Sexuality, Contraception, and Pregnancy in Kidney Transplantation
2021; Elsevier BV; Volume: 3; Issue: 5 Linguagem: Inglês
10.1016/j.xkme.2021.05.009
ISSN2590-0595
AutoresKrishna A. Agarwal, Martha Pavlakis,
Tópico(s)Neurological Complications and Syndromes
ResumoSexual dysfunction is defined as any abnormality in sexual arousal, libido, intercourse, orgasm, or satisfaction. It is prevalent in patients with chronic and end-stage kidney disease, with 70% to 84% of men and 30% to 60% of women reporting some form of sexual dysfunction. Although kidney transplantation improves the overall quality of life for patients receiving dialysis, it can have unexpected effects on sexual function owing to the use of immunosuppressive medications and comorbid illnesses. It is important to recognize these adverse effects and pre-emptively discuss them with patients to help mitigate consequent psychosocial discontent. Women of reproductive age will often recover fertility after kidney transplantation and therefore need to be empowered to prevent unwanted pregnancies and plan for a safe pregnancy if desired. Complications such as preeclampsia, pregnancy-induced hypertension, gestational diabetes, ectopic pregnancy, still birth, low birth weight, and preterm birth are more common in pregnant women with a kidney transplant. Careful monitoring for infection, rejection, and immunosuppressive dose adjustment along with comanagement by a high-risk obstetrician is of utmost importance. Breast-feeding is safe with most immunosuppressive medications and should be encouraged. Sexual dysfunction is defined as any abnormality in sexual arousal, libido, intercourse, orgasm, or satisfaction. It is prevalent in patients with chronic and end-stage kidney disease, with 70% to 84% of men and 30% to 60% of women reporting some form of sexual dysfunction. Although kidney transplantation improves the overall quality of life for patients receiving dialysis, it can have unexpected effects on sexual function owing to the use of immunosuppressive medications and comorbid illnesses. It is important to recognize these adverse effects and pre-emptively discuss them with patients to help mitigate consequent psychosocial discontent. Women of reproductive age will often recover fertility after kidney transplantation and therefore need to be empowered to prevent unwanted pregnancies and plan for a safe pregnancy if desired. Complications such as preeclampsia, pregnancy-induced hypertension, gestational diabetes, ectopic pregnancy, still birth, low birth weight, and preterm birth are more common in pregnant women with a kidney transplant. Careful monitoring for infection, rejection, and immunosuppressive dose adjustment along with comanagement by a high-risk obstetrician is of utmost importance. Breast-feeding is safe with most immunosuppressive medications and should be encouraged. Sexual Function in Kidney Failure and Earlier Stages of Chronic Kidney DiseasePatients with chronic kidney disease (CKD) frequently have associated comorbid conditions such as diabetes, heart disease, and vasculopathies. Disorders in sexual function span both the physical and psychosocial domains. CKD and associated vasculopathies affect physical function but also have psychosocial effects through changes in hormonal balance, emotion, and socioeconomic burden.1Fiuk J.V. Tadros N.N. Erectile dysfunction in renal failure and transplant patients.Transl Androl Urol. 2019; 8: 155-163Crossref PubMed Scopus (10) Google Scholar Sexual dysfunction can manifest as vaginal dryness or dyspareunia in women, erectile dysfunction or premature ejaculation in men, and decreased libido and inability to achieve an orgasm in both men and women.2Anantharaman P. Schmidt R.J. Sexual function in chronic kidney disease.Adv Chronic Kidney Dis. 2007; 14: 119-125Abstract Full Text Full Text PDF PubMed Scopus (107) Google ScholarA definitive assessment of the prevalence of sexual dysfunction in the CKD population is difficult because of the intimate nature of the topic, variable definitions, and lack of standardized registries for this data. Men with CKD have a reported prevalence of erectile dysfunction between 70%3Navaneethan S.D. Vecchio M. Johnson D.W. et al.Prevalence and correlates of self-reported sexual dysfunction in CKD: a meta-analysis of observational studies.Am J Kidney Dis. 2010; 56: 670-685Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar and 84%.4Esen B. Kahvecioglu S. Atay A.E. et al.Evaluation of relationship between sexual functions, depression and quality of life in patients with chronic kidney disease at predialysis stage.Ren Fail. 2015; 37: 262-267Crossref PubMed Scopus (24) Google Scholar Between 30% and 60% of women experience sexual dysfunction, higher in those receiving dialysis as compared with those with non–dialysis-dependent CKD.3Navaneethan S.D. Vecchio M. Johnson D.W. et al.Prevalence and correlates of self-reported sexual dysfunction in CKD: a meta-analysis of observational studies.Am J Kidney Dis. 2010; 56: 670-685Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar Women also tend to experience premature menopause, up to 4.5 years earlier, and infertility primarily owing to estrogen deficiency.5Holley J.L. The hypothalamic-pituitary axis in men and women with chronic kidney disease.Adv Chronic Kidney Dis. 2004; 11: 337-341Abstract Full Text Full Text PDF PubMed Scopus (87) Google ScholarThe sexual well-being of patients with CKD is underrecognized. It is neither regularly discussed by nephrologists nor reported in many "quality-of-life" trials.6Harrison T.G. Skrtic M. Verdin N.E. Lanktree M.B. Elliott M.J. Improving sexual function in people with chronic kidney disease: a narrative review of an unmet need in nephrology research.Can J Kidney Health Dis. 2020; 72054358120952202Crossref Scopus (2) Google Scholar Moreover, patients referred for kidney transplantation often do not know what to expect after transplantation with respect to their sexual function.Sexual Function Post–Kidney TransplantationKidney transplantation is recognized as the gold-standard treatment for end-stage kidney disease, offering better quantity and quality of life as compared with dialysis. Sexual health is an important quality-of-life domain in these patients. Although kidney transplantation improves the hormonal and metabolic milieu in recipients, the physical effects of the transplantation surgery can distort one's body image and hence affect sexual satisfaction.7Matas A.J. Halbert R.J. Barr M.L. et al.Life satisfaction and adverse effects in renal transplant recipients: a longitudinal analysis.Clin Transplant. 2002; 16: 113-121Crossref PubMed Scopus (100) Google Scholar The emotional and psychological distress can reduce interest in sexual activities and/or result in erectile dysfunction in men and vaginal dryness in women.8Muehrer R.J. Sexuality, an important component of the quality of life of the kidney transplant recipient.Transplant Rev. 2009; 23: 214-223Crossref Scopus (22) Google Scholar,9Espinoza R. Gracida C. Cancino J. Ibarra A. Prevalence of erectile dysfunction in kidney transplant recipients.Transplant Proc. 2006; 38: 916-917Crossref PubMed Scopus (20) Google Scholar Decreased sexual satisfaction can impair overall quality of life and reduce life satisfaction.7Matas A.J. Halbert R.J. Barr M.L. et al.Life satisfaction and adverse effects in renal transplant recipients: a longitudinal analysis.Clin Transplant. 2002; 16: 113-121Crossref PubMed Scopus (100) Google Scholar Immunosuppressive agents, particularly sirolimus, can impair sexual function.10Burra P. Sexual dysfunction after liver transplantation.Liver Transplant. 2009; 15: S50-S56Crossref PubMed Scopus (27) Google ScholarMale Sexual Function After TransplantationLibido, erectile function, orgasmic function, and sexual satisfaction are important components of male sexuality. A Dutch study reported a 48% prevalence of sexual problems in male kidney transplant recipients.11Diemont W.L. Vruggink P.A. Meuleman E.J.H. Doesburg W.H. Lemmens W.A.J.G. Berden J.H.M. Sexual dysfunction after renal replacement therapy.Am J Kidney Dis. 2000; 35: 845-851Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar This was lower than in patients receiving hemodialysis (HD; 62.9%) or peritoneal dialysis (69.8%) but greater than 5 times that in the control population (8.7%). The most commonly reported problems were erectile dysfunction (74%), decreased libido (41%), and orgasm concerns (29%). Similar results have been reported from France12Malavaud B. Rostaing L. Rischmann P. Sarramon J.P. Durand D. High prevalence of erectile dysfunction after renal transplantation.Transplantation. 2000; 69: 2121-2124Crossref PubMed Scopus (86) Google Scholar and Mexico.9Espinoza R. Gracida C. Cancino J. Ibarra A. Prevalence of erectile dysfunction in kidney transplant recipients.Transplant Proc. 2006; 38: 916-917Crossref PubMed Scopus (20) Google Scholar A recent study from Portugal explored sexual function and satisfaction in male kidney transplant recipients.13Mota R.L. Fonseca R. Santos J.C. et al.Sexual dysfunction and satisfaction in kidney transplant patients.J Sex Med. 2019; 16: 1018-1028Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Of the total 112 respondents, 66% had at least mild erectile dysfunction as measured by the International Index of Erectile Function (IIEF) score, 65% had desire dysfunction, 56% had orgasm dysfunction, and 76% had overall dissatisfaction with their sexual function. There was a significant negative correlation between body image satisfaction and sexual function, affecting recipients both within and more than 3 years after transplantation.The effects of kidney transplantation on pre-existing sexual dysfunction are controversial. Previous studies have shown improvement in erectile dysfunction after kidney transplantation14Barroso L.V.S. Miranda E.P. Cruz N.I. et al.Analysis of sexual function in kidney transplanted men.Transplant Proc. 2008; 40: 3489-3491Crossref PubMed Scopus (26) Google Scholar,15Nassir A. Sexual function in male patients undergoing treatment for renal failure: a prospective view.J Sex Med. 2009; 6: 3407-3414Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar but a recent study looked at both erectile and ejaculatory function prospectively in kidney transplant recipients.16Spirito L. Manfredi C. Carrano R. et al.Impact of kidney transplantation on male sexual function: results from a ten-year retrospective study.J Sex Med. 2020; 17: 2191-2197Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The mean IIEF score significantly decreased at 6 months and was unchanged at 12 months after transplantation. Ejaculatory function, as assessed by the Male Sexual Health Quality-Ejaculation Disorders (MSHQ-EjD) short form, also decreased significantly at the 6- and 12-month follow-up. Age, diabetes, hypertension, smoking, and pretransplantation testosterone levels were significantly associated with posttransplantation IIEF and MSHQ-EjD scores in addition to the baseline scores.Most (72.8%) kidney transplant recipients studied by Meuhrer et al17Muehrer R.J. Lanuza D.M. Brown R.L. Djamali A. Sexual concerns among kidney transplant recipients.Clin Transplant. 2014; 28: 1294-1302Crossref PubMed Scopus (10) Google Scholar reported that sexuality was important. A total of 71% were sexually active and 80% had a regular sexual partner. Only 60% received information about posttransplantation sexuality from their health care providers and 64% of the patients who did not thought that they wanted the information. Unfortunately, less than half the patients who received the information were satisfied with it. The greatest areas of concern were communication with health care providers about sexuality and sexual pleasure. Women reported greater concerns than men.Female Sexual Function After TransplantationIn the United States, 40% to 50% women of reproductive age have sexual concerns.18Hayes R.D. Bennett C.M. Fairley C.K. Dennerstein L. What can prevalence studies tell us about female sexual difficulty and dysfunction?.J Sex Med. 2006; 3: 589-595Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar Hypoactive sexual desire disorder is the most prevalent concern, followed by delayed orgasm and lack of orgasm.19Clayton A.H. Valladares Juarez E.M. Female sexual dysfunction.Psychiatr Clin North Am. 2017; 40: 267-284Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The literature on female sexual function in end-stage kidney disease and transplantation is scarce as compared with that on male sexual function. Several studies have reported a higher prevalence of sexual dysfunction in women receiving dialysis versus their counterparts without CKD, and sexual dysfunction was found in 94% of women receiving peritoneal dialysis and 100% of women receiving HD as compared with 45.8% of controls.20Yazici R. Altintepe L. Guney I. et al.Female sexual dysfunction in peritoneal dialysis and hemodialysis patients.Ren Fail. 2009; 31: 360-364Crossref PubMed Scopus (28) Google Scholar A large study conducted in Europe and South America revealed an 84% prevalence of sexual dysfunction in women receiving HD, independently associated with age, depressive symptoms, lower education, menopause, diabetes, and diuretic therapy.21Strippoli G.F.M. Sexual dysfunction in women with ESRD requiring hemodialysis.Clin J Am Soc Nephrol. 2012; 7: 974-981Crossref PubMed Scopus (74) Google Scholar Kurtulus et al22Kurtulus F.O. Salman M.Y. Fazlioglu A. Fazlioglu B. Effects of renal transplantation on female sexual dysfunction: comparative study with hemodialysis and a control group.Transplant Proc. 2017; 49: 2099-2104Crossref PubMed Scopus (14) Google Scholar reported sexual dysfunction in 56.7%, 89.7%, and 73.9% of the control, HD, and posttransplantation female patients, respectively.The Female Sexual Function Index, a commonly used questionnaire to assess female sexual function, improved significantly in women with a kidney transplant, specifically the lubrication, pain, and total scores.22Kurtulus F.O. Salman M.Y. Fazlioglu A. Fazlioglu B. Effects of renal transplantation on female sexual dysfunction: comparative study with hemodialysis and a control group.Transplant Proc. 2017; 49: 2099-2104Crossref PubMed Scopus (14) Google Scholar Similarly, women with end-stage kidney disease followed up prospectively for 5 years posttransplantation had their mean Female Sexual Function Index score improve significantly from 17.57 ± 7.07 pretransplantation to 25.3 ± 3.28 posttransplantation, and depression scores decreased significantly from 17.91 ± 8.56 to 3 ± 4.17. Improvement in sexual function was seen in all domains including desire, arousal, lubrication, orgasm, satisfaction, and pain.23Kettaş E. Çayan F. Efesoy O. Akbay E. Çayan S. The effect of renal transplantation for end-stage renal disease on female sexual function and depression.J Sex Med. 2010; 7: 3963-3968Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar These studies suggest that female sexual function may improve after kidney transplantation.Female sexual desire and satisfaction were significantly better in living donor recipients when compared with deceased donor recipients, but they were also significantly younger (38.5 vs 51.5 years) and had shorter dialysis vintage (30.5 vs 44.5 months) than deceased donor recipients. Only 34.6% of women reported discussing sexual issues with their health care providers before transplantation, whereas 73% believed it would have been important.24Cabral J.F. Cavadas V. Silva Ramos M. et al.Female sexual function and depression after kidney transplantation: comparison between deceased- and living-donor recipients.Transplant Proc. 2015; 47: 989-991Crossref PubMed Scopus (8) Google ScholarSpecial Considerations With DrugsIn addition to immunosuppressive medications, transplant recipients are often receiving drugs for blood pressure, diabetes, electrolyte disorders, gastrointestinal symptoms, contraception, and mood disorders. Many of these drugs may independently affect sexual function and should be evaluated in patients presenting with sexual dysfunction. Table 125La Torre A. Giupponi G. Duffy D. Conca A. Cai T. Scardigli A. Sexual dysfunction related to drugs: a critical review. Part V: α-blocker and 5-ARI drugs.Pharmacopsychiatry. 2016; 49: 3-13PubMed Google Scholar,26Park Y.W. Kim Y. Lee J.H. Antipsychotic-induced sexual dysfunction and its management.World J Mens Health. 2012; 30: 153Crossref PubMed Google Scholar summarizes some of these drugs and suggested alternatives.Table 1Drugs Affecting Sexual FunctionDrugSexual Side EffectManagementImmunosuppressive AgentsBelataceptNo direct effect.Can consider alternatives if severe side effects outweigh benefits; alternatively, use sexual enhancersTacrolimus, cyclosporineNo direct effect; depression, weaknessCan consider alternatives if severe side effects outweigh benefits; alternatively, use sexual enhancersSirolimus, everolimusDecreased sexual desire and erectile dysfunction in men; decreases testosterone levelsCan consider alternatives if severe side effects outweigh benefits; alternatively, use sexual enhancersMycophenolate mofetilErectile dysfunction in men; teratogenicCan consider alternatives if severe side effects outweigh benefits; alternatively, use sexual enhancersAzathioprineNo direct effectSteroidsDecreased testosterone; erectile dysfunction in men; menstrual irregularities in womenSteroid-sparing regimens when possible or lowest possible dose; alternatively, use sexual enhancersAntihypertensive AgentsThiazide diureticsDecreased libido, erectile dysfunction, and decreased ejaculation in menSwitch to loop diuretic; consider sexual enhancerPotassium-sparing diureticsDecreased libido, erectile dysfunction, and decreased ejaculation in menSwitch to loop diuretic; consider sexual enhancerβ-BlockersDecreased sexual desire in men and women; erectile dysfunction in menConsider alternative antihypertensive agents; use caution with PDE5 inhibitors in patients on antihypertensives, especially nitratesCentrally acting α-agonistDecreased sexual desire in men and women; erectile dysfunction in menConsider alternative antihypertensive agents; use caution with PDE5 inhibitors in patients on antihypertensives, especially nitratesα-Receptor blockersMay rarely decrease sexual desire in men and womenConsider using PDE5 inhibitors in combination with α-blockers and/or ARI when used for lower urinary tract symptoms in men25La Torre A. Giupponi G. Duffy D. Conca A. Cai T. Scardigli A. Sexual dysfunction related to drugs: a critical review. Part V: α-blocker and 5-ARI drugs.Pharmacopsychiatry. 2016; 49: 3-13PubMed Google Scholarα-reductase inhibitors (ARI)Decreased libido, erectile dysfunction, and decreased ejaculation in menConsider using PDE5 inhibitors in combination with α-blockers and/or ARI when used for lower urinary tract symptoms in men25La Torre A. Giupponi G. Duffy D. Conca A. Cai T. Scardigli A. Sexual dysfunction related to drugs: a critical review. Part V: α-blocker and 5-ARI drugs.Pharmacopsychiatry. 2016; 49: 3-13PubMed Google ScholarAngiotensin-converting enzyme inhibitors and angiotensin receptor blockersNo direct effects; extremely rare incidence of erectile dysfunction in men; teratogenicConsider alternative antihypertensive agents; sexual enhancersCalcium channel blockersRare; decreased libido in men and women; decreased penile tumescence, decreased ejaculation, and gynecomastia; galactorrhea in womenConsider alternative antihypertensive agents; sexual enhancersAntihistaminesDiphenhydramine, cetirizine, loratadineInhibited sexual arousal, vaginal dryness; erectile dysfunctionConsider timing medication away from sexual activity; use OTC lubricants for drynessH2-BlockersCimetidineDecreased libido, erectile dysfunction, and decreased sperm countUse alternative agents like famotidine or ranitidineAntidepressantsSSRIs, eg, fluoxetine, paroxetine, sertralineDecreased libido, erectile dysfunction; delayed orgasm; decreased sexual satisfactionConsider alternative agents like bupropion, mirtazapine, vortioxetine; reduce dose of SSRI or consider drug holiday and/or addition of sex-enhancing drugs like sildenafil or tadalafilSNRIs, eg, venlafaxine, desvenlafaxine, duloxetineDecreased libido, erectile dysfunction; delayed orgasm; decreased sexual satisfactionConsider alternative agents like bupropion, mirtazapine, vortioxetine; reduce dose of SSRI or consider drug holiday and/or addition of sex-enhancing drugs like sildenafil or tadalafilMonoamine oxidase inhibitors, eg, isocarboxazid, phenelzine, selegiline, tranylcypromine (used infrequently)Decreased libido, erectile dysfunction; delayed orgasm; decreased sexual satisfactionConsider alternative agents like bupropion, mirtazapine, vortioxetine; reduce dose of SSRI or consider drug holiday and/or addition of sex enhancing drugs like sildenafil or tadalafilTricyclic antidepressants, eg, amitriptyline, nortriptyline, clomipramine, doxepinDecreased libido, erectile dysfunction; delayed orgasm; decreased sexual satisfactionConsider alternative agents like bupropion, mirtazapine, vortioxetine; reduce dose of SSRI or consider drug holiday and/or addition of sex enhancing drugs like sildenafil or tadalafilAntipsychoticsProlactin-elevating agents, eg, haloperidol, risperidone, amisulprideDecreased libido, impaired arousal, and impaired orgasm; may also cause erectile dysfunction, delayed ejaculation in men; poor vaginal lubrication in womenDecreased dose or switch to alternate agent (prolactin-sparing) and/or addition of sex-enhancing drugsProlactin-sparing agents, eg, olanzapine, clozapine, quetiapine, aripiprazoleSame as above but much lesser frequency and severity26Park Y.W. Kim Y. Lee J.H. Antipsychotic-induced sexual dysfunction and its management.World J Mens Health. 2012; 30: 153Crossref PubMed Google ScholarDecreased dose or switch to alternate agent (prolactin-sparing) and/or addition of sex enhancing drugsAntianxiety AgentsLorazepam, diazepamDecreased arousal, libido, and delayed orgasmCognitive behavioral therapy; decreased dose and/or addition of sex-enhancing drugsHormonal Birth ControlCombined contraceptive pills, progestin-only pills, depo-MPADecreased arousal and libidoUse nonhormonal methods like barriers or vaginal ringAbbreviations: ARI, 5 α-reductase inhibitors; depo-MPA, depo medroxyprogesterone acetate; OTC, over-the-counter; PDE5, phosphodiesterase type 5; SNRI, serotonin and norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor. Open table in a new tab ContraceptionOf the 23,301 kidney transplantations performed in the United States in 2019, a total of 9,133 were in women, of which 3,474 (38%) were in the child-bearing ages (18-49 years) and 301 were younger than 17 years and could potentially be pregnant in the future.27National Database of the Organ Procurement & Transplantation Network. OPTN Database. Published 2019. Accessed September 1, 2021. https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/Google Scholar Ovulation and menstruation normalize within 6 to 9 months after transplantation and therefore fertility can return or increase.28Richman K. Gohh R. Pregnancy after renal transplantation: a review of registry and single-center practices and outcomes.Nephrol Dial Transplant. 2012; 27: 3428-3434Crossref PubMed Scopus (44) Google Scholar Studies show that pretransplantation contraception counseling is often inadequate. In Brazil, although 80% of female transplant recipients were sexually active and 72% were using a contraceptive, only 49% were counseled to use contraception. This group had an unintended pregnancy rate of 93%.29Guazzelli C.A.F. Torloni M.R. Sanches T.F. Barbieri M. Pestana J.O.M.A. Contraceptive counseling and use among 197 female kidney transplant recipients.Transplantation. 2008; 86: 669-672Crossref PubMed Scopus (45) Google Scholar In a report from Nebraska, 44% of female transplant recipients were unaware of pregnancy as a possibility after transplantation and only 43% of female recipients older than 13 years were counseled before transplantation about posttransplantation contraceptive use. Of these, only 50% had a specific method recommended and contraceptive pills were most commonly recommended (52%).30French V.A. Davis J.S. Sayles H.S. Wu S.S. Contraception and fertility awareness among women with solid organ transplants.Obstet Gynecol. 2013; 122: 809-814Crossref PubMed Scopus (43) Google ScholarContraception CounselingImportant considerations for contraception counseling:1.Patient selection: all kidney transplant recipients with child-bearing potential, current or future.2.Counseling should begin at the time of transplantation evaluation and continue into the posttransplantation period.3.Patients' own understanding of their sexuality, values, and beliefs about contraception and plan for pregnancy should be explored.4.All contraceptive methods should be offered and risks and benefits discussed. The choice of contraception would depend on patients' preferences and safety profiles based on other medical comorbid conditions and graft status.5.Implications of unintended pregnancy while receiving immunosuppressive agents should be discussed, including teratogenicity associated with mycophenolate.6.If patient intends to become pregnant, preconception counseling is essential to avoid adverse outcomes for the kidney transplant, the patient, and the child, and multidisciplinary care should be initiated as discussed later.Methods of ContraceptionThe World Health Organization published guidelines (Medical Eligibility Criteria for Contraceptive Use) for contraceptive use in women with specific comorbid conditions. In the United States, the Centers for Disease Control and Prevention adapted and issued guidelines.31Curtis K.M. Tepper N.K. Jatlaoui T.C. et al.U.S. medical eligibility criteria for contraceptive use, 2016.Mortal Wkly Rep Recomm Reports. 2016; 65: 1-103Crossref PubMed Scopus (577) Google Scholar Contraceptive methods are classified into the following 4 categories: (1) no restriction for use of method, (2) advantages generally outweigh theoretical or proven risks, (3) theoretical or proven risks usually outweigh the advantages, and (4) unacceptable health risk (method not to be used).Solid-organ transplant recipients are considered complicated in the setting of acute or chronic graft failure, rejection, or cardiac allograft vasculopathy. Uncomplicated solid-organ transplant recipients can initiate any contraceptive method (all are category 2), whereas complicated solid-organ transplant recipients may safely initiate treatment with progestin pills, progestin implant, and progestin injection. Complicated recipients may also continue to use a previously inserted intrauterine device (IUD; category 2), but insertion of new IUD is not advisable (category 3). Combined hormonal contraceptives are defined as category 4 (unacceptable) for complicated solid-organ transplant recipients.Permanent SterilizationIrreversible birth control includes male vasectomy and tubal ligation. The failure rate is <1%32CDC. Contraception | reproductive health.https://www.cdc.gov/reproductivehealth/contraception/index.htm#Birth-Control-MethodsDate accessed: January 9, 2021Google Scholar (Table 2).Table 2Contraceptive MethodsMethodProsRisksFailure RatePermanent SterilizationFemale tubal ligationSingle, 1-time procedureRisk for infection, bleeding, tubal ectopic pregnancy<1%Male vasectomySingle, 1-time procedureRisk doe infection, bleedingWaiting period before efficacy<1%IUDsLevonorgestrel IUDLong-lasting (up to 5 y), reversibleIrregular bleeding, pelvic pain0.1%-0.4%Copper-containing IUDLong-lasting (up to 10 y), reversiblePelvic inflammatory disease, bleeding, uterine perforation0.8%Hormonal implant (etonogestrel-based)Lasts up to 3 y, easy insertion, decreased bleedingWeight gain, abnormal uterine bleeding, breast tenderness0.1%Depot medroxyprogesteroneDecreased bleedingNeeds to be injected every 3 mo, decreased bone mineral density, abnormal uterine bleeding, weight gain, headaches4%Oral ContraceptivesProgestin-only pillNo estrogenic side effectsIrregular bleeding, headaches, breast tenderness, nausea7%Combined contraceptive pillRegulate menstrual cycle, predictable bleeding, reduction of dysmenorrhea, acne, hirsutismDecreased ovarian and endometrial cancer riskEstrogenic thrombotic risks including VTE, stroke, MI7%Vaginal or Exterior ContraceptivesVaginal ringCan self-insert and remove when desiredIrritation, bleeding, risk for infection7%Combined contraceptive patchSelf-administrationHigher estrogen exposure than other hormonal methods; VTE, hypertension, stroke, MI7%Barrier MethodsFemale condomEase of use, self-insertionIrritation, allergic reaction, sepsis, and toxic shock21%Diaphragm or cervical capEase of use, self-insertionIrritation, allergic reaction, sepsis, and toxic shock17%Vaginal sponge with spermicideEase of use, self-insertionIrritation, allergic reaction, sepsis, and toxic shock14%-27%Male condomProtection against STIsAllergic reaction13%SpermicidesCan be used in combination with other methodsAllergic reaction, irritation21%Abbreviations: IUD, intrauterine device; MI, myocardial infarction; STI, sexually transmitted infection; VTE, venous thromboembolism. Open table in a new tab Intrauterine DevicesLocal hormonal (levonorgestrel IUD) or nonhormonal (Copper T) T-shaped devices can be placed inside the uterus during a short office procedure.32CDC. Contraception | reproductive health.https://www.cdc.gov/reproductivehealth/contraception/index.htm#Birth-Control-MethodsDate accessed: January 9, 2021Google Scholar Rare risks include pelvic inflammatory disease and uterine wall perforation.33Birth control methods | womenshealth.gov.https://www.womenshealth.gov/a-z-topics/birth-control-methodsDate accessed: January 9, 2021Google ScholarLevonorgestrel IUD (
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