What are the contraceptive (Contraception Options for Contraception) options for smokers?

From the Guidelines

Smokers should avoid using combined oral contraceptives (COCs) due to the increased risk of cardiovascular complications, and instead consider progestin-only contraceptives or non-hormonal methods as safer alternatives. The risk of blood clots, heart attacks, and strokes associated with COCs is particularly concerning in women over 35 who smoke, as it is dose-dependent and increases with age, number of cigarettes smoked daily, and estrogen dosage 1.

Alternatives to COCs for Smokers

Some alternatives to COCs for smokers include:

• Progestin-only pill (mini-pill) taken daily at the same time
• Depo-medroxyprogesterone acetate (DMPA) injection given every 3 months
• Etonogestrel implant effective for 3 years
• Hormonal IUDs like Mirena or Kyleena lasting 5-7 years
• Non-hormonal methods such as copper IUDs, barrier methods, or fertility awareness

According to the 2024 guideline for the primary prevention of stroke, in individuals with specific stroke risk factors (such as age >35 years, tobacco use, hypertension, or migraine with aura) who are considering contraception, progestin-only contraception or nonhormonal contraception is reasonable to prevent the increased stroke risk associated with estrogen-containing contraception 1.

Key Considerations

Key considerations for smokers who use or are considering COCs include:

• Quitting smoking to minimize cardiovascular risks
• Using the lowest effective estrogen dose (20mcg) if COCs are absolutely required, although this is still not recommended
• Engaging in shared decision-making with healthcare providers to determine the best contraceptive choice and balance the risk of stroke from contraception and the risk of stroke with pregnancy 1.

From the FDA Drug Label

An increased risk of myocardial infarction has been attributed to oral contraceptive use This risk is primarily in smokers or women with other underlying risk factors for coronary artery disease such as hypertension, hypercholesterolemia, morbid obesity, and diabetes. The relative risk of heart attack for current oral contraceptive users has been estimated to be two to six (4 to 10). The risk is very low in women under the age of 30 Smoking in combination with oral contraceptive use has been shown to contribute substantially to the incidence of myocardial infarction in women in their mid-thirties or older with smoking accounting for the majority of excess cases (11)

For smokers, combined oral contraceptives (COCs) options should be chosen with caution due to the increased risk of myocardial infarction and cerebrovascular diseases.

• The risk of heart attack is higher in smokers who use COCs, especially those over 35 years old.
• Low-dose oral contraceptives may be considered, but the benefits and risks should be carefully weighed.
• Smokers over 35 years old should consider alternative contraceptive methods due to the increased risk of cardiovascular events.
• It is essential to assess the individual's overall health and risk factors before prescribing COCs to smokers 2.

From the Research

Contraceptive Options for Smokers

• The use of oral contraceptives (OCs) by smokers is a concern due to the increased risk of venous thrombosis and other cardiovascular events 3.
• Smokers over 35 years old who use OCs are at a higher risk of thrombotic events, and it is recommended that they be denied the use of OCs or be prescribed a low-dose OC with 20 micrograms of ethinyl estradiol 3.
• Progestin-only pills (POPs) are a viable alternative to combined oral contraceptives, with a median Pearl Index rate of 1.63 during typical use and 0.97 during perfect use 4.
• The effectiveness of POPs may be higher than currently estimated, with some studies suggesting a median Pearl Index rate of 2.00 during typical use and 1.05 during perfect use 4.

Considerations for Smokers

• Smokers should be encouraged to quit smoking, and their smoking status should be assessed at every visit 3.
• The decision to prescribe an OC should be based on a detailed personal and family history of thrombotic disease, and measurement of lipid profile should be considered for smokers over 35 years old 3.
• The use of OCs may influence smoking-related outcomes, including nicotine metabolism and physiological stress response, but more research is needed to fully understand this relationship 5.

Alternative Contraceptive Options

• Intrauterine devices (IUDs) and subdermal implants are highly effective contraceptive options with failure rates of less than 1% per year 6.
• These options may be suitable for smokers who are concerned about the risks associated with OCs or who prefer a non-hormonal method of contraception.
• Patient values and preferences should be taken into account when selecting a contraceptive method, and optimal contraceptive selection requires discussion between the patient and clinician 6.