The author reports no financial relationships relevant to this article.
CASE Multiple morbidities complicate choice of contraceptive
D.M. is a 27-year-old woman who has sickle cell disease, which led to a mild stroke during adolescence. She also has mild renal insufficiency and was given a diagnosis in adulthood of systemic lupus erythematosus, for which she takes prednisone on a maintenance basis.
D.M. is sexually active with her long-term boyfriend, and has undergone salpingectomy for ectopic pregnancy. Recently, she underwent exploratory laparotomy after a ruptured hemorrhagic ovarian cyst caused an intraperitoneal hemorrhage.
What method of birth control would be most appropriate for this patient?
The question is a daunting one, but it’s imperative for health-care providers to understand the nature and magnitude of contraceptive risks in medically complex women and provide the answers that these patients need.
In this article, I describe important considerations and sift the evidence regarding each of what I refer to here as highly effective contraceptive methods:
- safe hormonal contraceptives
- intrauterine contraceptives
- minimally invasive surgical sterilization.
These methods have given medically complex women greater control over their reproductive function and health, and a number of them offer benefits beyond contraception.
With some methods, such as progestin-only contraception, prospective data are lacking but retrospective studies show no elevated risk of cardiovascular events. And although combination hormonal contraceptives carry an elevated relative risk of cardiovascular events, absolute risk is very low.
First, who are these patients?
Women who have an extreme chronic medical condition, such as pulmonary hypertension, cardiomyopathy, or a dilated aortic root (>40 mm), face pregnancy-associated mortality as high as 10% to 50%—making unplanned pregnancy significantly more dangerous than any contraceptive. And even women who have a less severe medical condition stand to benefit from careful pregnancy timing: Those who have diabetes, lupus, or inflammatory bowel disease often need to optimize their medical condition before becoming pregnant. Still others may need to discontinue a teratogenic medication or treatment.
As for women who have multiple serious medical conditions, such as the patient described above, there is critical need to understand and prepare for the risks of pregnancy. These women deserve a contraceptive that has an efficacy rate approaching 100%.
All too often, however, these women settle for less effective barrier methods— or no method at all—out of concern that contraceptive and personal medical risks may interact adversely. Medical interests may drive these choices, but the unplanned pregnancies that result can pose more health risks than the rejected contraceptives.
A tool to weigh contraceptive risks
The World Health Organization (WHO) has categorized a large number of medical conditions according to their level of risk in regard to specific contraceptives.1 The four categories established by WHO range from no restrictions (category 1) to unacceptable health risks (category 4) (TABLE 1). With this system, you have a streamlined resource for weighing a contraceptive’s risks and benefits and finding an appropriate method for your patients.
TABLE 1
Four levels of risk in WHO categories
| CATEGORY | WHAT IT MEANS |
|---|---|
| 1 | A condition for which there is no restriction on the use of the contraceptive method |
| 2 | A condition in which the advantages of using the method generally outweigh the theoretical or proven risks |
| 3 | A condition in which the theoretical or proven risks usually outweigh the advantages of using the method |
| 4 | A condition that represents an unacceptable health risk if the contraceptive method is used |
Sifting risks and benefits of hormonal contraceptives
With typical use, hormonal contraceptive pills and injections prevent pregnancy in 92% to 97% of women who use one of these methods for 1 year.2 They also may decrease dysmenorrhea and menorrhagia, reduce the incidence of functional ovarian cysts, improve menstrual symptoms, and help prevent ovarian and endometrial cancers.2,3 In surveys in selected developed countries, the majority of women have used hormonal contraceptives at some time in their reproductive lives.2
Hormonal contraceptives also carry rare but potentially serious health risks that may deter their use—at times, inappropriately. Combined oral contraceptives (OCs) may double or triple the risk of myocardial infarction (MI)4 and stroke5,6 and triple or quadruple the risk of deep venous thrombosis (DVT) and venous thromboembolism (VTE).7
Recent data on the combined contraceptive patch suggest that it carries a risk of VTE twice as high as combined OCs.8 (Rates of MI and stroke were too small to compare accurately.8) We lack data on the vaginal ring contraceptive, but its medical risks are assumed to be similar to those of combined oral contraceptives.1