Medical Conditions and Contraception

Medical Conditions And Contraception

When choosing contraception for individuals with medical conditions, it’s essential to assess both safety and efficacy, guided by clinical risk-benefit analysis. Certain contraceptives, especially estrogen-containing methods, can worsen pre-existing conditions or increase the risk of life-threatening events. Hence, it is very important to assess underlying medical condition and choose appropriate methods of contraception. The WHO Medical Eligibility Criteria (MEC) offers a global standard, categorizing contraceptive methods from Category 1 (no restriction) to Category 4 (unacceptable health risk) of medical and lifestyle condition.

Key medical conditions and contraceptive considerations

1. Hypertension

Hypertension is a common chronic condition that significantly influences contraceptive choice due to the increased cardiovascular risk associated with certain hormonal methods—particularly those containing estrogen.

Why It Matters

Estrogen-containing contraceptives (e.g., Combined Oral Contraceptives or COCs) can raise blood pressure and increase the risk of stroke, myocardial infarction, and venous thromboembolism.

Blood pressure often increases subtly over time with COC use, even in normotensive individuals.

Preferred Contraceptive Options in Hypertension

1. Progestin-Only Pills (POP) – Safe in all levels of hypertension.

2. Implants (e.g., etonogestrel) – Highly effective, long-acting, and safe.

3. Copper IUD – Hormone-free, suitable even in severe hypertension.

4. Levonorgestrel IUS (LNG-IUS) – Acceptable if no severe HTN or vascular disease.

5. Injectables (DMPA) – Can be used with caution in moderate hypertension.

Avoid

1. Combined hormonal contraception (pill, patch, ring) in moderate-to-severe hypertension or if vascular complications are present (MEC 3/4).

Monitoring

1. Baseline and periodic blood pressure monitoring is essential for users of hormonal contraception, especially CHCs.

2. Reassess method suitability if blood pressure worsens.

1. Diabetes Mellitus

Diabetes Mellitus (DM)—especially long-standing disease or vascular complications—requires careful consideration to avoid cardiovascular risks, metabolic disturbances, and interactions with comorbidities.

Why It Matters

1. Estrogen-containing contraceptives can affect glucose metabolism, increase insulin resistance, and elevate cardiovascular risk in diabetics with complications.

2. However, in well-controlled diabetes without complications, most contraceptives are safe.

Preferred Methods in Diabetes

1. If NO vascular complications:

-Progestin-only pills

-Implants (e.g., etonogestrel)

-DMPA (use with monitoring)

-Copper IUD – Excellent choice with no metabolic impact

-LNG-IUS – Suitable with good glycemic control

1. If vascular complications are present or long-standing DM:

Avoid

1. COCs-combined oral contraceptives (MEC 3/4)

Clinical Follow-up

1. Monitor glycemic control regularly in hormonal contraceptive users.

1. Thromboembolic Disorders (DVT/PE)

Women with current or past venous thromboembolism (VTE) or a predisposing condition (e.g., thrombophilia) are at high risk of recurrence, and contraception must be chosen carefully to avoid increasing this risk.

Why This Matters

1. Estrogen-containing contraceptives (Combined Oral Contraceptives, patch, ring) increase hepatic synthesis of clotting factors, raising the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE).

2. Women with inherited thrombophilia (e.g., Factor V Leiden) or a strong family history of VTE are also at increased risk.

Preferred Contraceptive Options

1. Safe Methods for Women with VTE or Thrombophilia:

2. Progestin-only pills (POP) – Do not significantly affect coagulation.

3. Etonogestrel implant – Effective and safe.

4. Copper IUD – No hormonal impact; completely safe.

5. LNG-IUS – Acceptable with caution, particularly if on anticoagulants (monitor bleeding risk).

Avoid in All Cases of VTE or Thrombophilia

1. Combined hormonal contraception (COCs, patch, vaginal ring) – Significantly increases thrombotic risk (MEC 4).

Clinical Considerations

1. If on anticoagulation therapy, IUDs (both copper and LNG-IUS) may increase bleeding risk but are still MEC 2.

2. Assess risk vs. benefit individually, especially in cases of multiple risk factors (e.g., smoking, obesity, immobility).

1. Migraine

Migraine, especially when associated with aura, significantly impacts contraceptive choices due to the elevated risk of ischemic stroke, particularly with estrogen-containing contraceptives.

Why This Matters

Estrogen in Combined Hormonal Contraceptives (CHCs) can worsen migraines and increase stroke risk, especially in migraine with aura.

Preferred Contraceptive Options for Migraine

1. Progestin-Only Pills (POP)

2. Implants (e.g., etonogestrel)

3. Injectables (DMPA)

4. LNG-IUS – Also helps with menstrual migraine associated with heavy bleeding

5. Copper IUD – Non-hormonal and completely safe

Avoid in All Cases of Migraine with Aura

1. CHCs (estrogen-containing) – Strongly associated with increased ischemic stroke risk (MEC 4).

Clinical follow-up

1. Regular follow-up regarding changes or increase in frequency of migraine .

2. If migraines worsen or aura develops during CHC use, discontinue immediately.

1. Liver Disease

The liver is central to hormone metabolism, especially estrogen. In women with liver disorders, hormonal contraceptives can worsen liver function or interfere with metabolism, making careful method selection essential.

Why It Matters

1. Estrogen and progestins are metabolized by the liver.

2. Hormonal contraceptives may exacerbate liver disease, alter liver enzyme activity, or increase the risk of liver tumors (e.g., hepatic adenoma).

3. Some liver conditions are associated with increased thrombotic risk, influencing contraceptive choice.

Preferred Contraceptive Methods in Liver Disorders

1. Copper IUD: Safest option; non-hormonal and independent of liver metabolism.

2. Barrier methods: Condoms, diaphragm – safe and reversible.

3. Sterilization: For women with completed families and contraindications to hormonal methods.

Avoid

1. CHCs (Combined Hormonal Contraceptives) in all forms of active or severe liver disease and liver tumors (MEC 4).

2. Hormonal methods in decompensated cirrhosis, adenomas, or HCC – avoid or use with caution.

Special Considerations

1. LNG-IUS may be used cautiously if liver function is compensated, as systemic absorption is low.

2. In cases of acute viral hepatitis, delay any hormonal contraceptive initiation until liver function normalizes.

1. Systemic Lupus Erythematosus (SLE)

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune condition with variable disease activity and a predisposition to thromboembolic events, especially when antiphospholipid antibodies (APL) are present. Choosing a contraceptive method for women with SLE requires a nuanced, individualized approach.

Why It Matters

1. Estrogen can worsen disease activity in some women with SLE and significantly increases thrombosis risk in those with positive APL.

2. Pregnancy in SLE carries high maternal-fetal risk, so effective contraception is critical.

Preferred Contraceptive Options for SLE

1. If no APL and stable disease:

Progestin-only pills (POP)

Implants

Injectables (DMPA) – Caution if bone density loss is a concern

LNG-IUS – Use if no active infection or immunosuppression

Copper IUD – Suitable if no heavy menstrual bleeding or infection risk

1. If APL positive or thrombotic risk high:

Avoid all estrogen-containing methods (MEC 4)

Prefer non-estrogenic methods: Copper IUD, POPs, implants

Avoid

1. CHCs in any woman with positive antiphospholipid antibodies, past VTE, or ischemic stroke (MEC 4).

2. Hormonal methods in active severe SLE, unless clearly stable and under close rheumatology supervision.

Additional Considerations

1. Monitor disease activity and side effects regularly.

2. LNG-IUS is helpful for controlling heavy menstrual bleeding in women on anticoagulation or steroids.

3. Discuss long-term fertility plans, especially in women on cyclophosphamide or other gonadotoxic medications.

1. Epilepsy

In women with epilepsy, contraceptive choice must account for two major factors:

1. Enzyme-inducing antiepileptic drugs (EIAEDs) that reduce the effectiveness of hormonal contraceptives. Carbamazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate (>200 mg/day), rifampicin. These drugs induce cytochrome P450 enzymes, lowering the effectiveness of estrogen and progestins.

2. Hormonal contraceptives that may affect seizure threshold or medication levels.

Why It Matters

1. Unplanned pregnancy in epilepsy carries increased maternal and fetal risks (teratogenicity, seizure-related complications).

2. Drug interactions can lead to contraceptive failure or breakthrough seizures.

Preferred Contraceptive Methods for Women on Enzyme inducing anti-epileptic drugs-

1. Copper IUD: Highly effective, hormone-free.

2. LNG-IUS: Not significantly affected by EIAEDs; safe and effective.

3. DMPA (injectable): Reliable, not reduced by enzyme inducers.

4. Barrier methods: Condoms, diaphragm – offer additional protection, especially in dual-method use.

Avoid or Use with Caution

1. CHCs, POPs, implants if using EIAEDs – due to reduced efficacy.

2. Consider higher-dose estrogen pills (50 mcg ethinyl estradiol) only under specialist guidance, if CHC is required.

Additional Considerations

1. Contraceptive method may influence seizure control via hormone fluctuations.

2. Antiepileptics like lamotrigine levels may drop with CHCs, increasing seizure risk.

3. Counseling on folic acid supplementation (5 mg/day) is important for women of reproductive age.

1. HIV Infection

Women living with HIV or at high risk of acquiring it need effective, safe contraception that also addresses concerns of disease transmission, drug interactions, and reproductive autonomy. Choice of contraception must consider HIV disease status, ART regimen, and co-existing risk of STI transmission.

Key Considerations

1. Safety and Effectiveness

Most contraceptive methods are safe and effective for women with HIV.

The goal is to prevent unintended pregnancy while ensuring no increased risk of HIV disease progression or drug interaction.

1. Drug Interactions

Some antiretroviral therapies (ART), particularly those that are enzyme-inducing (e.g., efavirenz, nevirapine), may lower the efficacy of hormonal methods, especially: Implants, Progestin-only pills, CHCs (Combined hormonal contraceptives).

1. STI and HIV Transmission Prevention

Hormonal methods do not protect against HIV/STIs.

Condoms (male or female) are essential for dual protection (pregnancy + STI prevention).

Preferred Options

If on stable ART (not enzyme-inducing):

1. DMPA (Depot Medroxyprogesterone) – Reliable and unaffected by ART

2. Copper IUD – Highly effective, no interaction

3. LNG-IUS – Effective, safe with caution in immunosuppressed

4. Condoms – For dual protection

If on enzyme-inducing ART (e.g., efavirenz):

1. Avoid implants, CHC, POP alone due to reduced efficacy

2. Use DMPA or IUDs, and reinforce dual-method use

Special Considerations

1. IUD use: Safe in HIV-positive women with no active pelvic infections and stable disease.

2. LNG-IUS: May reduce menstrual bleeding and anemia in HIV-positive women.

3. Always provide dual protection counseling (condoms + another method).

1. Cardiovascular Disease

Contraceptive counseling in women with cardiovascular disease (CVD)—including conditions like ischemic heart disease, congenital heart disease, cardiomyopathy, arrhythmias, and valvular disease—requires careful selection to avoid worsening cardiovascular risk or triggering complications.

Why It Matters

1. Estrogen-containing contraceptives increase the risk of thromboembolism, stroke, and myocardial infarction—especially in women with pre-existing heart conditions.

2. Pregnancy poses high cardiovascular demands, so effective contraception is essential to prevent unintended pregnancy in women with limited cardiac reserve.

Preferred Methods for Women with Heart Disease

1. Copper IUD – Highly effective, non-hormonal, MEC 1 in most cases

2. Progestin-Only Pills (POP) – Safe, especially in uncomplicated cardiac disease

3. Implants – Long-acting and safe with minimal cardiovascular impact

4. LNG-IUS – Use with caution if anticoagulated; reduces menstrual blood loss

5. DMPA – Use cautiously in those with increased risk of fluid retention or dyslipidemia

Avoid in Most Cardiac Conditions

1. Combined Hormonal Contraceptives (CHCs) – Estrogen increases risk of: thrombosis, hypertension, stroke, Myocardial infarction.

2. CHC is MEC 4 (contraindicated) in most significant cardiovascular diseases.

Additional Considerations

1. Anticoagulation therapy may increase bleeding risk with IUDs – monitor and consider LNG-IUS for menorrhagia.

2. In cyanotic congenital heart disease or pulmonary hypertension, pregnancy is very high risk – permanent contraception may be considered.

References

1. WHO MEdical Eligibilty Criteria for Contraceptie Use,5 th Edition (2015)

1. FSRH(UK)Clinical Guidance on Contraceptive Choices

1. CDC U.S. Medical Eligibility Criteria (USMEC),2021