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Systemic lupus erythematosus with positive antiphospholipid antibodies — DFSRH MCQ

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EasyAutoimmune DiseaseSystemic lupus erythematosus with positive antiphospholipid antibodiesDFSRH

A 32-year-old woman with systemic lupus erythematosus and previous lupus nephritis requests contraception. Her disease is clinically quiescent on mycophenolate mofetil and hydroxychloroquine. Lupus anticoagulant and high-titre anticardiolipin IgG have remained positive on repeat testing, although she has never had thrombosis or pregnancy morbidity. Her platelet count is 210 × 10⁹/L. She reports objectively heavy regular menstrual bleeding that affects her work. Pelvic examination and ultrasonography show no structural uterine pathology. She wants highly effective reversible contraception requiring no regular action and accepts intrauterine contraception. Pregnancy is reasonably excluded. Which contraceptive method is most appropriate?

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Correct answer: E — 52 mg levonorgestrel intrauterine device

A 52 mg levonorgestrel intrauterine device provides highly effective, user-independent contraception and directly addresses her heavy menstrual bleeding. This is particularly important because mycophenolate is a potent human teratogen and reliable contraception is required during treatment and for 6 weeks after discontinuation. In SLE with positive antiphospholipid antibodies, the LNG-IUD is UKMEC 2, so its advantages generally outweigh theoretical or proven risks. The copper IUD is UKMEC 1 and highly effective, but it can increase menstrual blood loss and is therefore inferior in this patient with established heavy bleeding. The etonogestrel implant is also UKMEC 2 and highly effective, but bleeding is unpredictable and it is not the preferred treatment for heavy menstrual bleeding. Depot medroxyprogesterone acetate is UKMEC 2 and may eventually produce amenorrhoea, but it is less suitable than the LNG-IUD given its initial irregular bleeding, repeat-injection requirement and potential delay in return of fertility. The combined vaginal ring contains estrogen. Combined hormonal contraception is UKMEC 4 in anyone with positive antiphospholipid antibodies, even without previous thrombosis, because it represents an unacceptable thrombotic risk.

Reference: UK Medical Eligibility Criteria for Contraceptive Use: UKMEC 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 Mycophenolate mofetil 500 mg film-coated tablets: Summary of Product Characteristics (15 April 2026) — https://www.medicines.org.uk/emc/product/11559/smpc