Contraceptive Options for Women with Preexisting Medical Conditions

Abstract

Most healthy women have normal pregnancies; however, even healthy women may experience serious morbidity during pregnancy. Women with chronic medical problems face increased pregnancy-related risks compared with their healthy peers. Planning pregnancy improves maternal and fetal outcomes; medical conditions can be stabilized, teratogens can be avoided, and early antenatal intervention and surveillance can be instituted. The safest and most effective forms of contraception should be offered to women with medical conditions. Overestimatation of risk associated with the use of contraception among clinicians and women limits access to effective contraception. Contraception decision making should include consideration of the risks and benefits of a given method vs. the consequences of an unintended pregnancy. Published guidelines can inform contraceptive management of women with chronic medical conditions. Patient counseling should focus on helping women understand the need for contraception while optimizing their health for pregnancy.

Introduction

Currently, nearly 50% of all pregnancies in the United States each year are unintended.¹ Half of women with unintended pregnancy report using some contraceptive method during the month of conception, with failure commonly attributed to incorrect or inconsistent use of the method. A majority of the remaining unintended pregnancies result from women not using any form of contraception at all.²

Although most healthy women have uncomplicated pregnancies, pregnancy imparts a risk of serious morbidity and mortality, including the possibility for eclampsia, embolism, and hemorrhage. Avoiding unintended pregnancy is important for all women; however, women with medical conditions are more vulnerable to pregnancy-related complications than their healthy peers. For instance, one cohort study demonstrated that nearly one fifth of women with congenital heart disease experienced primary cardiac events, including pulmonary edema and sustained arrhythmias, with ongoing pregnancies.³ Mortality associated with pregnancy complicated by maternal pulmonary hypertension exists at rates between 17% and 33% based on a recent systematic review.⁴

Unfortunately, studies suggest that the rates of unintended pregnancy among women with some chronic conditions are similar to or may even exceed rates in the general population.^5,6 Many women with medical conditions expect to talk about birth control options with their healthcare provider,⁷ but women with some medical conditions receive less contraceptive counseling or inappropriate counseling, which leads them to use less effective or no contraceptive method.^8,9 As a consequence, these women are at increased risk for unintended pregnancy.

Approximately one half of women with unintended pregnancy seek abortion.¹⁰ Legal abortion is safe, much safer than carrying an unplanned pregnancy to term; however, surgical abortion also exposes women, particularly women with medical problems, to unnecessary risk.

Women may have severe medical disease, but illness does not translate to infertility. Women spend three decades of their lives at risk for pregnancy. Medical problems can arise at any time and can encompass a broad spectrum of conditions that impact contraception decision making and pregnancy planning. Women can be born with diseases that impact their long-term morbidity and mortality (i.e., cardiac defects, sickle cell anemia, cystic fibrosis, inborn errors of metabolism, prenatally acquired HIV infection). Childhood diseases, such as leukemia, can often be treated, but women may live with long-term morbidity as a consequence of treatment. Also, women develop diseases that historically they might not have survived, such as breast cancer, cardiac disease, or organ failure requiring transplant, and then confront the consequences of their treatment (cardiomyopathy, osteopenia) as well as residual effects of their disease (lifelong anticoagulation, arrythmia, lung disease). Finally, there are chronic illnesses, such as hypertension and diabetes, that develop and may worsen over time.

The relationship between medical conditions and pregnancy can be complex. Physiological adaptations during pregnancy can worsen medical conditions. The condition of women with compromised cardiovascular function may deteriorate with the increased cardiac output demands of pregnancy, and glycemic control for diabetics is more difficult in the setting of pregnancy-associated insulin resistance. Also, such medical conditions as hypertension predispose women to complications of pregnancy, for example, preeclampsia. Fetal well-being is also affected. Poor control of medical conditions, such as diabetes, can increase the risk of spontaneous abortion, macrosomia, intrauterine fetal growth retardation (IUGR), and stillbirth later in gestation. Teratogenic medications used to treat medical conditions may negatively impact fetal development. Examples include ACE inhibitors used for the treatment of hypertension and dilantin used to treat epilepsy, both of which are associated with major fetal malformations. Thus, preconception care should include consideration of medication changes to ensure maternal health and decrease fetal risk.

Recent data suggest the family planning needs of women taking teratogenic medications are unmet. In 1979, the Food and Drug Administration (FDA) created five pregnancy risk categories to rate drug formulary products for use in pregnancy. These categories A, B, C, D, and X, range from no evidence of damage to the fetus (category A) to clear teratogenicity (D and X). Approximately 2% of drugs fall into category A, 50% in category B, 38% in category C, 3%–5% in category D, and 1%–5% in category X. A recent study documented reproductive risks associated with prescription medication.¹¹ Women receiving prescriptions for teratogenic medications (categories D and X) were no more or less likely to receive contraceptive counseling, fill a contraception prescription, or have been sterilized compared with women filling prescriptions for safer category A or B medications. Also, the pregnancy rate between groups was not very different within 3 months of having filled a prescription.

Contraception should support women's fertility desires. In order to address a woman's contraceptive and preconception needs, pregnancy intention needs to be accurately assessed. It is important to recognize that as in the general population, ambivalence about future fertility may impact contraceptive choice as well; women's uncertainty about immediate and future pregnancy goals may complicate pregnancy planning. Retrospective and prospective studies demonstrate that ambivalence toward pregnancy is common and often associated with use of less effective contraceptive methods.^12,13

Importantly, contraceptive use allows women and their physicians to optimize maternal and fetal outcomes by facilitating planned pregnancies. A planned delay in pregnancy may be even more imperative for women with complex medical problems; this time can be used to stabilize medical conditions while addressing medication changes to avoid teratogenic exposures of the fetus in utero. Preconception planning reduces miscarriage and preterm delivery rates and also reduces the risk of other maternal and fetal morbidities.^14,15 To achieve planned pregnancy, women should be encouraged to use the most effective form of contraception available to them. In general, the risk associated with effective contraceptive methods is much less than the risk associated with unintended pregnancy.

Knowledge and Attitudes About Contraception: Providers and Patients

Provider lack of knowledge and discomfort in counseling about contraception reduce the number of women using safe and effective methods. Understanding the relative risks and benefits of a given birth control method helps women to make informed contraception choices from the greatest number of options.

A study assessing contraceptive counseling provided by internal medicine residents caring for women of reproductive age demonstrated that only a minority of practitioners routinely provided contraceptive care; many more respondents surveyed (39%) rarely or never participated in contraceptive counseling of their patients. This study also demonstrated that trainees felt most comfortable speaking to patients about condoms, combined hormonal methods, and abstinence. Fewer respondents cited comfort counseling women on use of nonestrogen-containing hormonal methods and intrauterine devices (IUDs). This lack of knowledge is a concern because internists regularly care for women with conditions incompatible with combined hormonal contraceptive use (e.g., vascular disease, diabetes).¹⁶ Consequently, women may find themselves at increased risk for preventable unplanned pregnancy as they opt for less effective methods or no method at all.

Women's choices for contraception are also limited by misperceptions of risk because of inaccurate information held by both healthcare providers and patients.^17,18 Fears about effective contraception (including hormonal methods and IUDs) restrict methods providers present for a woman's consideration and influence a woman's willingness to use particular methods. Providers may suggest methods, such as the male condom, that appear to be risk free but have a much higher rate of failure than hormonal or intrauterine methods A small study assessed whether adult women living with congenital heart disease received accurate contraceptive counseling. Overall, women had poor knowledge of long-acting hormonal methods, especially progestin-only injections and subdermal implants; just over one third of women reported no previous contraceptive education by providers. Of the women who had received counseling, 33% received inappropriate advice, leading them to use no method or less effective methods. With evidence-based counseling, 42% of women initiated contraceptive methods that were more effective than their current practice of nothing or condoms alone.¹⁹

Contraceptive consultations for women with medical conditions may require more than a quick 5–10-minute visit in an outpatient setting. At times, the complexity of these counseling sessions results in avoidance of more effective methods of contraception. However, resources are available to support best practices in contraceptive management of women with a variety of medical problems. As women's healthcare providers, our charge is to recommend the safest and most effective contraceptive methods available.

Counseling Resources

The World Health Organization (WHO) has identified medical conditions that expose women and their fetuses to an unacceptable health risk as a consequence of unintended pregnancy. These conditions include cancers of the breast, ovary, and uterus; severe cardiovascular disease (specifically, hypertension complicated by valvular disease, ischemic heart disease, stroke, and such thrombogenic mutations as sickle cell disease); diabetes; and severe liver disease. HIV/AIDS and other sexually transmitted infections (STIs), such as herpes and hepatitis, are included on this list as well. In settings where treatment is available (e.g., antiretroviral therapy for HIV/AIDS), however, pregnancy risk is somewhat reduced. WHO recommends that women with these conditions be educated by their healthcare providers about these serious health risks and discouraged from the sole use of contraceptive methods with typical use failure rates exceeding 10%.²⁰

Effectiveness

The WHO created a contraceptive counseling tool that presents the full spectrum of contraceptive options based on effectiveness, listing the methods from most effective to least effective (Fig. 1).²¹ This tool illustrates that the typical failure rate in 1 year for sterilization, implants, and IUDs is <1%. Sterilization is the most common form of long-acting contraception used in the United States; however, it does not have a role for women with medical conditions seeking to delay pregnancy until their health is optimized. This tool highlights that similarly effective and fully reversible contraceptive methods (IUD and contraceptive implants) are available. Effective contraceptive methods also include injectables and combined hormonal contraception (pills, patch, and ring), with a typical failure rate of 1%–9%. Typical failure rates for barrier methods and fertility awareness methods are 10%–25%, followed by withdrawal and spermicides with typical failure rates at approximately 30%. This tool helps to frame understanding of contraceptive effectiveness when discussing contraceptive options (www.infoforhealth.org/globalhandbook/book/tools/effectivenesschart.shtml).

FIG. 1.

World Health Organization (WHO) decision aid on contraceptive effectiveness. Adapted from WHO Department of Reproductive Health and Research (WHO/RRH) and Johns Hopkins Center for Communications Programs (CCP), INFO Project. Family Planning: A Global Handbook for Providers. Baltimore and Geneva: CCP and WHO, 2007.²¹

Risks

The WHO publishes the Medical Eligibility Criteria for Contraceptive Use, an evidence-based, comprehensive review of available contraceptive methods and the appropriateness of their use in a variety of contexts.²⁰ For each condition, all available contraceptive methods are rated from 1 to 4: 1, no restriction on use; 2, the advantages of the method outweigh any theoretical or proven risks; 3, theoretical or proven risks outweigh the advantages; 4, the contraceptive represents an unacceptable risk for that condition. This information is also available online at www.who.int/reproductive-health/publications/mec/.

Effective contraception and medical conditions

The American College of Obstetricians and Gynecologists (ACOG) has responded to the need for clinical guidance in making tough contraceptive decisions for women with medical problems in its publication, “Use of Hormonal Contraception in Women with Coexisting Medical Conditions.”²² This bulletin reviews 19 different medical conditions. It is important to focus on hormonal methods in particular, as the decision to use or not use hormonal contraception imparts the greatest challenge to contraceptive decision making. Women with medical conditions should not automatically be excluded from considering many of the most effective, easy to use, and reversible methods encompassed by hormonal contraception. As put forth in the ACOG bulletin, evidence supports the use of progestin-only contraceptive methods and intrauterine devices in a variety of clinical contexts; these methods confer effective protection against unintended pregnancy and minimal risk to women with a number of medical conditions. (Table 1) Also, combined hormonal contraceptive use should not be excluded from consideration among nonsmoking women under the age of 35 with well-controlled, monitored hypertension in the absence of end-organ vascular disease. Young, nonsmoking, otherwise healthy women with well-controlled diabetes without hypertension, nephropathy, retinopathy, or other vascular disease are candidates for a trial of combined hormonal contraception.

Table 1.

Conditions Where Progestin-Only Methods May Be More Appropriate

In women with the following conditions, use of progestin-only contraceptives, including depot medroxyprogesterone acetate, may be safer than combination oral, transdermal, or vaginal ring contraceptives. An intrauterine device also represents an appropriate contraceptive choice for women with these conditions.

• Migraine Headaches (especially those with focal neurologic signs)

• Cigarette smoking or obesity in women older than 35 years

• History of thromboembolic disease

• Hypertension in women with vascular disease or older than 35

• Systemic Lupus Erythematosus with vascular disease, nephritis, or antiphospholipid antibodies

• Less than 3 weeks postpartum^*

• Hypertriglyceridemia

• Coronary artery disease

• Congestive heart failure

• Cerebrovascular disease

Use of an intrauterine device may not be an appropriate contraceptive choice.

Reproduced from: Use of hormonal contraception in women with co-existing medical conditions. ACOG Practice Bulletin No. 73. American College of Obstetricians and Gynecologists 2006;107: 1453–72.

IUDs (copper and levonorgestrel IUDs) offer long-acting, highly effective, reversible contraception. Studies support the use of these methods in both nulliparous and multiparous women, with low risk for pelvic inflammatory disease and future infertility. These devices may be a preferred contraceptive method for women with given medical conditions. For instance, obese women who may be prone to dysfunctional uterine bleeding and endometrial hyperplasia may benefit from levonorgestrel IUD use. Women with breast cancer can safely use the copper IUD.²³

Interactions Between Contraception and Medication Used to Treat Chronic Disease

Hepatic enzyme inducers

Women with chronic illness may require long-term treatment with one or several medications. It is important to consider the interactions between medications used to treat chronic disease and hormonal contraception. Of particular importance are medications that induce the cytochrome p450 hepatic enzyme system, thereby increasing clearance of contraceptive steroids and potentially reducing contraceptive efficacy. The WHO publishes guidelines for such effects, with particular attention to anticonvulsants and antiretroviral therapy (Table 2).²⁰ Most antibiotics are not hepatic enzyme inducers; however, rifampin and griseofulvin do interact with the p450 cytochrome system and are included in the WHO guidelines as well. The complementary medical therapy St. John's wort induces the cytochrome p450 system and impacts contraceptive hormone levels.²⁴

Table 2.

Pharmacokinetic Interactions Between Combined Oral Contraception and Antiretroviral Medication

Antiretroviral (ARV) medication	Contraceptive steroid levels	ARV levels
Protease inhibitors
Nelfinavir	Decreased	No data
Ritonavir	Decreased	No data
Lopinavir/ritonavir	Decreased	No data
Atazanavir	Increased	No data
Amprenavir	Increased	Decreased
Indinavir	Increased	No data
Saquinavir	No data	No change
Nonnucleoside reverse transcriptase inhibitors
Nevirapine	Decreased	No change
Efavirenz	Increased	No change
Delavirdine	Increased	No data

Adapted from World Health Organization. Medical Eligibility Criteria for Contraceptive Use, 3rd ed. 2004.²⁰

Increased metabolism of contraceptive steroid hormones may decrease contraceptive efficacy. To date, studies have not examined the actual risk of ovulation in order to completely understand the clinical relevance of pharmacokinetic changes; however, clinicians may follow some general principles. Low-dose combined hormonal contraceptive pills, progestin-only pills, and progestin-only implants are not first-choice methods in the setting of liver enzyme-inducing medication use. Case series suggest the contraceptive efficacy of the levonorgestrol IUD remains high in this setting, making it a preferred choice in some instances.²⁵

Emergency Contraception

In addition to identifying a contraceptive method for routine use, women with medical problems should be aware of emergency contraception (ECP) as a backup to prevent unintended pregnancy. Although ECP should not be given to a woman who already has an established pregnancy, if a woman inadvertently takes the pills after she becomes pregnant, the limited available evidence suggests that the pills will not harm either the woman or her fetus. ECPs should be used for primary contraceptive failure and are not appropriate for regular use as an ongoing contraceptive method because of the higher possibility of failure compared with primary methods. Their repeated use poses no known health risks, however. According to the WHO, “… all women can use emergency contraception safely and effectively, including women who cannot use ongoing hormonal contraceptive methods.”²⁰

Conclusion

Contraception may be an effective tool to facilitate planned pregnancies among women with chronic medical conditions. Women with medical conditions require increased attention to their family planning needs. Employment of the available evidence to inform contraceptive decision making allows both providers and patients to consider the greatest array of contraceptive options and may increase uptake of effective contraception to reduce unintended pregnancy. For women whose conditions or clinical considerations are particularly complex, there is a growing community of family planning experts available for consultation. Addressing the reproductive needs of women with medical conditions supports healthy women, children, and families.

Footnotes

Disclosure Statement

M.D. and E.B. have no competing financial interests. A.D. receives research support from Bayer Pharmaceuticals and has served as a consultant for Wyeth; she also serves as a consultant for Ferring Pharmaceuticals.

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