Is Yasmin (drospirenone and ethinyl estradiol) safe for a 36-year-old female with migraines with aura?

No, Yasmin is absolutely contraindicated for this patient

Yasmin (drospirenone 3mg/ethinyl estradiol 30μg) is contraindicated in a 36-year-old woman with migraine with aura due to a dramatically elevated stroke risk. Combined hormonal contraceptives containing estrogen are explicitly prohibited in all women with migraine with aura, regardless of age. 1, 2

Why This Is Dangerous

The combination of migraine with aura and combined hormonal contraceptives creates a multiplicative stroke risk:

• Migraine with aura alone increases ischemic stroke risk 2.5-fold (RR 2.51) 3
• Adding combined hormonal contraceptives amplifies this to a 7-fold increased stroke risk (RR 7.02; 95% CI 1.51-32.68) compared to women without either risk factor 1, 2
• At age 36, this patient is in the highest risk category, as women under age 45 with migraine with aura face particularly pronounced stroke risk (RR 3.65; 95% CI 2.21-6.04) 1, 3
• The absolute risk translates to approximately 4 additional intracranial hemorrhage events per 10,000 women per year 1, 3

Guideline Consensus

The 2024 American Heart Association/American Stroke Association guidelines explicitly state that estrogen-containing contraceptives must be avoided in individuals with migraine with aura. 4 Yasmin contains 30μg ethinyl estradiol, which falls into the moderate-to-high stroke risk category (++ to +++ severity) per the AHA/ASA risk stratification table. 4

Safe Alternatives for This Patient

First-line recommendation: Progestin-only pills (POPs)

• Norethindrone or drospirenone-only formulations carry no increased stroke risk and may actually reduce migraine frequency 1, 2
• Classified as Category 1 (no restrictions) by CDC for women with migraine with aura 1
• Contraceptive effectiveness: <90% 2
• Main side effect is irregular bleeding, which is not harmful 1

Second-line options:

• Levonorgestrel intrauterine device (LNG-IUD): No stroke risk, >99% effective, manages menstrual irregularities 1, 2
• Etonogestrel implant: No stroke risk, >99% effective, provides 3 years of contraception 1, 2
• Depot medroxyprogesterone acetate (DMPA) injections: No stroke risk, 93-97% effective, may reduce migraine frequency 1, 2

Non-hormonal options:

• Copper IUD, barrier methods, or surgical sterilization all carry no stroke risk 4, 2

Critical Pitfalls to Avoid

• Do not prescribe any combined hormonal contraceptive (pills, patches, rings) to women with migraine with aura, even ultra-low-dose formulations 1, 2
• If the patient smokes, the stroke risk becomes catastrophic (RR 9.03; 95% CI 4.22-19.34) with the combination of migraine, estrogen, and tobacco 1, 3
• Screen for additional stroke risk factors (hypertension, diabetes, hyperlipidemia, thrombophilia) that would further compound risk 1, 3
• Even though some older research suggests modern low-dose formulations may have acceptable risk 5, 6, current guidelines from the highest-quality sources (2024 AHA/ASA) maintain the absolute contraindication 4, 1, 2

Monitoring If Progestin-Only Method Chosen

• Monitor blood pressure at every visit 3
• Reassess migraine frequency every 3-6 months 3
• Educate on stroke warning signs and how to distinguish them from typical aura (sudden vs. gradual onset, simultaneous vs. successive symptoms) 3
• If aura frequency increases or new neurological symptoms develop, evaluate immediately for stroke 3