Can a 32-year-old woman with a Body Mass Index (BMI) of 36 take combined oral contraceptives (COCs)?

Combined Oral Contraceptives in a 32-Year-Old Woman with BMI 36

A 32-year-old woman with a BMI of 36 should not take combined oral contraceptives due to significantly increased risk of venous thromboembolism. 1, 2

Risk Assessment

Obesity as a Risk Factor

• BMI ≥30 kg/m² is associated with increased cardiovascular risks when using combined hormonal contraceptives
• The FDA drug label specifically lists "severe hypertension" and "diabetes with vascular involvement" as contraindications 2
• The U.S. Medical Eligibility Criteria (MEC) indicates that women with multiple cardiovascular risk factors (including obesity) have higher risk with combined hormonal contraceptives 1

Specific Risks for Obese Women

• Obese women taking combined oral contraceptives have significantly higher risk of venous thromboembolism (VTE) 1, 3
• The WHO Collaborative Study found that OC-associated odds ratios were higher among women with a BMI above 25 kg/m² 3
• Current users of combined oral contraceptives who are older than 35 years show approximately 2.5-fold increased risk of VTE compared to non-users under 35 4

Alternative Contraceptive Options

Progestogen-Only Methods

• Progestogen-only contraceptives (POCs) are associated with substantially less risk of cardiovascular events than combined oral contraceptives 4
• Options include:
  • Progestin-only pills (POPs)
  • Implants
  • Levonorgestrel-releasing intrauterine device (LNG-IUD)
  • Copper intrauterine device (Cu-IUD)

Safety of Alternatives

• According to U.S. MEC, women with multiple cardiovascular risk factors should consider progestogen-only contraceptives 1
• The U.S. MEC classifies progestin-only pills, implants, and IUDs as category 1 (no restrictions) based on age alone for women over 45 years, indicating their safety profile 1

Clinical Approach

1. Avoid combined hormonal contraceptives in this patient due to BMI of 36
2. Recommend progestogen-only methods as safer alternatives:
   • Progestin-only pill
   • Implant
   • LNG-IUD
   • Copper IUD
3. Screen for additional cardiovascular risk factors that may further increase risk:
   • Smoking status
   • Hypertension
   • Diabetes
   • History of migraines with aura
   • Dyslipidemia

Important Considerations

• The risk of VTE with combined oral contraceptives is highest in the first year of use (OR: 4.17) 4
• Risk decreases after discontinuation, but may persist for several months 2
• Proper patient selection and risk assessment are crucial when prescribing any hormonal contraceptive 5
• The presence of multiple cardiovascular risk factors significantly increases the risks associated with combined hormonal contraceptives 1, 4

The evidence clearly demonstrates that for this 32-year-old woman with BMI 36, the risks of combined oral contraceptives outweigh the benefits, and a progestogen-only method would be a safer and more appropriate contraceptive choice.