Progestin-only-based birth control is thought to pose a lower risk of thrombosis than estrogen-containing products, so it can be used in these higher risk patients. Researchers are currently unclear whether progestin-based products carry any additional risk at all. Currently, the American College of Gynecology recommends progestin-only contraceptives as safer alternatives to combined contraceptives containing both estrogen and progestin in women who have lupus and positive aPL antibodies or a history of nephritis or vascular disease.13 When considering such risks, it is worth remembering that pregnancy itself poses a much higher risk of thrombosis than do any hormonal methods of contraception, including combined contraceptives.6
Long-acting reversible birth control methods include IUDs, the most commonly used form of reversible contraception worldwide. The most commonly used IUDs contain copper or a progestin. These devices pose a low risk of pelvic inflammatory infection, which has not been specifically studied in patients on immunosuppressive medications. However, studies from HIV patients showed no increased risk of infection.14
Moderately effective methods include combined hormonal contraceptives containing both estrogen and progestin (via pills, patch or vaginal ring). Although earlier uncontrolled studies showed that combined oral contraceptives might increase the risk of lupus flares, more recent trials have not found an increased risk in patients with stable disease.6
Progestin-only oral pills are also available, as is a progesterone-based injection, which must be administered every three months. Barrier methods of protection, such as the male condom, are less effective and require partner participation. However, the condom offers the advantage of protection against sexually transmitted infection, and it may be used in conjunction with other birth control methods.
Dr. Chakravarty is a strong proponent of IUDs. She points out, “They’re long-acting, so the onus is not on the patient to get the refill, to make their appointment in three months to get a shot. The patient doesn’t have to do anything once it is in. These are people who take a lot of medicines. Even an extra copay of another $5 for another prescription is a pain. If they’re doing nothing and they are passive, they are protected.” She also explains that because the hormones are not significantly absorbed systemically, it is even less of a concern for women who might have a clotting disorder or active lupus.
For rheumatic patients in particular, she also likes that the decision to try to conceive cannot be acted on immediately. Before trying to conceive, patients have to connect with a medical provider to have the IUD removed. She also appreciates that patients can get a pap smear to check for dangerous lesions at the same time. Dr. Chakravarty recommends progestin-based IUDs over the copper-based variety. She prefers them because progestin-based IUDs often result in amenorrhea, which can decrease patients’ risk of anemia from chronic disease.
Ideally, any high-risk medications should be switched over several months prior to conception. Such medications include cyclophosphamide, methotrexate, mycophenolate mofetil & leflunomide.
Doctors should also be aware of possible medication interactions with their patients’ birth control, which can lead to decreased effectiveness of either the contraception or the other medication. For example, mycophenolate and anticonvulsants such as carbamazepine may lower the effectiveness of combined oral contraceptives, whereas oral contraceptive use may increase the drug concentrations of cyclosporine and corticosteroids.6
