What are the absolute and relative contraindications to oral contraceptives (OCs) in perimenopause?

Absolute and Relative Contraindications to Oral Contraceptives in Perimenopause

Combined oral contraceptives can be safely used in healthy, nonsmoking perimenopausal women, but are absolutely contraindicated in women ≥35 years who smoke ≥15 cigarettes daily, and in those with current or history of venous thromboembolism, stroke, ischemic heart disease, migraine with aura, or current breast cancer. 1, 2

Absolute Contraindications (Category 4 - Unacceptable Health Risk)

Age and Smoking

• Age ≥35 years AND smoking ≥15 cigarettes daily - this represents the most common absolute contraindication in perimenopausal women due to dramatically increased risk of myocardial infarction and stroke 1, 3

Cardiovascular Conditions

• Current or history of deep vein thrombosis or pulmonary embolism 1, 2
• Acute VTE or history of VTE with ≥1 risk factor for recurrence 1
• Current or history of ischemic heart disease 1, 2
• Current or history of stroke 1, 2
• Known thrombogenic mutations (Factor V Leiden, prothrombin mutation) 1
• Multiple risk factors for atherosclerosis present simultaneously 1
• Valvular heart disease with complications 1
• Peripartum cardiomyopathy with impaired cardiac function 1
• Major surgery with prolonged immobilization 1

Hypertension

• Systolic blood pressure ≥160 mmHg OR diastolic blood pressure ≥100 mmHg 1
• Vascular disease 1

Neurological Conditions

• Migraine with aura - this carries particularly high stroke risk when combined with estrogen-containing contraceptives 1
• Multiple sclerosis with prolonged immobility 1

Malignancies

• Current breast cancer 1, 2
• Hepatocellular adenoma or malignant liver tumor 1, 2

Hepatic Conditions

• Acute or flare of viral hepatitis 1
• Severe or decompensated cirrhosis 1, 2
• Receiving Hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir (with or without dasabuvir) 2

Other Conditions

• Undiagnosed abnormal genital bleeding 2
• Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies 1
• Diabetes with nephropathy, retinopathy, neuropathy, other vascular disease, or duration ≥20 years 1
• Solid organ transplantation with complications 1

Relative Contraindications (Category 3 - Risks Usually Outweigh Benefits)

Age and Smoking

• Age ≥35 years AND smoking <15 cigarettes daily - while not an absolute contraindication, the risks generally outweigh benefits and progestin-only methods should be strongly preferred 1, 3

Hypertension

• Systolic blood pressure 140-159 mmHg OR diastolic blood pressure 90-99 mmHg 1
• Adequately controlled hypertension on medication 1

Cardiovascular History

• History of VTE with no current risk factors for recurrence 1
• Superficial venous thrombosis 1

Postpartum Period

• Breastfeeding women 21-29 days postpartum 1
• Breastfeeding women 30-42 days postpartum with other VTE risk factors 1
• Non-breastfeeding women 21-42 days postpartum with other VTE risk factors 1

Malignancy History

• Past breast cancer with no evidence of disease for 5 years 1

Special Considerations for Perimenopausal Women

Age-Related Classification

• The U.S. Medical Eligibility Criteria classifies combined hormonal contraceptives as Category 2 (benefits generally outweigh risks) for women ≥40 years in the absence of other contraindications 1, 4
• This reflects that cardiovascular risk increases with age, though age alone is not a contraindication 1, 5

Cardiovascular Risk Assessment

• While the incidence of venous thromboembolism and myocardial infarction is higher in OCP users aged 45-49 compared to younger users, a direct interaction between hormonal contraception and increased age has not been consistently demonstrated 4
• The absolute risk remains low in healthy nonsmoking perimenopausal women 6

Preferred Alternatives When Contraindications Exist

• Copper IUDs, levonorgestrel IUDs, contraceptive implants, and progestin-only pills are classified as Category 1 (no restrictions) for women over 40 and should be the first-line options when combined hormonal contraceptives are contraindicated 4, 3
• These methods avoid estrogen-related cardiovascular risks while providing highly effective contraception 4, 7

Duration of Use

• Contraception should be continued until confirmed menopause (12 months without menses) or age 50-55 years 4, 7
• The median age of menopause is approximately 51 years but can vary from 40-60 years 4
• No reliable laboratory tests confirm definitive loss of fertility; FSH levels are not accurate for this determination 4

Common Pitfalls to Avoid

• Do not assume fertility has ended before confirmed menopause - unintended pregnancies in perimenopausal women carry higher risks for maternal and fetal complications 4, 7
• Do not withhold combined oral contraceptives based on age alone - healthy nonsmoking women in their 40s can safely use COCs and benefit from menstrual regulation, vasomotor symptom relief, and cancer risk reduction 5, 8, 9
• Do not overlook smoking status - this is the single most important modifiable risk factor that converts COCs from safe (Category 2) to dangerous (Category 3-4) in women ≥35 years 1, 3
• Always measure blood pressure before prescribing - undiagnosed hypertension is common in perimenopausal women and represents a major contraindication 1