Contraception in Renal Disease
Three per cent of women of childbearing age have chronic kidney disease, and although end-stage renal failure impacts on fertility, pregnancies do occur. Surveys have demonstrated that a large proportion of pregnancies in women with kidney disease are unplanned, in part due to lack of fertility awareness. It should be emphasised that oligo- or amenorrhoea does not preclude the need for effective contraception.
The need for effective contraception in kidney disease should take into account:
- The risks (to both mother and foetus) of pregnancy in advanced CKD
- The risk of pregnancy in unstable CKD (e.g. early post-transplant period, acute glomerulonephritis)
- The risk of teratogenic medications (e.g. RAS inhibitors, MMF, rituximab)
- The risk of VTE in patients with cardiovascular disease and antiphospholipid antibody syndrome
The Renal Association recommends that safe and effective contraception is offered to all women of reproductive age who fall into any of the above ‘at risk’ categories, in addition to those who do not wish to conceive (1). The effectiveness of a particular contraceptive method is dependent upon acceptability to the patient as this is directly linked to compliance.
Key Learning Points
- Although fertility is reduced in renal disease, pregnancy can occur at all stages of CKD. Oligo- or amenorrhoea does not preclude the need for effective contraception.
- Safe and effective contraception should be made available to all women with CKD who do not wish to conceive, and those taking teratogenic medications.
- The choice of contraception will largely depend upon patient preference, however a subset of women with CKD will have contra-indications to oestrogen-containing preparations.
Progesterone-only methods, of which there are four, have an advantageous safety profile when compared to oestrogen-containing preparations. The progesterone-only ‘mini’ pill, intrauterine device (IUD, e.g. Mirena®), long acting injectable progesterone (e.g. Depo-Provera’) and subdermal implant (e.g. Nexplanon®) are safe and effective in women with CKD, including those on dialysis or who have undergone renal transplant. Unlike oestrogen-containing contraceptives, progesterone-only methods are not associated with an increased risk of hypertension or worsening proteinuria.
The IUD and implant are long-acting, reversible contraceptives, which last 3 to 5 years. Unlike the pill, they do not rely on daily user compliance and so are far more effective in preventing unwanted pregnancy, with a failure rate comparable to that of sterilisation. The long-acting injectable agents, such as medroxyprogesterone, are also very effective in preventing pregnancy, but restoration of fertility on cessation can take up to 18 months. They are also associated with a loss in bone mineral density, reversible on cessation of therapy. For this reason, an alternative option should be considered in women who are taking, or who may require, prednisolone therapy.
Concerns regarding the intrauterine system in women taking immunosuppression are unfounded and observational evidence does not demonstrate an increased risk of infection.
The pros and cons and cons of each of the progesterone-only contraceptives are summarised below:
|Progesterone-only ‘mini’ pill||Intrauterine device or “coil”||IM or SC injection or “depot”||Subdermal implant or “rod”|
|What is it?||A pill containing progesterone which is taken orally once per day, for 21 out of 28 days.||A small plastic T-shaped progesterone-releasing device which is placed into the uterus.||An injection of progesterone, which can be delivered intramuscularly or subcutaneously every 12-13 weeks.||A small, flexible rod inserted under the skin of the upper arm which releases progesterone.|
|Effectiveness (typical use)||91%||Over 99%||Around 94%||Over 99%|
|Advantage||Safer in those with kidney disease, vascular disease and hypertension.||Works for 3-5 years but can be removed sooner. Periods often become lighter, shorter and less painful.||Long-acting. Patients can be taught how to self-administer the sub-cut preparation.||Effective for 3 years but can be removed sooner.|
|Disadvantage||Narrow window for administration each day. Efficacy reduced by late or missed pills, or by severe vomiting and diarrhoea.||Irregular bleeding or spotting common in the first 6 months.||Cannot be removed once administered, effects may continue for some time resulting in a delay in return of fertility.||It requires a small procedure (under local anaesthetic) to implant and explant the rod. Can cause irregular bleeding in the first 6 months.|
Oestrogen-containing contraceptive methods include the ‘combined’ pill (containing oestrogen and progesterone), the transdermal patch, and the vaginal ring. Some preparations of the combined oral contraceptive pill, such as Loestrin and Microgynon, contain very low levels of oestrogen and are suitable for many patients with CKD, including those with well-controlled SLE (2). Indeed, a combined pill may be preferred given it’s efficacy profile when compared to progesterone-only pills.
Oestrogen-containing contraceptives may be contra-indicated in a subset of patients with CKD, including those with antiphospholipid syndrome, cardiovascular disease or heavy proteinuria, because of their association with hypertension, venous thromboembolism and arterial thrombosis. In these patients, progesterone-only contraception would be preferred.
Other methods of contraception
Barrier methods of contraception, such as condoms and diaphragms, offer protection against sexually transmitted infections whilst also avoiding any of the risks of systemic hormone therapy and potential drug interactions. However, barrier methods have a relatively high failure rate due to user error and are therefore most effective when combined with another method of contraception.
Methods of natural family planning or ‘fertility awareness’ are most effective in those women who have a regular menstrual cycle, and are therefore not recommended for patients with renal disease. Sterilisation is effective, but should be considered to be irreversible and only appropriate for those who are certain that they do not desire, or have completed, childbearing.
The most widely used emergency contraceptives (e.g, levonorgestrel) do not contain oestrogen and can therefore be used safely in patients with CKD to prevent pregnancy within 72 hours of unprotected intercourse.
For the medical termination of pregnancy, a combination of mifepristone and misoprostol is most commonly used. Only limited data are available on the use of both drugs in the context of renal impairment. Whereas mifepristone is largely metabolised in the liver, misoprostol is predominantly renally excreted. The peak concentration, half-life and bioavailability of misoprostol are all potentially increased in patients with CKD. The clinical relevance of potentially reduced clearance of misoprostol is unknown, and no dose reduction is recommended, although increased clinical surveillance should be considered for women with a pre-pregnancy estimated GFR of <30ml/min/1.73 m2 (3).
Wiles KS, Nelson-Piercy C, Bramham K. Reproductive health and pregnancy in women with chronic kidney disease. Nat Rev Nephrol. 2018; 14(3):165-184.
- The Renal Association Clinical Practice Guideline for Pregnancy and Renal Disease, 2019. URL: https://renal.org/wp-content/uploads/2019/09/FINAL-Pregnancy-Guideline-September-2019.pdf.
- Andreoli L, Bertsias GK, Agmon-Levin N, et al. EULAR recommendations for women’s health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndromeAnnals of the Rheumatic Diseases 2017;76:476-485.
- Bramham, K. et al. Pregnancy in renal transplant recipients: a UK national cohort study. Clin. J. Am. Soc. Nephrol. 8, 290–298 (2013).
Acknowledgements: Ashley Simpson was the original author for this page. It was last modified in September 2020.