1/18/2017

Contraception in Patients with Lupus

Author: Jennifer M. Keller, MD

Mentor: Nancy D. Gaba, MD

Editor: Natalie Bowersox, MD

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Systemic Lupus Erythematosus (SLE) is an autoimmune disease with a highly variable presentation that occurs more commonly in females than males (10:1 ratio) and is most common in women of reproductive age. Lupus affects between 40 and 200 per 100,000 people. The risk of unintended pregnancy in women with SLE is significant, and medications used to treat lupus may be teratogenic. Pregnancy may worsen the disease. In general, women with uncomplicated SLE are candidates for all contraceptive choices. There are special considerations for women with antiphospholipid antibodies, nephritis, vascular disease, or severe thrombocytopenia.

Combination Hormonal Contraceptives (CHCs)

CHCs do not impact disease progression. CHCs are acceptable (US Medical Eligibility Criteria (US MEC) Category 2) for women with uncomplicated SLE. CHCs are contraindicated in women with antiphospholipid antibodies because they are at increased risk for thrombosis (US MEC Category 4). CHCs should also be avoided in women with vascular disease or nephritis.

Progestin Only Methods (Pills, Implant, Injectable)

According to the US MEC, progestin only methods are Category 2 for women with uncomplicated lupus. Due to the extremely high risk of a thrombotic event, progestin only methods are category 3 for women with antiphopholipid antibodies. Due to bleeding concerns in lupus patients with severe thrombocytopenia, new starts of progestin only methods are category 3, although continuation is acceptable (category 2) if the patient is otherwise doing well.

Intrauterine Devices

The copper containing intrauterine device (Cu-IUD) is a safe and effective contraceptive option for women with SLE, including women with antiphospholipid antibodies. The only exception is women with severe thrombocytopenia, where placing the device is classed as category 3 because of risk of increased bleeding. Women with severe thrombocytopenia with Cu-IUDs already in place can continue use of an already placed IUD unless they are having bleeding problems (category 2).

The levonorgestrel containing intrauterine device (LNG-IUD) is also a safe and effective method for the majority of women with SLE, except for women with antiphospholipid antibodies. The LNG- IUD is classified as category 3 due to the slight increased risk of thrombosis in this already high risk population. Women for whom other methods are unacceptable due to heavy menstrual bleeding may be candidates for the LNG-IUD with appropriate counseling.

Women who take immunosuppressive medications for treatment of their SLE were previously believed to be at increased risk of infection from their IUD. Data have not supported this risk, and the US MEC lists both IUDs as Category 2 for women who are taking immunosuppressive medications in the absence of other complications.

Barrier Methods

Barrier methods such as condoms and diaphragm are safe for women with SLE, however the rate of unintended pregnancy using these methods may be unacceptably high.

Emergency Contraception

All forms of emergency contraception are both safe and effective options for emergency contraception in women with SLE, even in those with antiphospholipid antibodies.

Further Reading:

Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(3):1-103. doi: 10.15585/mmwr.rr6503a1.

Culwell KR, Curtis KM. Contraception for women with Systemic Lupus Erythematosus. J Fam Plann Reprod Health Care. 2013 Jan;39(1):9-11. doi: 10.1136/jfprhc-2012-100437. Epub 2012 Oct 26.

American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 206: use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2019 Feb;133(2):e128-e150. doi: 10.1097/AOG.0000000000003072.

Initial Approval October 2015; Revised January 2017; Reaffirmed July 2018; Reaffirmed September 2021

Initial publication version edited by Ronald T. Burkman, MD.

********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

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