Contraception in Women with Thromboembolism and Thrombophilia
10/1/2015 - Frances Casey, MD
Mentor: David Chelmow, MD
Editor: Christine R. Isaacs, MD
Estrogen administration increases the risk of venous thromboembolism (VTE) in women with a history of prior thromboembolism or known thrombogenic mutation by increasing hepatic production of coagulant factors. 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.
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 with a lower recurrence risk (no risk factors), the risks of CHC likely outweigh the benefits (Category 3). For women with a single VTE episode, a non-recurring risk factor (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, injections, subdermal implants, and intrauterine devices are not thought to have an increased risk of thromboembolism, so benefits likely outweigh any risk (Category 2). The copper intrauterine device can be used without restriction (Category 1).
Warfarin is a known teratogen, 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 device as patients are not at increased risk of bleeding complications during these procedures. Progestin only methods have the additional advantage of improving bleeding profiles for patients on anticoagulation with menorrhagia.
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. Due to rarity of VTE events, routine screening for thrombophilias prior to CHC initiation is not recommended. Progestin-only contraceptives do 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 intrauterine device can be used without restriction in patients with thrombophilias (Category 1).
The risk of VTE in women with superficial venous disorders is guided by the specific condition. Women with varicose veins can safely use all forms of contraception, including CHCs (Category 1). Women with a superficial venous thrombosis should limit contraception to progestin only and non-hormonal contraception options as CHCs risks likely outweigh the benefits of use (Category 3).
Centers for Disease Control and Prevention. US Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR. 2016;65:1-103. Available at: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm
Initial Approval: October 2015, Revised: November 2016, Reaffirmed March 2018
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