“Contraception for medically complex patients,” by Daniela A. Carusi, MD, MSc
I am surprised that Dr. Carusi recommends progestin-only pills for contraception for the woman described in her article who had sickle cell disease and a history of mild stroke. The article states that depot medroxyprogesterone acetate (DMPA) “may suppress ovarian function and is classified as [World Health Organization] category 3.” (Category 3 is reserved for conditions in which theoretical or proven risks usually outweigh the advantages of the contraceptive method.)
Because DMPA is associated with a reduction in sickle cell crisis and related pain, and is also highly effective, I had expected Dr. Carusi to recommend it for the patient in question.
Russ Jelsema, MD
Grand Rapids, Mich
Dr. Carusi responds: Many nuances influence choice of contraceptive
Dr. Richman is correct: We lack an appropriate study confirming diminished OC efficacy in obese women. Until such a trial is conducted, I think it is important to point out that some people misinterpret “less effective” as “ineffective” and fail to prescribe adequate contraception for obese women. However, as with most patients, pregnancy poses more risk to obese women than does combined hormonal contraception. If that is the only effective method that an obese woman can accept and comply with, it may be the best method for her. On the other hand, because of its high efficacy and lack of demonstrated cardiovascular or thrombosis risk, intrauterine contraception should be strongly considered for this group of patients.
Dr. Jelsema also raises an important point. However, when a patient has a history of sickle cell disease and mild stroke, the WHO treats DMPA differently than other progestin-only methods, including pills and Implanon; the latter are WHO category 2 (benefits generally outweigh risks), while DMPA is category 3 (risks generally outweigh benefits). To explain this distinction, the WHO points to the hypoestrogenic effect and reduced high-density lipoprotein cholesterol level in women who are taking DMPA.
Although there is a single small study (25 subjects) showing that DMPA may reduce painful crises in sickle cell patients, it is not sufficiently powered to confirm cardiovascular safety, particularly in a patient who has already suffered a cerebrovascular accident.1 For the patient described in my article, who was able to demonstrate excellent compliance with pill-taking and was willing to use barriers for prevention of sexually transmitted infection and backup contraception, progestin-only pills were thought to be her safest option.