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Systemic lupus erythematosus with thrombotic antiphospholipid syndrome and anticoagulant-associated heavy mens

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HardRheumatologySystemic lupus erythematosus with thrombotic antiphospholipid syndrome and anticoagulant-associated heavy menstrual bleedingDFSRH

A 36-year-old woman with systemic lupus erythematosus and thrombotic antiphospholipid syndrome requests highly effective reversible contraception. She has persistent lupus anticoagulant and high-titre anticardiolipin antibodies and has had two proximal deep-vein thromboses. She therefore takes lifelong warfarin with a target INR of 2.0–3.0. Since starting anticoagulation, her regular menses have become heavy, impairing her quality of life. Haemoglobin is 101 g/L. She has no intermenstrual or postcoital bleeding, pelvic examination is normal, and ultrasound shows no uterine pathology. Pregnancy has been reasonably excluded and her STI risk is low. Her warfarin dose has been unchanged for 4 months, previous INR results are stable, and the INR measured yesterday was 2.8. She has no history of excessive procedural bleeding and wishes to avoid pregnancy for at least 5 years. Which is the most appropriate contraceptive plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Fit a 52 mg levonorgestrel intrauterine device without interrupting warfarin, using local haemostatic precautions

Explanation lettering: B = shown as A · A = shown as B · E = shown as C · C = shown as D · D = shown as E

A 52 mg LNG-IUD best integrates her need for highly effective contraception, antiphospholipid-associated thrombotic risk and anticoagulant-associated heavy menstrual bleeding. In SLE with positive antiphospholipid antibodies, LNG-IUD use is UKMEC 2, whereas combined hormonal contraception is UKMEC 4. The 52 mg LNG-IUD also has evidence-based benefit for heavy menstrual bleeding and is preferable to a copper IUD, which commonly increases menstrual blood loss. Warfarin should not routinely be interrupted for insertion. Current FSRH guidance permits IUC insertion without withholding warfarin when the target INR is below 3.5 and previous results are stable. Appropriate procedural planning includes insertion during normal working hours, availability of local haemostatic measures and checking for bleeding before discharge. A is contraceptively effective and UKMEC 1 for antiphospholipid positivity, but may aggravate her established heavy bleeding and anaemia. B exposes a woman with recurrent thrombotic APS to avoidable thrombosis risk; interruption is not indicated with her stable INR target. C is contraindicated because oestrogen confers unacceptable thrombotic risk despite concurrent anticoagulation. E is medically eligible and warfarin need not be stopped, but implant-related bleeding is unpredictable and it does not offer the established first-line therapeutic benefit for heavy menstrual bleeding provided by a 52 mg LNG-IUD.

Reference: UK Medical Eligibility Criteria for Contraceptive Use (2016) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-ukmec-full-book-2019.pdf FSRH Guideline: Intrauterine Contraception (March 2023, amended January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf FSRH Guideline: Intrauterine Contraception (March 2023, amended January 2025) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf