What are the contraindications for oral contraceptive pills (OCPs) in a female patient of reproductive age with no specified medical history?

Contraindications for Oral Contraceptive Pills

Combined oral contraceptives (COCs) are absolutely contraindicated in women with severe hypertension (≥160/100 mmHg), history of venous thromboembolism, migraine with aura, current breast cancer, history of stroke or ischemic heart disease, severe liver disease, and in women ≥35 years who smoke ≥15 cigarettes daily. 1

Absolute Contraindications

Cardiovascular Conditions

• Current or history of ischemic heart disease - COCs are absolutely contraindicated regardless of control status 1
• Current or history of stroke - Any prior cerebrovascular event is an absolute contraindication 1
• Severe hypertension (SBP ≥160 mmHg or DBP ≥100 mmHg) - COCs should never be prescribed at these blood pressure levels 1
• Acute venous thromboembolism (VTE) or history of VTE with ≥1 risk factor for recurrence - The risk of VTE increases approximately 4-fold with COC use, with highest risk in the first year 1, 2

Neurological Conditions

• Migraine with aura at any age - This is an absolute contraindication due to substantially increased stroke risk 1

Age and Smoking

• Age ≥35 years combined with smoking ≥15 cigarettes daily - This combination increases myocardial infarction risk 10-fold 1, 3

Hepatic Conditions

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

Malignancy

• Current breast cancer - COCs are absolutely contraindicated in active disease 1

Autoimmune Conditions

• Systemic lupus erythematosus with positive or unknown antiphospholipid antibodies - This significantly increases thrombotic risk 1

Relative Contraindications

Moderate Hypertension

• Blood pressure 140-159/90-99 mmHg - COCs may be used with caution but risks must be carefully weighed 1
• Adequately controlled hypertension - Even with control, this remains a relative contraindication requiring careful monitoring 1
• Women with poorly controlled hypertension using COCs have approximately 3-fold increased risk of myocardial infarction and ischemic stroke, while hemorrhagic stroke risk increases 15-fold 3

Critical Pre-Prescription Requirements

Mandatory Blood Pressure Screening

• Blood pressure must always be measured before initiating COCs 1
• Medical society guidelines from Canada, Europe, and the United States recommend BP checks prior to CHC initiation, based on evidence showing higher risk of myocardial infarction and stroke among individuals without pre-initiation BP checks 4
• Women who had their blood pressure measured before COC use have 2-2.5-fold decreased risk of myocardial infarction and ischemic stroke 3

Ongoing Monitoring

• Once COCs are started, BP should be monitored at follow-up visits with frequency ranging from every 6 months to annually 4
• If BP increases significantly without another identifiable cause, ACOG recommends that the CHC be discontinued 4

Important Clinical Considerations

Risk-Benefit Analysis

• The risks and benefits of OCP use must be weighed against those associated with unintended pregnancy 4
• Although VTE risk is approximately 1.3-1.5 times higher among OCP users, risk is 3-10 times higher during pregnancy 4
• Entering pregnancy with cardiovascular risk factors such as hypertension and/or obesity is associated with substantially higher pregnancy-related morbidity and mortality 4

Multiple Risk Factors

• Assessing for multiple risk factors that may compound risk is crucial when prescribing COCs 1
• When a woman has multiple major risk factors, OCP use may increase her risk to an unacceptable level 4
• In women with multiple cardiovascular risk factors, progestogen-only contraceptives (POCs) should be considered as they are associated with substantially less cardiovascular risk than COCs 3

Progestin-Only Pills (POPs) as Alternative

• Current guidelines recommend that CHCs be avoided in individuals with hypertension, although POPs are thought to be safe 4
• BP monitoring is not generally recommended during POP use 4
• POC therapy is associated with substantially less risk of cardiovascular events than COCs 3

Common Pitfall

The most frequently missed contraindication is unrecognized hypertension - without standardized screening, unaided self-screening has relatively poor sensitivity and specificity (83% and 89%, respectively) for identifying contraindications to OCP use 4