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Contraception: What a Rheumatologist needs to know!
June 11 2015 9:18 AM ET — via RheumReports
Do you talk to your patients about contraception? Do you know the pros and cons of various contraceptive options? Dr. Eliza Chakravarty from Oklahoma Medical Research Foundation introduced the Pregnancy in Rheumatic Diseases Session on June 10, 2015 with an informative review on the various types of contraception and a compelling argument that rheumatologists should play a role in the discussion.
We often advise our patients to avoid pregnancy until their rheumatic disease is in remission and their medications are optimized. However, most rheumatologists leave the decision on how this is done to the patient, their partner and their primary care physician. Most of us probably don't even know the types of contraception that are available!
Barrier contraceptives are probably the most commonly used contraceptives in our patients. Condoms, but not diaphragms or sponges, have the additional benefit of protection from STIs. An advantage of barrier contraceptives is that they are not associated with risk of disease flare or thrombosis. However, they only work if they are used correctly, and even then, can rupture or fail, making them undesirable as a long-term strategy.
Oral contraceptives are another option for patients and work well when taken as prescribed. Estrogen-based contraceptives were previously avoided in patients with lupus due to the perceived risk of thrombosis and disease flares. With the advent of low-dose estrogen contraceptives and data from two RCTs in the early 2000s, practice around their use has changed. In both large RCTs, there was no increase in the rate of lupus flares in women receiving low-dose estrogen-based contraceptives compared to placebo. There was a slightly higher risk of thrombosis in all groups. However, patients with active lupus, previous history of thrombosis and antiphospholipid antibodies were excluded from these studies. Based on these studies, estrogen-based contraceptives are likely safe in women with stable lupus who do not have APLAs or a previous history of thrombosis.
The vaginal ring (NuvaRing) contains both estrogen and progestin. It is inserted by the patient herself into the vagina for three weeks, after which it is removed and another is inserted 7 days later. The ring has been shown to be as effective as oral contraceptives. It has never been studied in patients with connective tissue disease and is contra-indicated in patients with recurrent thrombosis.
Progestin-based contraceptives have not been associated with lupus or connective tissue disease flares. However, they have a theoretical increased risk of thrombosis. Third generation progestin has a higher risk of thrombosis compared to levonorgestrel or norethisterone. The progestin mini-pill contains ⅓ the progesterone and may have a lower risk of thrombosis. A meta-analysis by Mantha (BMJ 2012) did not find a significantly elevated risk of thrombosis, but was limited by the small number and quality of published studies available. There is a small risk of osteoporosis with progestin-based contraception, which is reversible when contraception is discontinued. Like other hormone-based contraception methods, if these are not taken exactly on time, efficacy is not reliable.
The most effective types of contraception are long-acting reversible contraceptives which include IUDs and intradermal progesterone implants. Available IUDs include the copper IUD (Novo-T and Flexi-T) and Mirena, a levonorgestrel-containing IUD. These need to be inserted and removed by qualified health care provider and have high rates of efficacy. Copper IUDs can be effective for up to 10 years, but are sometimes associated with heavy menses and cramping, limiting their utility in severely anemic patients. The Mirena IUD lasts 3-5 years and often has the additional benefit of amenorrhea, which is good for women with anemia or thrombocytopenia. The use of Mirena is limited by cost, which is around $300. IUDs have not been studied in women with rheumatic diseases. Hormone release is local and is unlikely to be associated with flare of underlying disease. There is a theoretical increased risk of infection, which has not been shown in other immunosuppressed populations. Implanon and Nexplanon are birth control implants which are implanted subdermally and release low doses of progestin. These can be costly and are not currently available in Canada.
Options for emergency birth control include copper IUDs and hormone-based therapy. Copper IUDs are 99% effective up to 10 days after intercourse and also provide long-term contraception. Hormone-based emergency options reduce the risk of pregnancy by 40-90% but are not a substitute for effective contraception.
Bottom Line: The options for contraception are constantly changing, with many new and improved products. If we are advising our patients to avoid pregnancy, we should at least have a basic idea of the contraceptive options available along with their pros and cons. After listening to the options available, I feel that I am better able to advise patients (and I hope you are too, after reading this!). If patients can afford it, the Mirena IUD has the best efficacy and is probably a safe option for our patients. Combination OCPs containing low-dose estrogen are a good second option, if patients have no history of thrombosis and have stable disease. Not only should we tell patients to avoid pregnancy, we should probably discuss strategies on how best to do this and have a reasonable understanding of the options available!
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About the Author
Dr. Shahin Jamal
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.
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