Are stroke and seizure contraindications for low-dose contraception (birth control) pills?

Stroke and Seizure as Contraindications for Low-Dose Contraceptive Pills

A history of stroke is a contraindication for estrogen-containing contraceptive pills, while seizure disorder alone is not a contraindication for low-dose contraceptive pills, though medication interactions should be considered. 1

Stroke History and Contraceptive Pills

Absolute Contraindication

A history of stroke represents an absolute contraindication for estrogen-containing contraceptive pills due to the increased risk of recurrent stroke. The American Heart Association/American Stroke Association guidelines clearly state that:

• Women with a history of stroke or thromboembolic events should avoid estrogen-containing contraceptives 1
• The risk of stroke increases with estrogen-containing contraceptives, even with modern low-dose formulations 1

Risk Stratification

The risk of stroke with hormonal contraception varies based on:

1. Estrogen content:

   • Higher estrogen doses correlate with greater stroke risk
   • For every 10 μg increase in estrogen, stroke risk increases by approximately 19% (OR 1.19,95% CI 1.16-1.23) 1
   • Low-dose pills (<50 μg estrogen) carry lower risk than higher-dose formulations, but still increase risk compared to no hormonal contraception 1

2. Additional risk factors that compound stroke risk with contraceptive use:

   • Age >35 years
   • Hypertension
   • Smoking
   • Migraine with aura
   • Previous thromboembolic events 1

Seizure Disorders and Contraceptive Pills

Seizure disorder alone is not listed as a contraindication for low-dose contraceptive pills in the guidelines. However, important considerations include:

1. Medication interactions: Some anti-epileptic drugs (particularly enzyme-inducing medications) may reduce contraceptive efficacy
2. Stroke risk assessment: Patients with seizures should be evaluated for other stroke risk factors that might contraindicate estrogen-containing contraceptives

Alternative Contraceptive Options

For women with stroke history or multiple stroke risk factors, safer alternatives include:

1. Progestin-only methods which show no increased stroke risk 1:

   • Progestin-only pills
   • Progestin injections (Depo-medroxyprogesterone)
   • Levonorgestrel intrauterine device (IUD)
   • Progestin implants

2. Non-hormonal methods:

   • Copper IUD
   • Barrier methods
   • Surgical sterilization

Clinical Decision Algorithm

1. Assess for absolute contraindications:

   • History of stroke or thromboembolic event → Avoid all estrogen-containing contraceptives
   • Current seizure disorder → Not a contraindication by itself

2. Evaluate stroke risk factors:

   • No additional risk factors → Low-dose estrogen contraceptives may be acceptable
   • One or more risk factors (age >35, smoking, hypertension, migraine with aura) → Consider progestin-only or non-hormonal methods

3. For patients with seizure disorders:

   • Review anti-epileptic medications for potential drug interactions
   • If using enzyme-inducing anti-epileptics → Consider higher-dose contraceptives or alternative methods
   • Assess overall stroke risk profile to determine safest contraceptive option

Important Caveats

• The absolute risk of stroke with modern low-dose contraceptives is small in young, healthy women without additional risk factors (approximately 8.8 events per 100,000 person-years) 1
• The risk-benefit calculation should include consideration that pregnancy itself carries a stroke risk (approximately 30 per 100,000 pregnancies) 1
• Progestin-only methods provide effective contraception without the increased stroke risk associated with estrogen-containing methods 1

In summary, while a history of stroke absolutely contraindicates estrogen-containing contraceptives, seizure disorder alone does not. However, medication interactions and overall stroke risk profile must be carefully evaluated in patients with seizure disorders to determine the most appropriate contraceptive option.