LUPUS AND BIRTH CONTROL
 
Veena Rao, M..D., and Tammy O. Utset, M.D., M.P.H.
 
Birth control issues are very important in women with lupus, as it is a disease seen primarily in women of childbearing age.  Effective contraception and proper understanding of contraceptive options are important, as unwanted pregnancy can result in health risks to the mother and fetus.
 
Oral Contraceptives: Oral contraceptives overall have a number of positive health effects in all women.  These include a lower risk of gynecologic cancers such as uterine, endometrial and ovarian cancers, ectopic pregnancy, benign breast disease and pelvic inflammatory disease.  However, estrogen-containing pills increase the risk of clotting events (venous thrombosis, pulmonary embolism, etc.) and need to be used carefully in patients with an underlying clotting disorder.  Similarly, oral contraceptives should not be used in women with a history of stroke or vascular disease, history of breast cancer, active liver disease or migraine headaches, or in smokers over age 35. 
 
Oral Contraceptives and Lupus: Historically, doctors have been hesitant to prescribe OC’s to patients with lupus.  This was because older studies suggested an increased risk of disease flares when women with lupus received a combination birth control pill (containing both estrogen and a progestin).  However, recent studies done over the past few years have shown that OC use actually doesn’t increase the risk of lupus flare, time to first flare, or global disease activity, in women with mild lupus.  Therefore, oral contraceptives containing lower doses of estrogen are probably safe in women with mild lupus, but should be avoided in women at increased risk of clotting, or in women with moderate to severe lupus.  This includes women with antiphospholipid antibodies, the antiphospholipid syndrome, or the nephrotic syndrome (renal lupus characterized by marked protein in the urine and an increased risk of clotting events). 
 
Progestin-only Pills: Progestin only pills are used much less frequently than combination pills, because of their association with breakthrough bleeding and a slightly higher failure rate than combined OC’s.  These pills need to be taken at about the same time each day and are taken every day without a pill free interval.  Variation of even a few hours in administration can result in reduced effectiveness.  Despite this, progestin-only pills don’t confer the increased risk of clotting events that estrogen-containing pills do.  Therefore, they may be a safer option in women with lupus and a tendency for clotting events.  
 
Other non-pill options for contraception include injectables, implants, and the IUD.
 
Depo-Provera: Depo-Provera is the only injectable contraceptive available in the U.S.  150 mg of medroxyprogesterone acetate (DMPA, a progestin) is given by intramuscular injection and results in effective contraception for 3-4 months.  Again, complications seen with estrogen containing contraception, such as worsening of migraine headaches and increased risk of clotting, are avoided with Depo-Provera.  Most women have a return of fertility 6-10 months after the time the next injection would have been given, but fertility can be delayed up to 18 months after stopping DMPA.  Side effects include irregular bleeding, prolonged bleeding or spotting, weight gain, and reversible bone loss.  This last side effect is particularly relevant to women with lupus, who may already be at higher risk of premature bone loss due to chronic steroid use.  
 
Implanon: Implanon is a single rod progestin implant, inserted as an outpatient procedure.  Contraception is provided for 3 years by slow release of the progestin etonogestrel.  Protection from pregnancy occurs within 24 hours of insertion when done correctly.  Major side effects include irregular bleeding and spotting.  Fertility typically returns rapidly after removal of the rod.  
 
IUD’s: Intrauterine devices are overall safe, effective, long-acting and rapidly reversible methods of contraception.  Copper and hormone releasing IUD’s are approved in the U.S., the later which releases a progestin.  IUD’s must be used with caution in women with recent or recurrent pelvic infection, or in women who are at increased risk for sexually transmitted diseases (STD’s).  IUD insertion in women with active or recent (within 3 months) STD’s increases the risk of upper genital tract infection.  
Women with lupus, who often are on medications that suppress the immune system, may be at increased risk for genital tract infection with IUD placement.  Therefore, an individual’s risk of infections and STD’s should be considered before deciding on the use of an IUD for contraception. However, in women at low risk for STD’s, such as those with a single, stable sexual partner, IUD’s may be a good option.