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Systemic lupus erythematosus with persistent antiphospholipid antibodies and heavy menstrual bleeding — DFSRH

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HardHydroxychloroquineSystemic lupus erythematosus with persistent antiphospholipid antibodies and heavy menstrual bleedingDFSRH

A 34-year-old woman with systemic lupus erythematosus requests contraception. Her disease has been clinically quiescent for 18 months on hydroxychloroquine 200 mg twice daily. Testing on three occasions has shown persistent lupus anticoagulant, high-titre anticardiolipin IgG and anti-beta-2-glycoprotein-I IgG antibodies. She has never had a venous or arterial thrombotic event and has had no previous pregnancy, so does not meet clinical criteria for antiphospholipid syndrome. She has regular, heavy, painful menstrual bleeding. Haemoglobin is 108 g/L and ferritin is 9 micrograms/L. Pelvic ultrasonography shows a normal uterine cavity. She wants highly effective, user-independent, reversible contraception and would welcome reduced menstrual bleeding. There are no method-specific contraindications to intrauterine contraception. She asks for the combined contraceptive patch, reasoning that hydroxychloroquine and the absence of previous thrombosis should offset the thrombotic risk associated with her antibodies. Which contraceptive method is most appropriate?

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Correct answer: B — 52 mg levonorgestrel intrauterine device

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

Persistent antiphospholipid antibody positivity is the decisive safety discriminator. Under UKMEC, combined hormonal contraception is category 4 in women with SLE and positive antiphospholipid antibodies. The absence of previous thrombosis and clinical antiphospholipid syndrome does not remove this classification, and hydroxychloroquine treatment does not make estrogen-containing contraception acceptable. A 52 mg LNG-IUD is UKMEC 2 and provides highly effective, user-independent reversible contraception. It also directly addresses her heavy menstrual bleeding and iron deficiency; FSRH identifies the 52 mg LNG-IUD as effective for HMB, with substantial reductions in menstrual blood loss. A is contraindicated because the patch is combined hormonal contraception. B is UKMEC 1 for antiphospholipid antibodies and is highly effective, but copper IUDs may increase menstrual bleeding and therefore poorly match her clinically important secondary objective. D is UKMEC 2 and highly effective, but implant-related bleeding is unpredictable and it is not the preferred treatment for established HMB. E is also UKMEC 2 and may eventually produce amenorrhoea, but requires repeat administration and is less directly supported than the 52 mg LNG-IUD for treatment of HMB. Hydroxychloroquine should not be stopped merely to facilitate contraceptive prescribing.

Reference: UK Medical Eligibility Criteria for Contraceptive Use (2016, amended September 2019) — 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 Hydroxychloroquine sulfate 200 mg film-coated tablets: Summary of Product Characteristics (20 January 2026) — https://www.medicines.org.uk/emc/product/1764/smpc