Are Combined Oral Contraceptive Pills (OCPs) contraindicated in a 36-year-old female with a history of smoking?

Combined OCPs in a 36-Year-Old Female with History of Smoking

Combined oral contraceptive pills (COCs) are contraindicated in a 36-year-old female with a history of smoking due to significantly increased cardiovascular risks, particularly if she currently smokes. 1

Risk Assessment Based on Age and Smoking Status

The US Medical Eligibility Criteria for Contraceptive Use provides clear guidance on this issue:

• For women aged ≥35 years who smoke <15 cigarettes/day: Category 3 (risks usually outweigh benefits) 1
• For women aged ≥35 years who smoke ≥15 cigarettes/day: Category 4 (unacceptable health risk) 1

This classification is primarily based on the increased risk of cardiovascular events, particularly myocardial infarction and stroke.

Cardiovascular Risks

The combination of age over 35, smoking, and COC use creates a dangerous synergy of cardiovascular risk factors:

• Current users of COCs who smoke have a 10-fold increased risk of myocardial infarction compared to non-smokers 2
• Smoking women >35 years using COCs have approximately 10-fold increased risk of venous thromboembolism compared to younger non-users 2
• The attributable risk of death from cardiovascular disease in smoking women >35 years using COCs is approximately 19.4 per 100,000 users 3
• Among smokers >35 years, the excess risk of death from COCs is higher than the risk of death from pregnancy 3

Alternative Contraceptive Options

For women with this risk profile, several safer alternatives exist:

1. Progestogen-only contraceptives (POCs) are associated with substantially less risk of cardiovascular events than COCs 2
2. Non-hormonal methods such as copper IUDs, barrier methods, or sterilization for those who have completed childbearing

Clinical Implications

The BMJ umbrella review (2020) confirms that the risk of both ischemic and hemorrhagic stroke is greatest in women who are smokers, aged over 35, or have hypertension 1. While the absolute risk of venous thromboembolism with COC use is small compared to pregnancy, the combination with smoking and age >35 creates an unacceptable risk level.

Common Pitfalls to Avoid

1. Underestimating the synergistic risk: The combined effect of smoking and COC use is greater than the sum of individual risks, with 85-97% of the cardiovascular risk in smokers using COCs attributable to this combination 3

2. Focusing only on current smoking status: Even with a "history of smoking," careful assessment of current smoking status is essential, as cardiovascular risk decreases after smoking cessation

3. Overlooking other cardiovascular risk factors: Hypertension, diabetes, or dyslipidemia would further increase risks 1

In conclusion, for a 36-year-old woman with a history of smoking, especially if she currently smokes, COCs represent an unacceptable cardiovascular risk and alternative contraceptive methods should be recommended.