Progestin-only options may be safer in women with cardiovascular risk
Women who face an unacceptable level of cardiovascular risk with combined OCs may still be candidates for progestin-only contraceptives. Although data are thin regarding the risks of progestins in the absence of estrogen, an international WHO study found no increased cardiovascular risk with the use of oral or injectable progestins.20
Current breast cancer is the only medical condition in which progestin-only contraception is contraindicated (category 4). Significant or multiple cardiac risk factors are classified as category 3 in regard to depot medroxyprogesterone acetate, and as category 1 or 2 for progestin-only pills.
Current DVT or VTE is classified as category 3 in regard to progestin-only contraception. A history of DVT or VTE is category 2 (TABLE 4).
TABLE 4
Risks of progestin-only contraceptives may outweigh benefits in these conditions
| CATEGORY 4 – CONTRAINDICATED |
| Current breast cancer |
| CATEGORY 3 – RISKS GENERALLY OUTWEIGH BENEFITS |
| Cardiovascular risk (for depot medroxyprogesterone acetate) |
Multiple CV risk factors
|
| Systolic BP >160 mm Hg |
| Diastolic BP >100 mm Hg |
| Current vascular disease |
Advanced diabetes
|
| Cardiovascular risk (for all progestin-only contraceptives) |
| History of ischemic heart disease while on the contraceptive |
| Clotting risk |
| Current deep venous thrombosis or pulmonary embolism |
| Stroke risk |
| History of stroke while on the contraceptive |
| Migraine with aura developing while on contraceptive |
| Gastrointestinal illness |
| Active viral hepatitis |
| Liver tumor |
| Decompensated cirrhosis |
| Cancer risk |
| History of breast cancer, remission up to 5 years |
| Unexplained vaginal bleeding |
| CV=cardiovascular |
| SOURCE: World Health Organization |
Liver disease, cancer may rule out use of hormones
Estrogens and progestins are metabolized by the liver, and women with significant liver dysfunction may accumulate medication. Hormones are also contraindicated in the setting of hormone-sensitive tumors, such as liver adenomas and breast cancer.
In addition, hormones may interact with—and should be avoided during use of—drugs that affect metabolic enzymes, such as certain anticonvulsants, rifampin, and some antiretrovirals.1
Intrauterine option is underused
Two types of intrauterine contraception (IUC) are available in the United States: the CuT-380A and the LNG-20. The former uses copper, whereas the latter delivers the progestin levonorgestrel directly to the endometrium. Both methods are extremely effective, with cumulative failure rates below 1% to 2% over 5 to 10 years.21 Unlike most hormonal contraceptives, IUCs do not require patient compliance, and the LNG-20 has the additional benefit of decreasing menstrual blood loss.21
Despite these advantages, fear of uterine infection has led to underuse of IUC in the United States.22 A worldwide review of prospective studies of IUC revealed that the risk of infection is limited to the first 20 days after insertion, when the risk of pelvic inflammatory disease (PID) is approximately 1%.23 Thereafter, the risk of infection is significantly lower and can be linked to other PID risk factors, such as young age and multiple partners.23,24 The risk may be even lower with the LNG-20 than with the copper system.25 The IUC’s safety and high level of effectiveness make it an excellent choice for many women with chronic medical conditions.
Picture is murky in immunocompromised women
Infection caused by IUC may be unlikely in a healthy woman, but use of IUC in immunocompromised patients carries uncertain risk. Data from HIV-infected women in Africa have been reassuring, demonstrating an acceptably low risk of infection.26 However, no studies have evaluated IUC among women on immunosuppressive drugs or those with otherwise impaired immune systems, and the WHO does not make formal recommendations for these patients. Two case reports of IUC failure in transplant patients led some to theorize that immune-mediated inflammation is necessary for IUC function, but this has not been proven.27
When immunocompromised women do not qualify for other highly effective contraceptives, the benefit of IUC may outweigh any theoretical risks. In this case, the LNG-20 may be preferable for its possibly lower risk of infection and decreased reliance on an inflammatory mechanism of action.
Contraindications to IUC include breast cancer, pelvic infection
Although the LNG-20 contains a hormone, the amount of levonorgestrel entering the circulation is very low, so the method is not restricted in women with cardiovascular risk factors. The only contraindications to IUC are:
- pelvic infection or sepsis
- pregnancy
- undiagnosed abnormal uterine bleeding or gynecologic cancer
- distorted uterine cavity
- breast cancer (for the LNG-20)
- Wilson’s disease (for the CuT-380A).
Sterilization is a safe option
For women ready to forego future childbearing, surgical sterilization is an excellent option. It requires no compliance or follow-up on the part of the patient, and efficacy rates approach that of IUC—at 98% to 99% or higher.
Beyond regret and sterilization failure, the risks of sterilization are limited to those of the surgical procedure itself. These may be negligible if tubal ligation is performed at the time of another indicated surgery, such as cesarean section.