Before we delve too far into this topic I want to emphasize that I am a pulmonologist, not a gynecologist. That being said, birth control is a core part of caring for women with pulmonary hypertension. What follows is the lung doctor’s take on birth control.
I have previously described the important physiologic changes that occur with pregnancy and the major risks to women with PAH who get pregnant. I want to focus now on birth control (contraception). We are very fortunate to have so many good options for preventing unplanned and potentially very risky pregnancies. An essential foundation of this topic is the ability to openly and honestly discuss sex and preventing pregnancy with your doctors. I try and make this discussion routine in the care of patients with childbearing potential.
There are several different categories of preventative birth control
- Barrier Methods: condoms, diaphragms, and cervical caps generally combined with a spermicide. Prevent pregnancy by preventing the sperm and egg from meeting.
- Short acting hormonal contraception: progesterone and combined progesterone/estrogen pills/patches and vaginal rings. Prevent pregnancy by preventing ovulation (release of an egg from the ovary)
- Long Acting Reversible contraception
- Hormonal: Depo Provera (quarterly progesterone injections)
- Intra-Uterine Device. Prevents pregnancy by decreasing sperm movement through the uterus and preventing the fertilized egg from implanting in the uterus
- Implanted Progesterone
- Tubal ligation
Male and female condoms are highly effective and provide the important additional benefit of preventing sexually transmitted diseases. The challenge with all barrier methods is that timing and consistency can be frustrating. For example condoms must be used 100% of the time and for the entire duration of intercourse. I generally counsel women to consider a second method of birth control in addition to condoms or other barrier methods.
Short Acting Hormonal Contraception
Oral Progesterone only strategies are not very commonly used in the general population. They are reported to be about 91% effective (9% of women with normal fertility who use progesterone-only pills for birth control will get pregnant in a year). The advantage of this oral progesterone is that the risk of blood clots (pulmonary embolism) is lower than with estrogen-containing birth control pills. The disadvantage is that you must take a pill every day. Sexually transmitted diseases are not prevented by this method.
Combined Estrogen and Progesterone birth control pills are the most commonly used medication for preventing pregnancy. They are very effective when taken properly. The problem in PAH patients is that the estrogen increases the risk of forming blood clots in the legs and lungs. As a result, in my practice I limit this strategy to women who are already on blood thinners. I would not prescribe blood thinners solely to allow use of estrogen containing pills however. 100% compliance is essential and as with progesterone only pills, there is no protection against sexually transmitted diseases. The risk of blood clot formation increases with age and is especially high in smokers.
There are hormonal patches and rings that are very similar to the combination (estrogen/progesterone) pills described above. The patch is changed weekly for three of the four weeks and no patch is used for the fourth week. The vaginal ring is used for three weeks and then removed for the fourth week.
Long Acting Reversible Contraception
Intra-uterine Devices (IUD) are perhaps the best known of this category. These small devices are inserted through the vagina and cervix into the uterus. The insertion procedure is done in the office and does not require sedation or anesthesia. The device may be removed in the office as well. Efficacy is greater than 99%. Some women notice increased cramping and heavier periods for the first few months. After that most women have a lighter cycle and cramping resolves. I consider this method of birth control to be preferred with the important warning that the IUD does not prevent sexually transmitted diseases. Once inserted an IUD remains effective for ten years.
This quarterly (every 3 month) intramuscular injection of long acting progesterone is highly effective and an excellent option for many women. When used properly this method is more than 99% effective in preventing pregnancy. A large study showed that this medicine does not promote weight gain. Early studies suggested that some women might experience mild hair loss. In more rigorous studies this was not found to be the case. Most women experience lighter periods while on this method of birth control. It is not uncommon to have some irregular spotting for the first few months. As with other hormonal contraceptives, Depo-Provera does not prevent sexually transmitted diseases. Many of my younger patients use this method of birth control.
Long Acting Implanted Progesterone
This form of birth control involves inserting a very small progesterone-containing rod into your arm. It delivers effective birth control for 3 years. It is more than 99% effective. The insertion procedure is done in the office with local anesthesia. As with other hormonal contraception, there is no protection against sexually transmitted diseases.
As we strive to deliver the best care for our patients with pulmonary hypertension, an honest open dialogue about sex and birth control is essential. Unplanned pregnancies carry enormous preventable risk. PAH does not mean an end to a healthy sex life. It does require some advanced planning to avoid pregnancies.