What is the recommended contraceptive option for a 26-year-old female smoker, progestin-only pill (POP) or combination pill (oral contraceptive pill (OCP))?

From the Guidelines

For a 26-year-old female smoker, the progestin-only pill (POP) is the recommended contraceptive option over the combination pill (oral contraceptive pill (OCP)). This recommendation is based on the increased risk of cardiovascular complications associated with smoking and estrogen-containing contraceptives, as highlighted in a statement from the Stroke Council of the American Heart Association 1. The combination pill, which contains both estrogen and progestin, can significantly increase the risk of blood clots, heart attacks, and strokes in women who smoke. In contrast, progestin-only pills like norethindrone (Micronor, Nor-QD) or drospirenone (Slynd) are safer choices for women who smoke because they don't contain estrogen.

Some key points to consider when prescribing POPs to smokers include:

• Taking the pill at the same time each day for maximum effectiveness (within a 3-hour window for traditional POPs, or a 12-hour window for drospirenone)
• Potential side effects, such as irregular bleeding, especially in the first few months
• Slightly lower effectiveness compared to combined pills with typical use (about 91% versus 93%), although this can be mitigated by consistent adherence to the daily regimen
• The importance of avoiding estrogen-containing contraceptives in women with additional risk factors, such as cigarette smoking or prior thromboembolic events, as emphasized in the American Heart Association statement 1.

Overall, the progestin-only pill is a reliable and safer contraceptive option for 26-year-old female smokers, minimizing the risk of serious cardiovascular complications associated with estrogen-containing contraceptives and smoking.

From the FDA Drug Label

WARNINGS Cigarette smoking greatly increases the possibility of suffering heart attacks and strokes. Women who use oral contraceptives are strongly advised not to smoke. The relationship between progestin-only oral contraceptives and these risks have not been established and there are no studies definitely linking progestin-only pill (POP) use to an increased risk of heart attack or stroke.

For a 26-year-old female smoker, the progestin-only pill (POP) may be a safer option compared to the combination pill (OCP), as there is no established link between POP use and an increased risk of heart attack or stroke 2. However, it is essential to note that cigarette smoking itself greatly increases the risk of heart attacks and strokes, and women are strongly advised not to smoke.

• The decision to use a POP or other contraceptive methods should be made after consulting a healthcare provider, considering the individual's overall health and risk factors.
• It is crucial for the healthcare provider to remain alert to the earliest manifestation of symptoms of any serious disease and discontinue oral contraceptive therapy when appropriate.

From the Research

Contraceptive Options for a 26-Year-Old Female Smoker

When considering contraceptive options for a 26-year-old female smoker, it's essential to weigh the benefits and risks of different methods. The two options in question are the progestin-only pill (POP) and the combination pill (oral contraceptive pill, OCP).

Risks Associated with Combination Pills for Smokers

• Combination pills, which contain both estrogen and progestin, may increase the risk of cardiovascular events, such as myocardial infarction (MI) and stroke, especially in smokers over 35 years old 3.
• However, for women under 35 who smoke, the risk of MI and stroke associated with combination pill use is still a concern, but the evidence suggests that the risk is lower compared to older smokers 3.
• The study by 4 suggests that the risk of thromboembolic disease is related to the estrogen dose, and smoking further increases this risk.

Progestin-Only Pill as an Alternative

• The progestin-only pill (POP) is a valuable option for women who are ineligible for or choose not to use combination oral contraceptives (COCs) due to concerns about estrogen-related adverse effects or cardiovascular risks 5.
• POPs have been associated with lower contraceptive effectiveness compared to COCs, although the POP containing desogestrel has shown similar effectiveness to COCs 5.
• The most common complaints among women using POPs are bleeding problems, which can be managed with proper counseling and patient education 5.

Recommendations for a 26-Year-Old Female Smoker

• Given the age and smoking status of the individual, the progestin-only pill (POP) may be a safer option compared to the combination pill, as it eliminates the risk of estrogen-related cardiovascular events 3, 6.
• However, it's crucial to consider the individual's overall health profile, medical history, and personal preferences when selecting a contraceptive method.
• As stated by 7, understanding the benefits and risks of different hormonal contraceptives allows clinicians to make informed recommendations for effective contraception.