From the Guidelines
Blood clots are a contraindication to Combined Oral Contraceptive Pills (OCPs). Women with a history of deep vein thrombosis (DVT), pulmonary embolism (PE), or other venous thromboembolism (VTE) should not use combined hormonal contraceptives containing estrogen, as stated in the 2020 American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases 1. This includes women with current blood clots or those with a history of clots, as well as women with known thrombogenic mutations such as Factor V Leiden or Protein C deficiency. The estrogen component in combined OCPs increases coagulation factors and decreases anticoagulant proteins, creating a hypercoagulable state that significantly increases the risk of developing new blood clots or recurrent clotting events, as noted in the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 1.
For women with a history of blood clots who need contraception, safer alternatives include:
- Progestin-only methods, such as mini-pills or implants
- Intrauterine devices (hormonal or copper)
- Barrier methods However, it's worth noting that the use of Depo-Provera injections may impart a higher VTE risk than other progestin-only contraceptives, as suggested by the 2020 American College of Rheumatology guideline 1. Women currently taking anticoagulants for blood clots should specifically avoid estrogen-containing contraceptives as the combination can complicate management of their anticoagulation therapy. The copper IUD is a highly effective alternative that does not increase the risk of VTE, but it may increase menstrual bleeding and cramping for several months after insertion, as mentioned in the 2020 guideline 1.
Key considerations for managing contraceptive needs in women with a history of blood clots include:
- Avoiding combined estrogen-progestin contraceptives
- Selecting progestin-only or non-hormonal methods
- Weighing the risks and benefits of each contraceptive option
- Monitoring for signs and symptoms of VTE or other complications Ultimately, the choice of contraceptive method should be individualized based on a woman's medical history, preferences, and needs, with careful consideration of the potential risks and benefits of each option, as emphasized in the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 1 and the 2020 American College of Rheumatology guideline 1.
From the Research
Blood Clots and OCPs
- Blood clots are a significant concern when it comes to the use of Combined Oral Contraceptive Pills (OCPs) 2, 3, 4, 5, 6
- Studies have shown that combined hormonal contraceptives, which contain estrogen and a progestogen, are associated with a roughly 2- to 3-fold increased risk of venous and a 2-fold increased risk of arterial thromboembolism, including stroke and acute myocardial infarction 2
- This increased risk is a contraindication for women with a history of thrombosis and those at high risk for thrombosis 3, 4, 5
Contraindications
- Women with a history of blood clots or those at high risk for thrombosis should not use Combined Oral Contraceptives (COCs) 3, 4, 5
- Progestin-only pills (POPs) are generally considered safe for women with a history of thrombosis and may be a viable alternative 3, 6
Management
- Optimal management of hormonal contraception in patients with venous thromboembolism (VTE) requires an individualized approach considering its potential benefits and complications during and after anticoagulant treatment 6
- Combined oral contraceptives should be stopped before anticoagulant therapy may be discontinued, preferably after the second last menstrual cycle of the intended anticoagulant treatment period 6