Curriculum · Gynecology / Women's Health / Infertility / Perinatal Care / Birth Spacing
Contraception in sickle cell disease
What it is
Contraception for a woman with SCD is chosen from the same four groups set out for any woman: the condom, diaphragm and cervical cap; the combined OCP; progesterone only methods; and intrauterine devices. SCD itself appears twice in that table, and both times the choice moves away from estrogen. SCD is named among the relative contraindications to the combined OCP, alongside DM, HTN, dyslipidemia, anticonvulsant use and gallbladder disease. Acute SCD crisis is named among the non-contraceptive uses of DMPA, the IM agent Depo Provera, also written as depot medroxyprogesterone acetate.
How it is treated
Progesterone only contraception comes in two types: the mini pills, taken daily, and the IM agents (Depo Provera, DMPA), given once every 3 months. Their stated advantages are that there is no DVT risk because there is no estrogen, that they are used when estrogen is contraindicated, and that they are safe in breast feed and improve milk quality. Ovulation is immediately reversible with the POP, so menses return. The combined OCP is given as 21 active pills with 7 placebo; it suppresses LH and FSH to give anovulation, thickens the cervical mucosa to inhibit migration and thins the endometrial lining to inhibit implantation, and its failure is 0.1%. The two are set against each other on absorption as well: the combined pill depends on gut flora, that is bacteria, for its absorption, so it is affected by Abs, and it has a low effect if taken with an anticonvulsant or griseofulvin, while the progesterone only methods do not depend on gut flora and are not affected by ABS. Intrauterine devices alter tubal motility. The copper IUD (paragard) lasts 10-12 yrs with 0.8% failure and acts by a fall in sperm motility and acrosomal enzyme action and by endometrial inflammation, while the hormonal IUD (Mirena) contains progesterone, thickens the cervical mucus, thins the endometrium, lasts 7 yrs with 0.1% failure and improves menorrhagia. The condom and diaphragm reduce STD and PID, but the cap does so only if it contains spermicide. After giving birth, contraception is required after day 21, since the earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum and sperm can survive for up to 7 days. The progestogen only pill can be started at any time postpartum, and after day 21 additional contraception is used for the first 2 days; a small amount of progestogen enters breast milk but this is not harmful to the infant. The combined pill may be started from day 21, which gives immediate contraception, and after day 21 additional contraception is used for the first 7 days. The Mirena intrauterine system and the copper IUD can be used from 4 weeks postpartum, and the copper device should not be inserted before day 28 postpartum because of the increased risk of uterine perforation. The progestogen only implant can be inserted at any time, and contraception is not required before day 21. Lactational amenorrhoea is an effective contraceptive in itself, 98% effective, provided the woman is fully breast-feeding with no supplementary feeds, is amenorrhoeic, and is under 6 months post-partum.