Dear Editor,
Contraception appears to be an essential component of reproductive health care in that it improves women's reproductive autonomy and reduces unintended pregnancies. Despite the unequivocal benefits of contraceptive agents, there is a slight increase in the risk of venous thromboembolism (VTE) associated with them. This risk becomes even more concerning in the context with COVID-19 pandemic, where the disease itself may predispose the patients to both venous and arterial thrombosis, due to excessive inflammation, platelet activation, endothelial dysfunction, and stasis [1]. Thus, it becomes crucial to review the current literature to have guidance on contraceptive advice during COVID-19 pandemic (Table 1 ).
Table 1.
Current recommendations of hormonal contraception with the background of COVID-19 and risk of Venous thromboembolism [3,4].
| Recommendations | |
|---|---|
| 1. | Women should not be encouraged to withdraw contraception unless they want to get pregnant. |
| 2. | For those with confirmed COVID-19 with mild symptoms who are undergoing treatment at home, it is recommended that they can continue COC but are advised to switch to progestin-only methods for the presence of any additional risk factors. |
| 3. | Risk stratification of VTE in COVID-19 women who are not hospitalised should be done, to look for other VTE risk factors; to define the severity of COVID-19 impairment; evaluate the benefit-risk ratio of the prescription of preventive anticoagulant treatment, and to specify the type of hormone treatment. |
| 4. | Women with confirmed COVID-19 admitted to hospital should withdraw COC and start low-molecular-weight heparin (LMWH) at prophylactic doses. |
| 5. | The decision to switch from COC to other alternative forms of contraception should be taken after considering the facts that discontinuation of oral COC requires at least 2 months to restore coagulation parameters and the strong protection it offers to avoid unwanted pregnancy. |
According to ACOG recommendation, telemedicine facilities should be used to screen, counsel and manage complications related to oral contraceptives. Wherever possible, long-acting reversible contraceptives (LARC) like the insertion of IUDs or contraceptive implants, and permanent contraception should be offered. Oral contraceptives can be advised if LARC methods are unavailable, as a bridge to delayed insertion. ACOG also recommends postponing routine LARC removals, if possible [2]. There is evidence suggesting that VTE risk increases in direct proportion to the number of predisposing factors. This increase in cumulative risk becomes even more concern in those affected with COVID-19. Current guidelines are in agreement to recommend that VTE risk stratification should be done for hospitalised patients with COVID-19. Spanish guidelines state that women with confirmed COVID-19 admitted to hospital should withdraw COC and start low-molecular-weight heparin (LMWH) at prophylactic doses. For those with confirmed COVID-19 with mild symptoms who are undergoing treatment at home, it is recommended that they can continue COC but are advised to switch to progestin-only methods for the presence of any additional risk factors [3]. French recommendations from the National College of Teachers of Medical Gynecology acknowledge the fact that there is a delay (6–8 weeks) in return of coagulation profile to the baseline after discontinuation of COC. So it states that it is not reasonable to change the COC due to changes in the underlying coagulation because of this delay in returning to baseline. However, it further states that the addition of LMWH could help women with symptomatic COVID19 and will be benefited from this [4].
The decision to switch from COC to another alternative form of contraception should be taken after considering the facts that discontinuation of oral COC requires at least two months to restore coagulation parameters and the strong protection it offers to avoid unwanted pregnancy which itself is a hypercoagulable state in addition to its other adverse aspects [4]. Moreover, Estrogen is believed to have a protective role in the setting of a SARS-CoV-2 infection by regulating the expression of the angiotensin-converting enzyme 2 (ACE2), in differentiated airway epithelial cells [5].
Adoption of Contraceptive method is a life-saving measure, and women should receive their preferred method of contraception. The switch of contraceptive methods should be decided based on various factors like the presence of risk factors of VTE, the severity of COVID-19 etc. Further studies are needed to better guide contraception counselling during this pandemic.
Funding
None.
Ethical statement
This article does not contain any studies with animals performed by any of the authors.
Declaration of Competing Interest
The authors report no declarations of interest.
References
- 1.Connors J.M., Levy J.H. Thromboinflammation and the hypercoagulability of COVID-19. J Thromb Haemost. 2020 doi: 10.1111/jth.14849. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.American College of Obstetricians and Gynecologists; 2020. COVID-19 FAQs for obstetricians-gynecologists, gynaecology.https://www.acog.org/clinical-information/physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics Available from: [Google Scholar]
- 3.Ramírez I., De la Viuda E., Baquedano L., et al. Managing thromboembolic risk with menopausal hormone therapy and hormonal contraception in the COVID-19 pandemic: recommendations from the Spanish Menopause Society, Sociedad Española de Ginecología y Obstetricia and Sociedad Española de Trombosis y Hemos. Maturitas. 2020;137:57–62. doi: 10.1016/j.maturitas.2020.04.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.2020. Collège National des Enseignants de Gynécologie Médicale; L’Unité d’Hémostase Clinique de Cochin. Prévention du risque thromboembolique veineux chez les femmes COVID + non hospitalisées utilisant un traitement hormonal (Contraception, Traitement hormonal de ménopause, Tamoxifène) [Internet] [cited 2020 May 30]. Available from: http://www.cngof.fr/coronavirus-go-cngof/apercu?path=HEMOSTASE%2B-%2BRISQUE%2BDE%2BMTE% 252FHemostase-PreventionMVTECOVIDHormones.pdf&i=36239. [Google Scholar]
- 5.Stelzig K.E., Canepa-Escaro F., Schiliro M., et al. Estrogen regulates the expression of SARS-CoV-2 receptor ACE2 in differentiated airway epithelial cells. Am J Physiol Lung Cell Mol Physiol. 2020;318(6):L1280–L1281. doi: 10.1152/ajplung.00153.2020. [DOI] [PMC free article] [PubMed] [Google Scholar]