Estrogen-Containing Contraceptives in Multiple Sclerosis
Estrogen-containing birth control is NOT contraindicated in women with multiple sclerosis, except in those with prolonged immobility due to severe disability. 1
Primary Recommendation
Women with MS can safely use combined hormonal contraceptives unless they have prolonged immobility. The 2016 US Medical Eligibility Criteria for Contraceptive Use, developed by the CDC after systematic evidence review, concluded that most contraceptive methods are safe for women with MS. 1 The only restriction applies to combined hormonal contraceptives in women with prolonged immobility due to concerns about venous thromboembolism risk. 1
Evidence Supporting Safety
The available evidence demonstrates reassuring safety data:
A systematic review found that combined oral contraceptives (COCs) do not worsen MS disease progression, including disability level, disease severity, relapse rates, or new brain lesions on MRI (Level I-II evidence). 2
Long-term retrospective data suggest COC use may actually be associated with less severe disease progression. A study of 174 women with MS found that COC users had lower disability scores and were less likely to evolve to secondary-progressive MS compared to non-users, particularly among those receiving immunomodulatory treatment. 3
No evidence exists that hormonal contraception worsens the clinical course of established MS. 2, 4
Critical Distinction: MS vs. Autoimmune Rheumatic Diseases
This guidance for MS differs substantially from recommendations for systemic lupus erythematosus (SLE) and antiphospholipid antibody-positive patients, where estrogen-containing contraceptives are absolutely contraindicated due to thrombosis risk. 5, 6 MS does not carry the same thrombotic risk profile as SLE or antiphospholipid syndrome, and these conditions should not be conflated when making contraceptive recommendations.
Practical Clinical Algorithm
For women with MS and normal mobility:
- All contraceptive methods are appropriate options, including combined hormonal contraceptives 1
- Choice should be based on patient preference, side effect profile, and need for highly effective contraception
For women with MS and prolonged immobility:
- Avoid combined hormonal contraceptives (pills, patches, rings) 1
- Recommend progestin-only methods (pills, implants, injections) or intrauterine devices 1
For women with MS taking teratogenic disease-modifying therapies:
- Strongly consider long-acting reversible contraception (IUDs or implants) as the most effective option to prevent pregnancy during treatment 1
- Disease-modifying therapies do not appear to decrease hormonal contraceptive effectiveness, though formal drug interaction studies are limited 1
Important Caveats
One case-control study suggested a weak association between COC use and MS/CIS susceptibility (OR 1.52), particularly with levonorgestrel-containing formulations. 7 However, this finding relates to MS risk development in healthy women, not disease progression in women already diagnosed with MS, and the authors themselves urged cautious interpretation, suggesting unmeasured lifestyle confounders as more likely explanations. 7