Vaping and Hormonal Birth Control: Clotting Risk Assessment
A 30-year-old female who vapes should not use combined hormonal contraceptives (CHCs) due to significantly elevated thrombotic risk, and should instead be offered progestin-only contraceptive methods.
Understanding the Compounded Risk
The combination of vaping/smoking with combined hormonal contraceptives creates a multiplicative thrombotic risk that is clinically unacceptable:
- Women who use CHCs and smoke have a 10-fold increased risk of myocardial infarction compared to non-smoking non-users 1
- The risk of stroke increases nearly 3-fold in CHC users who smoke 1
- Venous thromboembolism risk is approximately 4-fold higher with CHC use alone, and this is compounded by smoking status 1, 2
- Current CHC users over age 35 who smoke have a 10-fold increased VTE risk compared to younger non-smoking users 1
While this patient is 30 years old, the thrombotic risk from the combination of nicotine exposure (whether from cigarettes or vaping) and estrogen-containing contraceptives remains clinically significant at any age over 35, and the risk trajectory begins in the early 30s 1, 3.
Mechanism of Increased Risk
Combined hormonal contraceptives create a hypercoagulable state through multiple mechanisms:
- Increased plasma fibrinogen and coagulation factors (especially factors VII and X) 4
- Decreased antithrombin III, the primary inhibitor of coagulation 4
- Enhanced platelet aggregation 4
- Cigarette smoking is specifically identified as a contributor to breakthrough bleeding and thrombotic complications in CDC guidelines, indicating recognized vascular effects 5
Recommended Contraceptive Alternatives
Progestin-only contraceptives (POCs) are the appropriate choice for this patient and include:
- Progestin-only pills (POPs): No increased VTE risk demonstrated 6
- Etonogestrel implant: Minimal VTE risk (RR 1.4) 2, 6
- Levonorgestrel IUD: No increased VTE risk 2, 6
- Depot medroxyprogesterone acetate (DMPA): Some evidence suggests modest VTE increase (RR 3.6), but substantially less than CHCs 2, 6
POCs are associated with substantially less cardiovascular risk than CHCs in women with cardiovascular risk factors 1.
Clinical Action Steps
- Discontinue combined hormonal contraceptives immediately if currently in use 1
- Counsel the patient on smoking/vaping cessation as the definitive risk reduction strategy 1
- Initiate a progestin-only method based on patient preference and medical eligibility 1, 6
- Monitor blood pressure if continuing any hormonal method, as hypertension further compounds risk 1
Critical Caveat
If the patient has additional cardiovascular risk factors (hypertension, diabetes, obesity, thrombogenic mutations, personal or family history of VTE), even progestin-only methods require careful consideration, with DMPA potentially avoided in favor of POPs, implants, or LNG-IUD 6. The presence of poorly controlled hypertension with CHC use is associated with 3-fold increased MI risk, 3-fold increased ischemic stroke risk, and 15-fold increased hemorrhagic stroke risk 1.