What are the contraindications for Combined Oral Contraceptive Pills (OCPs)?

Contraindications for Combined Oral Contraceptive Pills (COCPs)

Combined oral contraceptive pills are absolutely contraindicated in patients with conditions that represent unacceptable health risks, including severe hypertension, history of venous thromboembolism, migraine with aura, and current breast cancer. 1

Absolute Contraindications (Category 4)

These conditions represent unacceptable health risks if COCPs are used:

Personal Characteristics and Reproductive History

• Age ≥35 years and smoking ≥15 cigarettes daily 1
• ≤21 days postpartum, regardless of breastfeeding status 1

Cardiovascular Disease

• Severe hypertension (SBP ≥160 mmHg or DBP ≥100 mmHg) 1
• Vascular disease 1
• Acute venous thromboembolism (VTE) or history of VTE with ≥1 risk factor for recurrence 1
• Major surgery with prolonged immobilization 1
• Known thrombogenic mutations 1
• Multiple risk factors for atherosclerosis 1
• Current or history of ischemic heart disease 1
• Current or history of stroke 1
• Valvular heart disease with complications 1
• Peripartum cardiomyopathy with normal or impaired cardiac function for ≤6 months or moderate/severely impaired cardiac function 1

Neurological Conditions

• Migraine with aura (at any age) 1, 2, 3

Gastrointestinal/Hepatic Conditions

• Acute or flare of viral hepatitis 1
• Severe or decompensated cirrhosis 1
• Hepatocellular adenoma 1
• Malignant liver tumor (hepatoma) 1

Other Conditions

• Diabetes with nephropathy, retinopathy, neuropathy, other vascular disease, or with duration ≥20 years 1
• Current breast cancer 1
• Past breast cancer with no evidence of disease for 5 years 1
• Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies 1
• Solid organ transplantation complicated by acute or chronic graft failure, rejection, or cardiac allograft vasculopathy 1

Relative Contraindications (Category 3)

These conditions represent situations where theoretical or proven risks usually outweigh the benefits:

Cardiovascular Disease

• Age ≥35 years and smoking <15 cigarettes daily 1, 4
• Breastfeeding patient 21-29 days postpartum 1
• Breastfeeding patient 30-42 days postpartum with other VTE risk factors 1
• Non-breastfeeding patient 21-42 days postpartum with other VTE risk factors 1
• Moderate hypertension (SBP 140-159 mmHg or DBP 90-99 mmHg) 1
• Adequately controlled hypertension 1
• VTE with no risk factors for recurrence 1
• Superficial venous thrombosis 1

Special Considerations

Hypertension and COCPs

• Combined oral contraceptives can increase blood pressure and should be used with caution in women with hypertension 1
• Women with hypertension using COCPs have a 3-fold increased risk of myocardial infarction and ischemic stroke 4
• Blood pressure should always be measured before initiating COCPs 1
• Discontinuation of COCPs may improve blood pressure control in women with hypertension 4

Migraine and COCPs

• Migraine with aura is an absolute contraindication due to increased stroke risk 2, 3
• Even with newer low-dose formulations, the risk remains significant enough to warrant avoiding COCPs in women with migraine with aura 2
• For women with migraine without aura, COCPs may be used with caution if no other risk factors are present 2, 3

Venous Thromboembolism Risk

• COCPs increase the risk of VTE approximately 4-fold 4
• The highest risk occurs in the first year of use (OR: 4.17) 4
• The absolute risk of VTE with COCPs (3-9 per 10,000 person-years) remains small compared to the risk during pregnancy (5-20 per 10,000 person-years) or postpartum (40-65 per 10,000 person-years) 1

Multiple Risk Factors

• Women with multiple cardiovascular risk factors should consider progestogen-only contraceptives instead of COCPs 4
• The combination of COCPs with other risk factors (smoking, hypertension, age >35) creates a multiplicative effect on cardiovascular risk 4

Clinical Approach to COCP Prescription

1. Obtain comprehensive medical history focusing on contraindications
2. Measure blood pressure before prescribing
3. Assess for multiple risk factors that may compound risk
4. Consider progestin-only pills for women with contraindications to COCPs
5. Weigh risks against benefits, particularly when prescribing for non-contraceptive indications 1, 5

Remember that while COCPs have important contraindications, they also offer non-contraceptive benefits including reduced risk of ovarian and endometrial cancers, improved bleeding patterns, and management of menstruation-related symptoms 5.