Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit

A unit funded by the FFPRHC and supported by the University of Aberdeen and the Scottish Programme for Clinical Effectiveness in Reproductive Health (SPCERH) to provide guidance on evidence-based practice

MEMBERS ENQUIRY RESPONSE Enquiry Reference: 1718 Prepared: 27th July 2006

Sent:

27th July 2006

A: Question
For women with polyarthritis and ulcerative colitis who have had a colectomy, can combined oral contraception or an intrauterine device be used safely?

B: Response
FFPRHC CEU guidance recommends that women with inflammatory bowel disease (IBD) should be offered the same contraceptive choices as women without IBD. Certain contraceptive methods may have specific cautions for disorders associated with IBD (Grade C evidence). Women with ulcerative colitis can use oral contraception (Grade C evidence). No evidence was identified specifically relating to the risk of venous thromboembolism (VTE) in combined oral contraceptive (COC) users with IBD. Women who have had a colectomy and ileostomy have no enteroheptaic circulation of ethinyl estradiol. The efficacy of COC does not appear to be reduced in this situation. N intrauterine device (IUD) can also be used safely in a women with IBD. Polyarthritis is most often caused by an auto-immune disorder but can also be caused by infections. Some patients will go on to develop rheumatoid arthritis. Some evidence exists to suggest that oral contraception may help to decrease the occurrence of rheumatoid arthritis. The CEU could find no evidence to suggest that the use of an IUD would be contraindicated for a woman with poly- or rheumatoid arthritis and suggest that it may be used without restriction.

C: Evidence-Based Medicine Question (which guided our literature search strategy)

Population: Intervention: Outcome: Women with polyarthritis and ulcerative colitis who have had a colectomy Combined oral contraception or an intrauterine device Safety

Keywords:

Combined oral contraception; COC; intrauterine device; IUD; ulcerative colitis; colectomy; inflammatory bowel disease; IBD; polyarthritis; 1718

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Email: ffp.ceu@abdn.ac.uk

D: Information Sources
The CEU searched the following sources in developing this Members Enquiry Response Source Searched Information Identified
Existing FFPRHC and RCOG guidance The National Guidelines Clearing House The WHO Improving Access To Quality Care In Family Planning. Medical Eligibility Criteria For Contraceptive Use, 2004 and Selected Practice Recommendations For Contraceptive Use, 2005 The Cochrane Library MEDLINE and EMBASE from 1996 to 2005

See below No relevant information See below No relevant information See below

E: Evidence Reviewed
Ulcerative Colitis

Existing FFPRHC and RCOG guidance

FFPRHC CEU guidance on Contraceptive Choices for Women with Inflammatory Bowel Disease1 recommends that women with inflammatory bowel disease (IBD) should be offered the same contraceptive choices as women without IBD. Certain contraceptive methods may have specific cautions for disorders associated with IBD (Grade C evidence). Women with ulcerative colitis can use oral contraception (Grade C evidence). No clinical studies were identified that assess efficacy of hormonal contraception in women with IBD. Absorption is unlikely to be affected in large bowel disease and the efficacy of oral contraception should not be reduced. Women who are at increased risk of venous thromboembolism, or who have coexisting disease such as primary sclerosing cholangitis and osteoporosis may not be eligible. No evidence was identified specifically relating to the risk of venous thromboembolism (VTE) in combined oral contraceptive (COC) users with IBD.1 The World Health Organisation Medical Eligibility Criteria for Contraceptive Use (WHOMEC)2 recommends that COC should not be used in women with primary sclerosing cholangitis (WHO 4). Women with IBD have osteopenia or osteoporosis more commonly than the general population. No studies have specifically investigated the use of COC in women with IBD and its effects on osteoporosis.1 More recent FFPRHC CEU guidance on Drug Interactions with Hormonal Contraception3 advises that women who have had a colectomy and ileostomy have no enteroheptaic circulation of ethinyl estradiol. The efficacy of COC does not appear to be reduced in this situation. 4 The FFPRHC are currently in the process of developing a UK version of the World Health Organization Medical Eligibility Criteria for Contraceptive Use (WHOMEC) guidelines.2 Through a consensus process the condition Inflammatory Bowel Disease was added to the guidelines. The recommended categories for the use of the various contraceptive methods in women with IBD are shown on Table 1.0.

Tel: 01224 553623

Fax: 01224 551081

Email: ffp.ceu@abdn.ac.uk

Table 1.0: UKMEC categories for the use of contraception in women with IBD
CONDITION INFLAMMATORY BOWEL DISEASE (includes Crohns disease, Ulcerative colitis)
Key:
I: Initiation of method, C: Continuation of method CHC: Combined hormonal contraception; POP: Progestogen-only pill; DMPA: Depot-medroxyprogesterone acetate; NET-EN: Norethisterone oenathate; IMP: Progestogen-only implants; Cu-IUD: Copper bearing intrauterine device; LNG-IUS: Levonorgestrel-releasing intrauterine system Category 1: A condition for which there is no restriction for the use of the contraceptive method; Category 2: A condition where the advantages of using the method generally outweigh the theoretical or proven risks; Category 3: A condition where the theoretical or proven risks usually outweigh the advantages of using the method; Category 4: A condition which represents an unacceptable health risk if the contraceptive method is used

CHC 2

POP 2

DMPA / NET-EN 1

IMP 1

Cu-IUD 1

LNGIUD 1

Polyarthritis Polyarthritis is any type of arthritis which involves five or more joints. Polyarthritis is most often caused by an auto-immune disorder such as rheumatoid arthritis, psoriatic arthritis, and lupus erythematosus but can also be caused by infections. It may be experienced at any age and is not gender specific. Some patients will go on to develop rheamatoid arthritis.5 Some evidence exists to suggest that oral contraception (OC) may help to decrease the occurrence of rheumatoid arthritis. Spector and Hochberg found that from meta-analysis of hospital and population based studies OCs had a protective effect on rheumatoid arthritis of up to 30 % (adjusted OR, 0.73; 95% CI, 0.51-0.85).6 Similarly, Jorgensen et al found a more significant protective effect protective effect of OCs. They found that for women who used OCs for > 5 years the relative risk of developing mild disease was 0.1 (95% CI 0.01-0.6).7 Another study found the OR for developing rheumatoid arthritis was 0.56 (0.34-0.92).8 The CEU could find no evidence to suggest that the use of an intrauterine device would be contraindicated for a woman with poly- or rheumatoid arthritis and suggest that it may be used without restriction. The CEU could find no other information in the literature on the use of contraception in women with polyarthritis.

Tel: 01224 553623

Fax: 01224 551081

Email: ffp.ceu@abdn.ac.uk

F: References
1. Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Contraceptive choices for women with inflammatory bowel disease. The Journal of Family Planning and Reproductive Health Care 2003;29:127-34. 2. World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Third edition. 2004. 3. Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Drug Interactions with Hormonal Contraception. Journal of Family Planning and Reproductive Health Care 2005;31:139-50. 4. Grimmer SFM, Back DJ, Orme ML'E, Cowie A, Gilmore I, Tjia J. The bioavailability of ethinyloestadiol and levonorgestrel in patients with an ileostomy. Contraception 1986;33:51-9. 5. Meador, R. and Schumacher, H. R. Evaluating and treating patients with polyarthritis of recent onset. http://www.turner-white.com/pdf/hp_mar03_recent.pdf. 2003. 6. Spector TD,.Hochberg MC. The protective effect of the oral contraceptive pill on rheumatoid arthritis: an overview of the analytic epidemiological studies using meta-analysis. Journal of Clinical Epidemiology 1990;43:1221-30. 7. Dawe, Fiona and Meltzer, Howard. Contraception and Sexual Health, 2002. 1-50. 2002. London, Office for National Statistics. 8. Doran, M. F., Crowson, C. S., O'Fallon, W. M., and Gabriel, S. E. The effect of oral contraceptives and estrogen replacement therapy on the risk of rheumatoid arthritis: a population based study. Journal of Rheumatology 31(2), 207-213. 2004.

The advice given in this Member's Enquiry Response has been prepared by the FFPRHC Clinical Effectiveness Unit team. It is based on a structured search and review of published evidence available at the date of preparation. The advice given here should be considered as guidance only. Adherence to it will not ensure a successful outcome in every case and it may not include all acceptable methods of care aimed at the same results. This response has been prepared as a service to FFPRHC members, but is not an official Faculty guidance product; Faculty guidance is produced by a different and more lengthy process. It is not intended to be construed or to serve as a standard of medical care. Such standards are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances. Members are welcome to reproduce this Response by photocopying or other means, in order to share the information with colleagues. Enquiry response by: GS Tel: 01224 553623 Fax: 01224 551081 Email: ffp.ceu@abdn.ac.uk