What are the contraindications to combined oral contraceptives (COCs)?

From the Guidelines

Combined oral contraceptives (COCs) are contraindicated in several conditions, including current or history of venous thromboembolism (VTE), known thrombogenic mutations, current or history of ischemic heart disease or stroke, complicated valvular heart disease, migraine with aura, breast cancer, severe liver disease or liver tumors, smoking in women over 35 years old, uncontrolled hypertension, diabetes with vascular complications, and systemic lupus erythematosus with positive antiphospholipid antibodies, as outlined in the 2024 guidelines of care for the management of acne vulgaris 1. The main contraindications to COCs can be categorized into absolute and relative contraindications. Absolute contraindications include:

• Personal characteristics and reproductive history, such as age ≥35 y and smoking ≥15 cigarettes daily
• Cardiovascular disease, including current or history of ischemic heart disease or stroke
• Vascular disease, including acute VTE or history of VTE with ≥1 risk factor for recurrence
• Gastrointestinal conditions, such as severe or decompensated cirrhosis, hepatocellular adenoma, or malignant liver tumor
• Diabetes with nephropathy, retinopathy, neuropathy, other vascular disease, or with duration ≥20 y
• Current breast cancer
• Migraine with aura Relative contraindications include:
• Age ≥35 y and smoking <15 cigarettes daily
• Breastfeeding patient 21-29 d postpartum
• Breastfeeding patient 30-42 d postpartum, with other VTE risk factors
• Nonbreastfeeding patient 21-42 d postpartum, with other VTE risk factors
• SBP 140-159 mmHg or DBP 90-99 mmHg
• Adequately controlled hypertension
• VTE with no risk factors for recurrence
• Superficial venous thrombosis These contraindications are based on the increased risk of thrombosis, cardiovascular events, or worsening of existing conditions, as outlined in the US Medical Eligibility Criteria for Contraceptive Use 1. For women with these contraindications, alternative contraceptive methods should be considered, such as progestin-only pills, intrauterine devices, or barrier methods. A thorough medical history and physical examination should be conducted before prescribing COCs to ensure their safe use. Some key points to consider when evaluating the contraindications to COCs include:
• The risk of VTE is increased in women with a history of VTE, known thrombogenic mutations, or other risk factors for recurrence 1
• The risk of cardiovascular events is increased in women with current or history of ischemic heart disease or stroke, complicated valvular heart disease, or other cardiovascular conditions 1
• The risk of worsening existing conditions is increased in women with severe liver disease or liver tumors, diabetes with vascular complications, or systemic lupus erythematosus with positive antiphospholipid antibodies 1 By carefully evaluating these contraindications and considering alternative contraceptive methods, healthcare providers can help ensure the safe and effective use of COCs in women.

From the Research

Contraindications to Combined Oral Contraceptives (COCs)

The following are contraindications to COCs:

• History of thromboembolic disease, ischemic heart attack, or cerebral stroke 2
• Patients requiring long-term anticoagulant treatment 2
• Essential hypertension 2
• Severe liver diseases 2
• Migraine and diabetes mellitus (relative contraindications) 2
• Long-term diseases, such as Crohn's disease, epilepsy, and sickle cell anemia (require individualized consultation) 2
• Venous thromboembolism (VTE) risk factors, including:
  • Inherited thrombophilia 3
  • Personal history of VTE 3
  • Obesity 3
• Category 3 or 4 contraindications, including:
  • Hypertension 4
  • Smokers older than age 35 years 4
  • History of venous thromboembolism 4
  • Diabetes with complications 4
  • Coronary artery disease 4
  • Systemic lupus erythematosus with antiphospholipid antibodies 4
  • Breast cancer 4
  • Migraine headaches with aura 4

Cardiovascular Risks

COCs are associated with an increased risk of cardiovascular events, including:

• Venous thromboembolism (VTE) 5, 6, 3
• Arterial thromboembolic events 6
• Myocardial infarction 6
• Stroke 6
• Cardiovascular risk factors, such as:
  • Age older than 35 years 6
  • Current smoking 6
  • Poorly controlled hypertension 6

Prescribing Considerations

When prescribing COCs, consider the following:

• Women with medical contraindications to estrogen use should be offered alternative contraceptive methods, such as long-acting reversible contraceptives (LARCs) 4
• Women with cardiovascular risk factors should be carefully evaluated and monitored 6
• The lowest possible dose of ethinylestradiol and good compliance should be prescribed 5