What are the contraindications for oral contraceptive pills (OCPs)?

Oral Contraceptive Pill Contraindications

Combined oral contraceptive pills (COCs) are absolutely contraindicated in patients with uncontrolled hypertension, history of thromboembolism, cardiovascular disease, breast cancer, liver tumors, and during the early postpartum period. 1, 2

Absolute Contraindications for Combined Oral Contraceptives

Based on the US Medical Eligibility Criteria for Contraceptive Use, the following are absolute contraindications (Category 4) for COCs 1:

Cardiovascular Conditions

• Thrombophlebitis or current thromboembolic disorders
• Past history of deep vein thrombophlebitis or thromboembolic disorders
• Cerebral vascular or coronary artery disease
• Severe hypertension (SBP ≥160 mmHg or DBP ≥100 mmHg)
• Vascular disease
• Major surgery with prolonged immobilization
• Known thrombogenic mutations
• Multiple risk factors for atherosclerosis
• Current or history of ischemic heart disease
• Current or history of stroke
• Valvular heart disease with complications
• Peripartum cardiomyopathy

Reproductive/Oncologic Conditions

• Current diagnosis of, or history of, breast cancer
• Undiagnosed abnormal genital bleeding

Hepatic Conditions

• Acute or flare of viral hepatitis
• Severe or decompensated cirrhosis
• Hepatocellular adenoma
• Malignant liver tumor (hepatoma)
• Cholestatic jaundice of pregnancy or jaundice with prior pill use

Other Conditions

• Age ≥35 years and smoking ≥15 cigarettes daily
• ≤21 days postpartum, regardless of breastfeeding status
• Diabetes with nephropathy, retinopathy, neuropathy, other vascular disease, or duration ≥20 years
• Migraine with aura
• Multiple sclerosis with prolonged immobility
• Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies
• Solid organ transplantation with complications
• Receiving Hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir 2

Relative Contraindications for Combined Oral Contraceptives

The following conditions represent relative contraindications (Category 3) where risks usually outweigh benefits 1:

• Age ≥35 years and smoking <15 cigarettes daily
• Breastfeeding patient 21-29 days postpartum
• Breastfeeding patient 30-42 days postpartum with other VTE risk factors
• Nonbreastfeeding patient 21-42 days postpartum with other VTE risk factors
• Moderately elevated blood pressure (SBP 140-159 mmHg or DBP 90-99 mmHg)
• Adequately controlled hypertension
• VTE with no risk factors for recurrence
• Superficial venous thrombosis

Progestin-Only Pills (POPs) Contraindications

POPs have fewer contraindications than COCs and may be suitable for women with certain cardiovascular risk factors 3, 4:

• Known or suspected pregnancy
• Known or suspected carcinoma of the breast
• Undiagnosed abnormal genital bleeding
• Hypersensitivity to any component of the product
• Benign or malignant liver tumors
• Acute liver disease

Clinical Considerations

Hypertension and OCPs

Hypertension is one of the most common contraindications to COC use 1. In the United States, approximately 10% of reproductive-aged women have SBP ≥140 or DBP ≥90 mmHg. Blood pressure measurement is essential before initiating hormonal contraceptives 1, 5.

Age and Smoking

The combination of age ≥35 years and smoking significantly increases cardiovascular risks with COC use 4:

• Current users of COCs older than 35 years have approximately 2.5-fold increased risk of venous thromboembolism compared to younger users
• COC users who are current smokers have 10-fold increased risk of myocardial infarction and nearly 3-fold increased risk of stroke 4

Venous Thromboembolism Risk

COCs are associated with approximately 4-fold increased relative risk of venous thromboembolic events 4:

• Highest risk occurs in the first year of use (OR: 4.17)
• Risk decreases to 2.76 over baseline after 4 years of therapy
• Absolute risk remains low in most women without other risk factors

Alternative Options

For women with contraindications to COCs, consider:

• Progestin-only pills - associated with substantially less risk of cardiovascular events than COCs 4
• Non-hormonal methods (copper IUD, barriers)
• Long-acting reversible contraceptives (LARCs) - have failure rates of less than 1% per year 6

Practical Approach to Prescribing OCPs

1. Assess for absolute contraindications - Thoroughly review medical history for any Category 4 conditions
2. Evaluate relative contraindications - Consider risk-benefit ratio for Category 3 conditions
3. Measure blood pressure - Essential before initiating any hormonal contraceptive
4. Consider age and smoking status - Particularly important for women ≥35 years
5. Evaluate other cardiovascular risk factors - Multiple risk factors may compound risk
6. Consider alternative methods - POPs or non-hormonal methods for women with contraindications to COCs

Common Pitfalls to Avoid

• Failing to measure blood pressure before initiating OCPs
• Overlooking smoking status in women over 35
• Not recognizing that certain medications (e.g., Hepatitis C treatments containing ombitasvir/paritaprevir/ritonavir) are contraindications
• Assuming all contraceptives carry the same risks - POPs have fewer cardiovascular contraindications than COCs
• Not considering the postpartum period - COCs are contraindicated ≤21 days postpartum regardless of breastfeeding status

Remember that while OCPs have important contraindications, they remain a safe and effective contraceptive option for most women without risk factors, with the benefits often outweighing the risks 6, 7.