The article (1) is not an overview of various contraceptive methods (which are therefore not discussed in detail) but rather of contraception in situations of increased risk (1). Here, all non-hormonal methods, such as natural family planning, barrier methods, and non-hormonal intrauterine forms of contraception can be used almost without restriction and are therefore always an alternative that should be included in the education (cf. Figure in ). However, oral contraceptives predominate in frequency of use. The most common question is whether hormonal contraception is possible in patients who are at increased risk.
We were only able to present a few selected at-risk situations. A more comprehensive overview is presented in our textbook (2).
The issue of contraception in obesity has been comprehensively described. It is clear that, due to the increased associated risk of thrombosis, the trend is reverting to using non-hormonal contraceptive methods, whereby intrauterine methods are primarily recommended, especially for higher levels of obesity (BMI >35).
Contraception after bariatric surgery affects only a relatively small number of patients, but both pre- and postoperative counseling should take place, as the WHO recommends safe contraception for these patients for at least 12–18 months postoperatively (3).
However, very limited data are available on the pharmacokinetics of oral contraceptives in this particular situation (3). As this also includes progestogens, oral progestin-only mini-pills are not a real alternative for this. Injection of depot progestins make more sense, with the exception of depot MPA, which is associated with an increased risk of thrombosis.
The reference to low-dose pills (less than 35 µg) is correct but plays a rather minor role in practice, as pills with 20 µg or 30 µg ethinyl estradiol are almost exclusively prescribed in Germany. Favorable data regarding the risk of thrombosis are available for estradiol-containing combined oral contraceptives (COCs) (comparable to levonorgestrel [LNG]/ethinyl estradiol [EE] COCs). It is not clear why oral progestin-only preparations should be associated with an increased risk of thrombosis.
Hyperlipidemia is often associated with other risk factors and should be carefully considered. It is important to differentiate what type of dyslipidemia is present. In hypercholesterolemia, depending on the values and other risk factors (WHO category 2), alternatives such as progestin-only mini-pills are preferable. If COCs are prescribed, micro-pills with progestins (dienogest, levonorgestrel) are preferred, as these have less influence on lipids. In familial hypertriglyceridemia, COCs can be used in exceptional cases. This also depends on the dose of ethinyl estradiol as well as on the selected progestins (4). Ethinyl estradiol at the lowest possible doses, or even an estradiol preparation with a relatively lipid-neutral progestin, are preferable.
There are numerous other at-risk situations in which the choice of contraception is particularly challenging. Data on interactions between COCs and other medicinal products are often insufficient. There are many factors to consider when choosing a safe and low-risk contraceptive method, which ideally need to be clarified in an interdisciplinary dialogue.
Prof. Dr. med. Thomas Römer
Evangelisches Klinikum Weyertal GmbH, Köln; Germany
Conflict of interest statement
Prof. Römer has served as a paid consultant for Bayer and GedeonRichter. He has received reimbursement of congress participation fees from Bayer, travel and accommodation expenses from Aristo Pharma, Exelitis, Dr. Kade, and Hexal, and lecture fees from Bayer, Exeltis, Hexal AG, and Aristo Pharma.
|1.||Römer T: Medical eligibility for contraception in women at increased risk. Dtsch Arztebl Int 2019; 116: 764–74 VOLLTEXT|
|2.||Römer T, Göretzlehner G: Kontrazeption mit OC in 238 Problemsituationen. 3rd edition, Berlin: De Gruyter 2017; 3–320 CrossRef|
|3.||Paulen ME, Zapata LB, Cansino C, Curtis KM, Jamieson DJ: Contraceptive use among women with a history of bariatric surgery: a systematic review. Contraception 2010; 82: 86–94 CrossRef MEDLINE|
|4.||Berenson AB, Rahman M, Wilkinson G: Effect of injectable and oral contraceptives on serum lipids. Obstet Gynecol 2009; 114: 786–94 CrossRef MEDLINE PubMed Central|