Contraception and Lupus

Systemic lupus erythematosus mainly affects women of reproductive age. Pregnancy during active disease raises the risk of flare, nephritis, pre-eclampsia, foetal loss and preterm birth, and several medicines (mycophenolate, cyclophosphamide, methotrexate) are teratogenic. Contraception choice depends on antiphospholipid antibodies, disease activity, renal involvement, hypertension and thrombocytopenia.

Assessment. Disease activity, antiphospholipid antibody status (lupus anticoagulant, anticardiolipin, anti-beta-2 glycoprotein I), thrombosis history, nephritis, hypertension, platelet count, current immunosuppression, corticosteroid dose, osteoporosis risk and pregnancy intention.

Antiphospholipid antibodies. Positive or unknown antibodies carry thrombosis risk and restrict most hormonal methods.

Severe thrombocytopenia. Platelets under 50 x 10^9/L increase bleeding with the copper device and with injections.

Effectiveness. First-year pregnancies per 100 women with typical use: implants 0.05, intrauterine devices 0.2 to 0.8, injectables 3, combined pills 8.

Eligibility.

Method comparison. The copper device is first choice when antibodies are positive or unknown. The levonorgestrel device and implants are acceptable when antibodies are negative. Combined methods are avoided in active disease, nephritis, hypertension and antibody positivity.

Medicine interactions. Mycophenolate may reduce exposure to contraceptive hormones and is highly teratogenic; use a long-acting method plus condoms or two methods. Hydroxychloroquine and azathioprine are compatible with pregnancy and do not interact meaningfully. Cyclophosphamide and methotrexate need reliable contraception.

Special groups. Corticosteroid users have bone loss, so DMPA is used with caution. Lupus nephritis follows the kidney disease rules.

Regimen lines.

• Copper T 380A: up to 12 years; insert within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup; avoid insertion if platelets are under 50 x 10^9/L.

• Levonorgestrel 52 mg device: 5 years; only when antiphospholipid antibodies are negative.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding; only when antibodies are negative.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, only when antibodies are negative and bone health is acceptable.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• Combined pill: only in stable inactive disease, antibody negative, normotensive and non-smoking.

Planned pregnancy. Conceive after at least 6 months of quiet disease on pregnancy-compatible medicines (hydroxychloroquine, azathioprine, low-dose prednisolone), with low-dose aspirin and antibody-specific therapy as advised by the specialist.

Follow up. Review disease activity, blood pressure, platelets and medicines at each rheumatology visit.

Flare on a hormonal method. Disease flare is managed on its own merits; stop oestrogen-containing methods during active disease.

Thrombosis. Unilateral leg swelling or chest pain needs urgent assessment; positive antibodies after a thrombotic event need lifelong anticoagulation advice.

Bleeding. Heavy bleeding with low platelets needs haematology review; tranexamic acid is avoided with antibody positivity.

Red flags. Chest pain, leg swelling, severe headache, haematuria, new rash with fever.

Referral and escalation. Refer active disease, nephritis, positive antibodies with thrombosis, pregnancy, and teratogenic therapy exposure to rheumatology and obstetrics.