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Systemic lupus erythematosus with thrombotic antiphospholipid syndrome, anticoagulation-associated heavy menst

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HardSystemic Lupus ErythematosusSystemic lupus erythematosus with thrombotic antiphospholipid syndrome, anticoagulation-associated heavy menstrual bleeding and mycophenolate exposureDFSRH

A 33-year-old woman with systemic lupus erythematosus and previous lupus nephritis requests highly effective reversible contraception. She has persistently triple-positive antiphospholipid antibodies and had an unprovoked proximal deep-vein thrombosis 2 years ago. She takes lifelong warfarin, with a target INR of 2.0–3.0, and mycophenolate mofetil. Her INR was 2.6 yesterday and has remained between 2.2 and 2.9 for 3 months. Since starting warfarin, her regular menstruation has become heavy and prolonged, causing iron-deficiency anaemia. She has no intermenstrual bleeding, pelvic pain or pressure symptoms. Pelvic examination and transvaginal ultrasonography show a normal uterus and cavity. Pregnancy is reasonably excluded, and there is no current risk of sexually transmitted infection. She would welcome a method that reduces menstrual bleeding. Which is the most appropriate contraceptive management plan?

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Correct answer: E — Insert a 52 mg levonorgestrel intrauterine device today without interrupting warfarin, using procedural haemostatic precautions

A 52 mg LNG-IUD best integrates her need for highly effective contraception during mycophenolate exposure, antiphospholipid-associated thrombosis risk, heavy menstrual bleeding and anticoagulation. In SLE with positive antiphospholipid antibodies, an LNG-IUD is UKMEC 2, whereas combined hormonal contraception is UKMEC 4. Therapeutic anticoagulation does not remove that contraindication. The LNG-IUD is also recommended as first-line treatment for heavy menstrual bleeding when no significant uterine pathology is identified. A copper IUD is medically eligible but may increase menstrual blood loss, making it a poor choice in established anticoagulation-associated bleeding and anaemia. DMPA is a possible progestogen-only alternative, but is less well aligned with her preference and clinical need than an LNG-IUD, which combines very high contraceptive effectiveness with a direct endometrial effect. Warfarin should not routinely be interrupted. FSRH advises that intrauterine contraception can be inserted without stopping warfarin when the target INR is below 3.5 and previous values are stable. An experienced clinician should minimise cervical trauma, have local haemostatic measures available, check bleeding before discharge and avoid NSAIDs. Bridging or reversal would expose this patient with high-risk antiphospholipid syndrome to avoidable thrombosis without a guideline-supported procedural benefit.

Reference: UK Medical Eligibility Criteria for Contraceptive Use: UKMEC 2016 (Amended September 2019) — https://www.fsrh.org/Common/Uploaded%20files/Standards-and-Guidance/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 NICE NG88: Heavy menstrual bleeding—assessment and management (March 2018) — https://www.nice.org.uk/guidance/ng88/chapter/Recommendations