Correspondence

Oral Contraceptives in Women with Systemic Lupus Erythematosus

N Engl J Med 2006; 354:1203-1204March 16, 2006

Article

To the Editor:

As Petri et al. state (Dec. 15 issue),1 oral contraceptives are the most widely used form of reversible contraception. However, the most effective contraceptive is the intrauterine device (IUD). With a first-year failure rate of 0.1 percent, the levonorgestrel IUD is superior to sterilization2 and constitutes an excellent choice when pregnancy is dangerous. In the large trials of IUDs sponsored by the World Health Organization and cited by Sánchez-Guerrero et al. in the same issue of the Journal,3 the risk of upper genital tract infection was limited to the first 20 days after insertion.4 As such, it would be important to know the relationship between infections and IUD insertion before concluding that, “although no differences in the incidence of severe infections were observed . . ., the possibility of a higher risk with the use of an IUD should be considered.” A careful study indicates that the risk of infection associated with IUD insertion is too small to warrant routine use of prophylactic antibiotics.5 Recently, the Food and Drug Administration removed immunosuppression from its list of contraindications to IUD use. Since safe and highly effective contraception is essential for women with systemic lupus erythematosus, further study of the IUD in this population is warranted.

Eleanor B. Schwarz, M.D.
Patricia A. Lohr, M.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 15213
schweb@upmc.edu

5 References

1. 1

   Petri M, Kim MY, Kalunian KC, et al. Combined oral contraceptives in women with systemic lupus erythematosus. N Engl J Med 2005;353:2550-2558
   Full Text | Web of Science | Medline

2. 2

   Trussell J. Contraceptive failure in the United States. Contraception 2004;70:89-96
   CrossRef | Web of Science | Medline

3. 3

   Sanchez-Guerrero J, Uribe AG, Jimenez-Santana L, et al. A trial of contraceptive methods in women with systemic lupus erythematosus. N Engl J Med 2005;353:2539-2549
   Full Text | Web of Science | Medline

4. 4

   Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339:785-788
   CrossRef | Web of Science | Medline

5. 5

   Walsh T, Grimes D, Frezieres R, et al. Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices. Lancet 1998;351:1005-1008
   CrossRef | Web of Science | Medline

Author/Editor Response

We appreciate the interest of Drs. Schwarz and Lohr in our study, as well as the opportunity to clarify their very relevant comment. As they mention, the risk of upper genital tract infections is higher during the 20 days after insertion of an IUD.

In our study, no episode of pelvic inflammatory disease was observed. The five episodes of severe infections that occurred among patients assigned to IUD were meningitis (two episodes), cellulitis of the leg (two), and herpes zoster (one). One episode of meningitis and one of cellulitis developed 4 and 12 days after insertion of the IUD, respectively. All other infections occurred between 3 and 11 months after IUD insertion.

Whether IUD use increases the risk of severe infections in women with systemic lupus erythematosus cannot be determined from our results; thus, the infections we noted must be considered observational. Properly designed studies undertaken specifically to define this issue need to be conducted.

Jorge Sánchez-Guerrero, M.D.
Luisa Jiménez-Santana, M.D.
María-del-Carmen Cravioto, M.D.
Instituto Nacional de Ciencias Médicas y Nutrición, Salvador Zubirán, 14000 Mexico City, Mexico
jsanchez@innsz.mx

Citing Articles (4)

Citing Articles

1. 1

   Iris Tong, Raymond O. Powrie. 2010. Contraception for Women with Medical Disorders. , 653-660.
   CrossRef

2. 2

   Eleanor Bimla Schwarz, Susan Manzi. (2008) Risk of unintended pregnancy among women with systemic lupus erythematosus. Arthritis & Rheumatism 59:6, 863-866
   CrossRef

3. 3

   Stephanie B. Teal, David M. Ginosar. (2007) Contraception for Women with Chronic Medical Conditions. Obstetrics and Gynecology Clinics of North America 34:1, 113-126
   CrossRef

4. 4

   (2006) Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiology and Drug Safety 15:9, i-xii
   CrossRef