Birth Control After a Pulmonary Embolism, DVT, Blood Clot, Factor V Leiden, Thrombophilia, or Other Clotting Condition
Problems With Oral Contraception
Oral contraception is commonly used by many women. It is also the cause of many blood clots. Combined oral contraception can increase the chance of blood clots such as pulmonary embolism or deep vein thrombosis (DVT). While the risk is only raised between 4-8%, the risk is much higher for women who have had a previous pulmonary embolism or DVT, especially if the blood clot occurred while the woman was on hormone therapy or oral contraception. For women who have had a pulmonary embolisn, DVT, or have thrombophilia this is a huge problem. Once a woman has had a clot or has been diagnosed with thrombophilia (the most common being Factor V Leiden), doctors will typically recommend that hormone based contraception be avoided.
Involving Your Doctor
Birth control is a very important topic to go over with a doctor. Speaking to more than one of the doctors that is working with a patient is often the best way to get an answer that the patient can be confident about. Some of the best choices of doctors to speak with are the patient's primary care physician, hematologist, and OBGYN. The various doctors can answer questions about the risks of pregnancy, interactions with anticoagulation, and risks and benefits of the different forms of contraception.
Please discuss everything in this Hub with your doctor. I am not a medical professional, just a patient and patient advocate.
An Introduction to Hormone Based Contraception
Understanding the risk of blood clots, pulmonary embolism, or DVT with hormone based contraception requires a basic understanding of the general classes that these medications fall into.
There are primarily two types are hormones that can affect fertility: estrogen and progesterone. Contraception will never list estrogen or progesterone, rather it will list the name of the synthetic variation of the hormone or hormones that are used. Progesterone that is used in smaller doses without estrogen has little impact on the clotting system. When estrogen and progesterone are used together, the risk of a clot increases. patients with a clotting condition such as Factor V Leiden who were using birth control pills that contained estrogen and progesterone can have up to a 35 fold higher risk of a clot.
Some contraception only uses progesterone while other forms combine estrogen and progesterone. This will be a very important distinction in the discussion of birth control and clots. Other factors that can influence clotting include the dose strength of the hormones, the type of synthetic progesterone used, and the delivery method that is used.
Dangerous Birth Control - High Clotting Risk
There are a few forms of birth control that come with a very high risk for clots. These forms of birth control should not be used by anyone with a history of pulmonary embolism, DVT, blood clot, or stroke. Additionally, patients with a blood clotting condition (thrombophilia) such as Factor V Leiden should not use these forms of birth control.
According to the National Alliance for Thrombosis and Thrombophilia, you may be able to use some of the below methods if you are on anticoagulation therapy. Coumadin (warfarin) can cause increased menstrual bleeding that may be eased by some forms of hormonal contraception. This can be discussed with doctors to determine if this is the right decision for a patient.
Combined Oral Contraceptives
Most oral contraceptives fall into this category. This type of pill is any pill that contains both estrogen and progesterone. These pills raise the clotting risk because they contain both of these hormones. There is some concern that the newer brands of COCs put women at an even higher risk of blood clots than the older, second generation pills. Many women have their first clots while on a COC.
Anti-Androgen Oral Contraceptives
A less common form of the pill contains estrogen and an anti-androgen known as cyproterone. Pills with cyproterone put users with no history of clotting conditions at an 8% higher risk of having a clot. If it increases the risk this much in the typical population, it will be an even larger risk for people already at a higher risk of clots.
The birth control patch (Ortho Evra) seems to put patients at a higher clotting risk than combined oral contraceptives. It also contains both estrogen and progesterone. It seems that women that are using the patch absorb approximately 60% more estrogen into their bodies than women who are using COCs. In 2006 the FDA required the name brand patch Ortho Evra to update their labeling to note the increased risk of venous thromboembolism, the type of clots that cause DVT and pulmonary embolism.
The Ring / Hormonal Vaginal Insert
The birth control ring (NuvaRing) also contains estrogen and progesterone. It seems to carry the same risks as combined oral contraceptives and should also be avoided.
Lower Risk Birth Control
As mentioned above, progesterone by itself does not seem to cause clotting problems in the dosages that are given in hormonal contraception. While progesterone given in large doses to treat things like vaginal bleeding does cause clots, progesterone in the smaller doses used for contraception does not appear increase the risk of pulmonary embolism or DVT.
All of this being said, many doctors and patients still have some concern about hormone use after a pulmonary embolism or DVT. On pulmonary embolism recovery support group boards I have seen a number of people who feel that progesterone only contraception contributed to their pulmonary embolisms. WHO rates progesterone only contraception as a "2". A 2 means that progesterone only contraception can general be used but should be monitored and followed up with caution. In fact, many of the brands of progesterone only contraception will note that patients with a history of venous thromboembolism (blood clots like a pulmonary embolism or DVT) will need to speak with a doctor about clots before using the product. If you are interested in any progesterone based contraception the best bet is to talk it over with your pulmonary embolism recovery team. Your OBGYN, general practitioner, and hematologist can give you their feelings about this type of contraception. Based on what they tell you, you can make an informed decision about what is right for your body.
Skyla is the newest IUD available in the United States. Skyla is exciting because it is a very small IUD and may be more comfortable for women who have never been pregnant. Skyla is also exciting because it has no prescribing warnings for blood clot survivors or individuals with thrombophilia. For more information about Skyla and blood clots see Clot Connect. Skyla has very low levels of progesterone. These levels are lower than Mirena. Due to the low progesterone levels, Skyla must be replaced every 3 years. Skyla is over 99% effective at preventing pregnancy.
Progesterone Only Pills (POPs, Minipill)
Progesterone only oral contraceptives (also known as POPs or the minipill) are nowhere near as common as combined oral contraceptives. If taken exactly as prescribed, the minipill offers 92% effectiveness at preventing pregnancy. Due to the lower amount of hormones in the minipill the patient must take it at exactly the same time everyday. If the minipill is taken even an hour late the risk of pregnancy goes up! This contraceptive also changes the menstrual cycle quite a bit and often causes spotting.
Depo Provera (Progesterone injections)
Depo Provera is a progesterone injection that is given every three months. It has a 97% effectiveness rating. It changes the menstrual cycle substantially when used. Many women will stop having a period while on these injections. Like other progesterone only methods, there is no research indicating that it will increased blood clots, but a doctor should be involved when there is a prior history of pulmonary embolism, DVT, or other clots.
Mirena (IUD with progesterone instead of copper)
Mirena is an intrauterine device (IUD) that is coated with progesterone. It is placed in the uterus by an OBGYN and then will remain in place for p to five years. While the progesterone in this method does enter the body, some feel that it is more localized to the uterus and may be less of a risk for progesterone based side effects. It changes the period dramatically and many women stop menstruating after some time. For these reasons, it reduces the effects of PMS and menstruation. It is 99% effective at preventing pregnancy. Doctors used to feel that IUDs were only useful for women who had been pregnant in the past. It is now known that women who have never carried a child MAY use an IUD. One of the downsides to this method is that it puts women at a slightly higher risk for infection and pelvic inflammatory disease. For this reason, IUDs are not a good choice for women who have multiple sex partners.
Implannon (Progesterone Implants)
Implannon is a progesterone implant that is implanted in the upper arm. It releases progesterone into the body. It is 99% effective and carries the same risk of blood clots as other progesterone only methods. It will work for three years at the end which it can be removed or replaced. Like Mirena and Depo Provera, Implannon disrupts the menstrual cycle.
Hormone Free, No Clotting Risk Birth Control
Birth control without any hormones is the safest method of birth control for anyone who has a history of blood clot, DVT, pulmonary embolism, Factor V Leiden, or any clotting conditions or thrombophilias. All hormones increase the clotting risk. Some increase it by a small amount while others are a huge risk.
Hormone free birth control largely consists are various barrier methods although IUDs, natural family planning, and withdrawal also fall into this category.
Throughout the world there are many types and brands of copper IUDs. In the United States there is only one brand, Paraguard. The copper IUD is typically a small plastic, t-shaped piece of plastic wrapped in copper wire. Most forms of the copper IUD are 98% effective at preventing pregnancy, although this does vary by brand. In some countries there is a smaller version of the copper IUD that is available for women who have never been pregnant. This version is not available in the United States. Some women will find this to be a challenge as there is a higher rate of expulsion (the body kicking out the IUD) for women who have never been pregnant who use the standard size copper T. Like other IUDs, the copper IUD puts a woman at a higher risk for PID. This means that it is only a good choice for monogamous couples. It also may not be a good choice for women who have problems with menstrual cramps or excessive bleeding.
Note: Some women will have excessive bleeding during menstruation while on Coumadin/warfarin. Talk to you doctors about this possibility.
Condom (male and female)
The condom may be the most famous birth control out there. It is convenient as it takes no prescription. They can be obtained at numerous stores in person or through the Internet. Standard, male condoms are 98% percent effective when used every time and used correctly. There is also a female condom available. It is slightly less effective (between 80%-95%), more expensive, and can be more difficult to find in stores.
A cervical cap is a small, cuplike device that is worn inside up against a woman's cervix. Different brands have different effectiveness ratings but all of them are over 90%. In the United States, a cervical cap requires a prescription. The brand that is currently available is called FemCap. This particular brand is 92% effective when used with spermicide. Many people like that it can be placed before intercourse and that it can be used for multiple intercourse sessions. A downside of this method is that some people cannot tolerate nonoxynol-9, the primary ingredient in spermacide. FemCap's makers note that this cervical cap has a special ridge to hold the spermacide and reduce irritation. To get a FemCap, visit the company website or order one online at Lady to Baby.
The diaphragm is another well known birth control method. It is another internal device that is worn by the female to cover and block the cervix. It also is used with spermacide so users who are irritated by nonoxynol-9 may have problems with this device. It is only85% effective at preventing pregnancy. It must be fitted by a trained OBGYN. It must be re-fitted after weight changes, pregnancy, or abortion. Some couples like that it can be placed before intercourse and can be left in for multiple intercourse sessions.
Spermacide can be used on its own as a contraceptive. There are a number of types of spermacide available for this purpose. At this time, they all contain nonoxynol-9, a known irritant. By itself spermacide is only 78% effective. The tissue irritation that nonoxynol-9 causes, can be very painful for some people. Also, research is showing that the irritation increases the risk of contracting a sexually transmitted disease such as HIV.
The contraceptive sponge is another option that uses nonoxynol-9. It is 89% effective. It is placed internally to prevent sperm from entering the cervix. It is available over the counter and can be purchased at most drug stores. It cannot be used while a woman is menstruating. In the United States it goes by the brand name Today's Sponge.
Natural Family Planning
Natural family planning is a method that uses the woman's body signals and schedule to determine when she is least likely to become pregnant during sex. It is accepted by some churches as a way to prevent pregnancy when it is an unsafe time for a woman to conceive. There are many versions of this method. Some now include the use of electronic fertility monitors. These can be found at Lady to Baby. The site is above in the recommended links. The methods vary greatly on reliability. Research the different methods if you are interested to learn which one is best for you.
There are a number of contraceptive choices available for women who are at an increased risk for clotting. This is important as pulmonary embolisms can be fatal. It is also important for women who are recovering from pulmonary embolisms as their bodies often need time to heal before becoming pregnant. Hormone methods that include estrogen should be avoided unless recommended by a doctor while a woman is on anticoagulation. Other options that are not mentioned here include sterilization and withdrawal. Also, if absolutely necessary, Plan B can be discussed as it is a progesterone based emergency contraception.
It is very important to consider health conditions, medical treatments, and personal lifestyle when making this decision. Read over everything and discuss it with your doctor.
References Consulted For This Hub:
- Birth Control: Visualizing the Risks
- Birth Control: Clarifying the (Small) Heart Attack & Stroke Risks | The Blog That Ate Manhattan
- Clot Connect: Skyla IUD - New Birth Control for Women at Risk for Blood Clots
- Skyla Information
- Birth Control & Blood Clots: Visualizing The Risks | The Blog That Ate Manhattan
- Lady to Baby
- Today Sponge - Official Website
- World Health Organization (WHO): Medial Eligibility Criteria for Contraceptive Use
- Epigee Pregnancy Resource
- Relation between oral contraceptive hormones and blood clotting
- Birth Control: MedlinePlus
- Birth Control Methods - Birth Control Options
- Cell Survival
- Oral Contraceptives
- New Generation Contraceptive Birth Control Pills Double Risk Of Blood Clot
- Managing Contraception: Reproductive health and contraceptive education
- Birth Control Patch Represents Higher Blood Clot Risk than Birth Control Pills: FDA Approves Update
- Third Generation Oral Contraception Blood Clot Risk
- Women's Health | Blood Clots
- Oral Contraceptives and Blood Clots
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