Contraception in systemic lupus erythematosus and antiphospholipid antibody syndrome

Family planning and contraception are central to disease management in people with rheumatic musculoskeletal diseases (RMD), particularly systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), in whom unplanned pregnancy can carry substantial maternal and fetal risk. This review summarizes current evidence and guideline-based recommendations regarding contraceptive choices in women with SLE and APS, with a focus on thrombotic risk, bone health, and cardiovascular considerations.

Estrogen-containing hormonal contraception is well established as a pro-thrombotic risk and should be avoided in those with APS, antiphospholipid antibodies (aPL), lupus nephritis, or at least moderately active SLE. Emerging data also suggest an association of certain higher dose progestins such as norethindrone acetate, and injectable preparations such as depot medroxyprogesterone acetate (DMPA), with increased venous thromboembolism (VTE) risk. Regarding bone health, oral contraceptive pills (OCPs) and combined hormonal contraception (CHC) may slow the rate of bone mass acquisition in adolescents with uncertain long-term effects on fracture risk, whereas use in adult women is associated with modestly higher bone mineral density and lower osteoporotic risk. While awareness of the importance of contraception in the rheumatology community is improving, real-world practice reveals that implementation of reproductive health guidelines is lagging.

For women with SLE and APS, contraception selection must account for thrombotic risk, bone health, and cardiovascular comorbidities. Long-acting reversible contraceptives, particularly progestin-only intrauterine devices (IUDs) and subdermal implants, remain highly effective and well tolerated for those with SLE and APS. Ongoing efforts to improve guideline implementation, shared decision-making, and patient and provider education are essential to reduce unplanned pregnancies and optimize reproductive outcomes in this population.