions

Women with rheumatic diseases significantly underutilize effective contraception despite facing substantial pregnancy risks from active disease and teratogenic medications, making early and repeated contraceptive counseling by rheumatologists essential for preventing unplanned pregnancies and optimizing maternal-fetal outcomes. 1, 2

Current State of Contraceptive Awareness

The awareness gap is substantial: Studies demonstrate that women with rheumatic and musculoskeletal diseases (RMD) typically underutilize effective contraception, with only 42.7% of women with rheumatoid arthritis of childbearing age documented to be using any contraceptive method. 1, 3 Among those not using contraception, only 22.1% received documented counseling regarding pregnancy planning. 3

This represents a critical failure in reproductive healthcare delivery, as many of these women are prescribed disease-modifying antirheumatic drugs (DMARDs) with teratogenic potential, including methotrexate (used by 55.3% in one study). 3

Essential Contraceptive Counseling Framework

Timing and Approach

The American College of Rheumatology strongly recommends discussing contraception and pregnancy planning at the initial or early visit with all women of reproductive age, and periodically thereafter, especially when initiating potentially teratogenic medications. 1

The "One Key Question" approach provides a simple framework: "Would you like to become pregnant in the next year?" 1 This opens the door to individualized contraceptive counseling that addresses both efficacy and safety considerations specific to rheumatic disease.

Disease-Specific Contraceptive Selection Algorithm

Step 1: Assess Antiphospholipid Antibody (aPL) Status 1, 4

• If aPL positive:

  • Preferred: IUDs (copper or progestin) with <1% failure rate 1
  • Alternative: Progestin-only pill (less effective at 5-8% failure rate) 1
  • ABSOLUTELY AVOID: All combined estrogen-progestin contraceptives due to Category 4 thrombotic risk 1, 4

• If aPL negative: Proceed to Step 2

Step 2: Evaluate for Systemic Lupus Erythematosus (SLE) 1

• SLE with low/stable disease activity:

  • Preferred: IUDs or progestin implant (<1% failure rate) 1
  • Acceptable: Combined estrogen-progestin pill, progestin-only pill, vaginal ring, or DMPA 1
  • AVOID: Transdermal estrogen patch (higher estrogen exposure increases flare/thrombosis risk) 1, 5

• SLE with moderate-high disease activity:

  • Strongly preferred: IUDs or progestin implant over other hormonal contraceptives 1
  • Acceptable alternatives: Combined estrogen-progestin pill, progestin-only pill, vaginal ring, or DMPA 1
  • AVOID: Transdermal estrogen patch 1, 5

Step 3: Consider Special Medication and Bone Health Circumstances 1

• If taking mycophenolate mofetil/mycophenolic acid:

  • Require: IUD alone OR two other contraceptive methods combined (due to potential reduction in oral contraceptive efficacy) 1

• If at risk for osteoporosis (glucocorticoid use or underlying disease):

  • AVOID: DMPA long-term (causes up to 7.5% bone mineral density decline over 2 years) 1, 5

• If on immunosuppressive therapy:

  • Strongly recommended: IUD (copper or progestin) despite theoretical infection concerns, as studies in HIV patients and solid organ transplant recipients show no increased infection risk 1

Step 4: For all other rheumatic conditions (RA, spondyloarthritis, etc.) without SLE or positive aPL:

• Strongly recommended: Any effective contraceptive method (hormonal or IUD) 1, 5
• Preferred: Long-acting reversible contraceptives (IUDs or implants) due to lowest failure rates 1, 5

Contraceptive Efficacy Hierarchy

Highly Effective (Long-Acting Reversible Contraceptives - <1% failure rate): 1

• Copper IUD (safe in all RMD; may increase menstrual bleeding)
• Progestin IUD (safe in all RMD; may decrease menstrual bleeding)
• Progestin implant (limited data but likely safe in all RMD)

Effective (3-8% failure rate): 1

• Progestin-only pill (5-8% failure; requires same-time daily dosing)
• DMPA injection (3% failure; contraindicated if aPL positive or osteoporosis risk)
• Combined estrogen-progestin pill (5-8% failure; contraindicated if aPL positive or very active SLE)
• Vaginal ring (5-8% failure; contraindicated if aPL positive or very active SLE)
• Transdermal patch (5-8% failure; contraindicated if aPL positive or any SLE due to higher estrogen exposure)

Less Effective (12-28% failure rate): 1

• Barrier methods (condoms 18%, diaphragm 12%)
• Fertility awareness methods (24%)
• Spermicide (28%)

Critical Safety Considerations

Emergency Contraception Access

All patients with rheumatic disease, including those with SLE or positive aPL, should be counseled about emergency contraception availability. 1, 5 Levonorgestrel (over-the-counter) has no medical contraindications, including thrombophilia, and the low risks are far outweighed by unplanned pregnancy risks. 1, 4

Common Clinical Pitfalls

Pitfall #1: Failing to assess aPL status before prescribing estrogen-containing contraceptives significantly increases thrombosis risk. 5 Always obtain antiphospholipid antibody panel (anticardiolipin, anti-β2-glycoprotein I, lupus anticoagulant) before initiating combined hormonal contraception. 4

Pitfall #2: Assuming IUDs are contraindicated in immunosuppressed patients. Evidence from HIV-positive women and solid organ transplant recipients demonstrates no increased infection risk, making IUDs the most effective option for women on immunosuppressive therapy. 1

Pitfall #3: Prescribing DMPA to patients on chronic glucocorticoids or with underlying bone disease without considering osteoporosis risk. 1, 5

Pitfall #4: Failing to provide dual contraception counseling for women on mycophenolate medications, which may reduce hormonal contraceptive efficacy. 1

Dual Protection Strategy

IUDs and hormonal contraceptives provide zero STI protection. 1 Women with rheumatic disease on immunosuppression face increased STI complication severity, making consistent condom use essential for dual protection even when using highly effective contraception. 4

Coordination with Specialists

Rheumatology consultation is required before IUD placement to ensure disease activity is stable, as active lupus flares may increase procedural complications. 4 The rheumatologist should work collaboratively with gynecology to determine the safest, most effective contraceptive method for each patient. 2, 6

Evidence Quality and Nuances

The 2020 American College of Rheumatology guidelines represent the highest quality evidence available, based on systematic review and expert consensus. 1 However, important limitations exist: controlled studies of estrogen-progestin contraceptives in SLE enrolled only women with stable, low disease activity and specifically excluded those with high disease activity or thrombosis history. 1 This means recommendations for moderate-high disease activity SLE are based on lower-quality evidence and expert opinion, justifying the conditional rather than strong recommendation for preferring IUDs/implants in this population. 1

The mycophenolate-contraceptive interaction remains controversial, with the FDA package insert recommending additional barrier methods, while the European Medicine Agency recently stated "two forms of contraception are preferred but no longer mandatory." 1 Given the severe teratogenic risk of mycophenolate, the conservative approach of requiring IUD or dual contraception is prudent in clinical practice. 1