Contraceptive Choices for Women With Common Medical Problems
Aug 2009 – by N. Santoro, MD
Obstetrician-gynecologists are frequently asked to provide contraceptive counseling for women with medical problems that complicate decision-making and may limit choices. As the medical condition becomes more serious, it sometimes becomes imperative to avoid pregnancy, as it might threaten the life of the woman. It is of paramount importance to remember that pregnancy may worsen the underlying medical issue and to balance the risks of contraceptive method against the risk of pregnancy, not against the risks associated with the non-pregnant state!
An extremely useful clinical tool to assist in decision making can be found at the WHO website.
A total of 19 contraceptive methods are evaluated over 54 health conditions. The recommendations for use are graded from 1-4 as follows:
- No restrictions
- Advantages generally outweigh risks
- Risks usually outweigh advantages
- Unacceptable health risk
Emergency contraception is a category 1-2 method over virtually all types of medical conditions. The duration of exposure is low, and the potential to avoid an unwanted and perhaps unsafe pregnancy is sufficient to warrant this level of recommendation.
Intrauterine devices have few complicating medical conditions. For the most part, medical contraindications are similar for the copper IUD and the LNG IUS. In many situations, the LNG IUS is a preferred choice, because of the reduction or even cessation of menses that can occur with its use. However, the LNG IUS, because of its unknown potential to cause hormonal side effects, albeit at a low dose, is relatively contraindicated (category 3) in women with a past history of breast cancer, whereas a copper IUD has no restrictions. It is considered category 2 (advantages outweigh risks) in women with type 1 or 2 diabetes or in women with known gall bladder disease, whereas the copper IUD is again without restrictions in such women.
Common Medical Conditions
Obesity. Obese women have an increased metabolic rate, may clear exogenously administered steroid hormones more rapidly, and may sequester these drugs in body fat. These factors have long been believed to make oral contraception less efficacious for obese women. Implantable contraceptives containing only progestin are known to have a higher failure rate in the obese. Depo medroxyprogesterone acetate (MMPA), the LNG IUS and the copper IUD, as well as all barrier methods, have similar efficacy for obese women as they do for those of normal body mass index (BMI). However, there is concern that women who take Depo MPA who are obese are prone to gain even more weight.1
Bariatric surgery. Little is known about the long term reproductive and contraceptive outcomes of women who undergo bariatric surgery. However, reports of improved pregnancy outcomes following surgically induced weight loss indicate that fertility is improved with decreased BMI.2 It stands to reason that, if a malabsorptive procedure, such as a Roux-en-Y diversion, has been performed, as opposed to a purely restrictive (banding) procedure, oral absorption of hormonal contraceptives may be compromised. Therefore, such patients are best maintained on non-oral hormonal methods. Implantables should also be used with caution until substantial weight loss occurs.
Hypertension. Oral contraceptives are relatively contraindicated in the face of hypertension, per WHO guidelines. In cases where hypertension is well controlled, and blood pressure can be frequently measured, oral contraceptives can be considered. However, for women who are not adherent to their antihypertensive medications, and/or those who cannot reliably measure their blood pressure at frequent intervals to assure that it is normal, the risks of oral contraceptives may outweigh the benefits and alternative methods should be considered. Progestin only agents, implantables, and the IUD or IUS are all reasonable alternatives.
Women taking anticonvulsants undergo induction of key liver enzymes regulating drug metabolism. These changes result in increased clearance of estrogens, and decreased serum levels of both estrogen and progestin. Although higher dose pills are often recommended, there is surprisingly little medical evidence to support this practice. Because of the likelihood of overall lower efficacy of hormonal methods in women taking anticonvulsants, depo MPA, the IUD and the IUS are most highly recommended.
Diabetes. Women with type 1 or type 2 diabetes who do not have evidence of end-organ disease can probably safely take oral contraceptives.
- Bonny AE, Ziegler J, Harvey R, Debanne SM, Secic M, Cromer BA. Weight gain in obese and nonobese adolescent girls initiating depo medroxyprogesterone, oral contraceptive pills, or no hormonal contraceptive method. Arch Pediatr Adolesc Med 2006; 160: 40-5.
- Maggard MA, Yeremilov I, Li Z, Maglione M, Newberry S, Suttorp M, Hilton L, Santry HP, Morton JM, Livingston EH, Shekelle PG. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA 2008; 300:2286-96.