What are the contraindications for the various birth control methods, including combined oral contraceptives, progestin‑only pills, sub‑dermal implants, depot medroxyprogesterone injection, levonorgestrel intrauterine system, copper intrauterine device, tubal ligation, and barrier methods?

Contraindications for Birth Control Methods

The contraindications for birth control vary dramatically by method, with combined hormonal contraceptives (CHCs) having the most extensive list of absolute contraindications, while progestin-only methods, IUDs, and barrier methods have remarkably few restrictions, making them safer options for most women with medical conditions.

Combined Hormonal Contraceptives (Pills, Patch, Ring)

Absolute Contraindications (Category 4 - Do Not Use)

Combined hormonal methods are contraindicated in women with:

• Cardiovascular conditions: Active thrombophlebitis, current or past thromboembolic disorders, cerebral vascular disease, or any history of venous thromboembolism 1
• Migraine with aura (affects 12.4% of postpartum women) 2
• Hypertension (particularly uncontrolled or with vascular disease) 2
• Known or suspected pregnancy 3
• Undiagnosed vaginal bleeding 3
• Known or suspected breast malignancy 3
• Significant liver disease 3
• Age ≥35 years who smoke 1

Research shows that approximately 19.1% of postpartum women have contraindications to CHCs, with migraine with aura and hypertension being the most common 2. Women who are older (≥30 years), overweight/obese, Black, or insured have higher rates of contraindications 2.

Progestin-Only Pills (POPs)

POPs have minimal contraindications, making them an excellent alternative when CHCs are restricted:

• Only 0.8% of women have any contraindication to progestin-only pills 2
• Among over-the-counter users, only 0.3% reported contraindications to POPs 4
• Primary contraindication: Current breast cancer 1
• Can be used safely in women with migraine with aura, hypertension, and history of VTE 5

Depot Medroxyprogesterone Acetate (DMPA/Depo-Provera)

Absolute Contraindications

• Known or suspected pregnancy 3
• Undiagnosed vaginal bleeding 3
• Known or suspected breast malignancy 3
• Active thrombophlebitis or current/past thromboembolic disorders 3
• Cerebral vascular disease 3
• Significant liver disease 3
• Known hypersensitivity to medroxyprogesterone acetate 3

Important caveat: Only 5.4% of postpartum women have contraindications to DMPA (with only 0.1% being absolute) 2. However, bone mineral density loss is a critical consideration, especially in adolescents and those using it long-term, though this is a risk-benefit consideration rather than an absolute contraindication 3.

Levonorgestrel Intrauterine System (LNG-IUD)

The LNG-IUD has very few contraindications:

• Current pelvic inflammatory disease (though can be treated while IUD remains in place per management guidelines) 1
• Known or suspected pregnancy 1
• Anatomic uterine abnormalities that distort the cavity 1
• Current breast cancer 1

Only 0.6% of women have contraindications to the implant (similar safety profile) 2.

Copper Intrauterine Device (Cu-IUD)

The Cu-IUD is the method with the fewest contraindications:

• Known or suspected pregnancy 1
• Current pelvic inflammatory disease 1
• Anatomic uterine abnormalities distorting the cavity 1
• Wilson's disease or copper allergy 1

Critical advantage: Can be used in women with all cardiovascular conditions, migraine with aura, breast cancer history, and virtually all medical conditions that contraindicate hormonal methods 6.

Subdermal Implant (Etonogestrel)

Extremely few contraindications:

• Current breast cancer 1
• Known or suspected pregnancy 1

Only 0.6% of women have contraindications to the implant 2, making it one of the safest options across all populations.

Tubal Ligation

No medical contraindications specific to the method itself, but surgical risks must be considered:

• Contraindications relate to anesthesia and surgical risks
• Not recommended during acute pelvic infection
• Requires careful counseling about permanence 1

Barrier Methods (Condoms, Diaphragm, Cervical Cap)

Virtually no medical contraindications:

• Latex allergy (use non-latex alternatives) 1
• Diaphragm/cap: Anatomic abnormalities, recurrent UTIs, history of toxic shock syndrome 1
• Spermicide sensitivity 1

Key Clinical Pitfalls

1. Migraine with aura is frequently missed: This affects 12.4% of women and is an absolute contraindication to CHCs but NOT to progestin-only methods 2

2. Postpartum period: Nearly one in five postpartum women has contraindications to CHCs, yet only 10.3% of those with contraindications were inappropriately using CHCs 2. Counsel prenatally to facilitate informed postpartum decisions.

3. Age and obesity increase contraindication prevalence: Women ≥30 years, overweight, or obese have 1.4-1.6 times higher prevalence of contraindications 2

4. Self-screening works: OTC users accurately self-screen for contraindications, with only 0.3% having contraindications to POPs 4

5. When in doubt, use the U.S. MEC 2024: This evidence-based guideline classifies conditions as Category 1-4, where Category 3-4 represent contraindications 1, 6