Who should not take combination (combo) birth control pills?

Who Should Not Take Combination Birth Control Pills

Women with thrombogenic mutations, current breast cancer, severe liver disease (hepatocellular adenoma or malignancy), history of stroke, complicated valvular heart disease, peripartum cardiomyopathy, or who are postpartum <21 days should absolutely not use combined hormonal contraceptives (U.S. MEC Category 4). 1

Absolute Contraindications (U.S. MEC Category 4 - Unacceptable Health Risk)

Cardiovascular & Thrombotic Conditions:

• Women with thrombogenic mutations due to markedly increased venous thromboembolism risk 1
• History of stroke (cerebrovascular accident) 1
• Complicated valvular heart disease 1
• Peripartum cardiomyopathy with normal or mildly impaired cardiac function <6 months postpartum, or with moderately/severely impaired cardiac function at any time 1
• Multiple risk factors for arterial cardiovascular disease (combination of older age, smoking, diabetes, hypertension) 1
• Postpartum <21 days (highest VTE risk period) 1

Malignancies:

• Current breast cancer 1
• Hepatocellular adenoma or liver malignancy 1

Age & Smoking:

• Women age ≥35 years who smoke ≥15 cigarettes/day 1, 2

Other Conditions:

• Systemic lupus erythematosus with positive (or unknown) antiphospholipid antibodies 1
• Solid organ transplantation with complications 1

Conditions Where Combined Pills Generally Should Not Be Used (U.S. MEC Category 3)

Hypertension:

• Severe hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg) should not use combined hormonal contraceptives 3
• Less severe hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) or adequately controlled hypertension generally should not use 3
• Women with hypertension using combined pills have 6-68 fold increased risk of myocardial infarction and 3.1-14.5 fold increased risk of ischemic stroke 1, 4

Metabolic Conditions:

• Women with dyslipidemia have a 25-fold increased risk of myocardial infarction when using combined pills (OR 25,95% CI 6-109) 3
• Some hyperlipidemias depending on type, severity, and presence of other cardiovascular risk factors 3, 5
• Complicated diabetes (with vascular disease, nephropathy, retinopathy, or neuropathy) 3

Migraine:

• Migraine with aura - women with migraine using combined hormonal contraceptives have 2-16 fold greater risk of stroke 1, 6

Smoking:

• Age ≥35 years smoking <15 cigarettes/day 1

Postpartum:

• 21-42 days postpartum with other VTE risk factors 1

Other:

• History of venous thromboembolism 2, 6
• Acute or flare of viral hepatitis 1
• Severe thrombocytopenia in systemic lupus erythematosus 1

Critical Clinical Pitfalls

Common Inappropriate Use: Research shows that 39% of women with medical contraindications to estrogen still use combined hormonal contraceptives, suggesting widespread inappropriate prescribing 6. This puts women at substantially increased cardiovascular risk.

Age-Related Risk Amplification: Current combined pill users >35 years have a 10-fold increased risk of venous thromboembolism compared to younger users, and smokers in this age group have a 10-fold increased risk of myocardial infarction 4.

First Year Highest Risk: The risk of venous thromboembolism is highest in the first year of use (OR 4.17) and decreases to 2.76 after 4 years 4.

Safer Alternatives for High-Risk Women

For women with contraindications to estrogen:

• Copper IUD is first-line with no metabolic effects on glucose, lipids, or blood pressure 3
• Levonorgestrel IUD has minimal systemic hormonal effects 3
• Progestin-only contraceptives (pills, injection, implant) are associated with substantially less cardiovascular risk than combined methods 4, 2

Special populations:

• Women with sickle cell disease may benefit from Depo-Provera which reduces painful crises 2
• Women with epilepsy may prefer Depo-Provera due to drug interactions with antiepileptics 2

Pre-Initiation Screening

Blood pressure measurement is required before initiating combined hormonal contraceptives 3. Women who had blood pressure measured before use have 2-2.5 fold decreased risk of myocardial infarction and ischemic stroke 4.

Routine screening NOT required for: glucose, lipids, liver enzymes, thrombogenic mutations, or breast examination in asymptomatic women, as the low prevalence makes universal screening not cost-effective 1, 3.