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10/1/2015

Contraception in Women with Thromboembolism and Thrombophilia

Contraception options in patients with history of thromboembolism or thrombophilia remains challenging. Estrogen-containing medications significantly increase the risk of venous thromboembolism (VTE) in women with a history of prior thromboembolism or thrombophilia. Additive risk factors include age over 35 years and BMI greater than 25 kg/m2. The incidence of VTE is greater in women using combined hormonal contraceptives (CHCs) compared to women not using them and is highest during pregnancy and the postpartum period, with the first week of the postpartum period representing the highest risk throughout the entire pregnancy and postpartum periods.

CHCs including pills, patch, and ring are contraindicated (CDC Medical Eligibility Criteria Category 4) in patients with an acute deep vein thrombosis (DVT) or pulmonary embolism (PE). For women with history of VTE, recurrence risk must be considered whether or not the patient is anticoagulated. High recurrence risk factors include history of estrogen-associated DVT/PE, pregnancy-associated DVT/PE, idiopathic DVT/PE, and known thrombophilia, including antiphospholipid syndrome. For patients with a history of DVT/PE with high recurrence risk, all CHCs are contraindicated (Category 4).

For women without known risk factors, the risks of CHC likely outweigh the benefits (Category 3). For women with a single VTE episode, a non-recurring risk factor such as surgery or trauma, and no additive risk factors, the risk of CHC use is low but still elevated compared to progesterone-only methods.

Progesterone-only methods, including progesterone-only pills, medroxyprogesterone acetate injection (DMPA), etonogestrel implants, and progesterone-containing intrauterine devices are not thought to have an increased risk of thromboembolism, so benefits likely outweigh any risk (Category 2). The copper-containing intrauterine device and sterilization can be used without restriction (Category 1).

Medications such as isotretinoin and warfarin are known teratogens, so reproductive-aged woman taking it should use an effective method of contraception. No change in a patient's anticoagulation is necessary when injecting DMPA or placing subdermal contraceptive implants or intrauterine. Progestin-only methods have a potential advantage of improving bleeding profiles for patients on anticoagulation with heavy menstrual bleeding.

CHCs are contraindicated (Category 4) for women with heritable thombophilias including factor V Leiden mutation, prothrombin G2010 A mutation, protein C or protein S deficiency, and acquired thrombophilias, including antiphospholipid syndrome and antithrombin deficiency. Routine screening for thrombophilias prior to CHC initiation is not recommended.

The assessment of progestin-only contraceptives does not show significant changes in clotting factors. Benefits of progestin-only contraception are thought to outweigh risks in women with thrombogenic mutations (Category 2). The copper-containing intrauterine device can be used without restriction in patients with thrombophilias. (Category 1).  Methyltetrahydrofolate reductase polymorphisms or measurement of fasting homocysteine levels is not recommended.

Further Reading:

Centers for Disease Control and Prevention. US Medical Eligibility Criteria for Contraceptive Use, 2024. Avalable at: U.S. Medical Eligibility Criteria for Contraceptive Use, 2024 | MMWR.

Initial Approval: October 2015, Revised: November 2016, March 2018; Reaffirmed September 2019; Reaffirmed May 2021, Minor Revision March 2023. Revised November 2024.

 

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