What contraindications and safety considerations should I assess before prescribing hormonal contraception to my patient?

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Safety Assessment Before Prescribing Hormonal Contraception

Before prescribing hormonal contraception, measure blood pressure for combined hormonal methods, screen for absolute contraindications (active thromboembolism, uncontrolled severe hypertension ≥160/100 mmHg, migraines with aura, current breast cancer, active liver disease), and verify the patient is not pregnant—no pelvic exam is needed except for IUD placement. 1

Mandatory Pre-Initiation Requirements by Method Type

Combined Hormonal Contraceptives (Pills, Patch, Ring)

  • Blood pressure measurement is the only required examination before initiating combined hormonal contraceptives 1, 2
  • No pelvic exam, breast exam, or laboratory testing is needed 1, 3
  • Verify reasonable certainty of non-pregnancy using clinical criteria 1

Progestin-Only Methods (Pills, Implant, DMPA)

  • No physical examination is required before initiating progestin-only pills, implants, or depot medroxyprogesterone acetate 1, 2
  • Verify reasonable certainty of non-pregnancy 1

Intrauterine Devices

  • Bimanual examination and cervical inspection are required before IUD placement 1, 2
  • Screen for sexually transmitted infections if risk factors present, but do not delay insertion to await results unless purulent cervicitis is visible 1, 2

Absolute Contraindications to Combined Hormonal Contraceptives

Combined hormonal contraceptives should NOT be prescribed if the patient has: 1

  • Severe uncontrolled hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg) 1
  • History of or current thromboembolism (deep vein thrombosis or pulmonary embolism) 1, 2
  • Known thrombophilia (factor V Leiden, antiphospholipid antibody syndrome, protein C/S/antithrombin deficiency) 1
  • Migraines with aura or focal neurologic symptoms 1
  • Current or history of breast cancer 1, 4
  • Active liver disease or benign/malignant liver tumors 1, 4
  • Complicated valvular heart disease 1
  • Diabetes with vascular complications (nephropathy, retinopathy, neuropathy) 1
  • Complicated solid organ transplantation 1

Progestin-Only Method Contraindications

Progestin-only contraceptives have fewer contraindications and can be used when combined methods are restricted: 2

  • Current breast cancer is a contraindication 4
  • Undiagnosed abnormal genital bleeding requires evaluation first 4
  • Active liver disease or liver tumors 4
  • Progestin-only methods are generally safe even with thromboembolism risk factors where combined hormonal contraceptives are contraindicated 2

Critical Drug Interactions to Screen For

Medications That Reduce Contraceptive Effectiveness

The following medications significantly decrease hormonal contraceptive efficacy and require alternative contraception or backup methods: 1

  • Rifampin or rifabutin (category 3 contraindication for combined hormonal contraceptives and progestin-only pills) 1
  • Anticonvulsants: phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine (category 3) 1, 4
  • St. John's Wort (category 2—may reduce effectiveness) 1, 4
  • Certain ritonavir-boosted protease inhibitors may decrease contraceptive hormone levels 1

Medications Affected by Combined Hormonal Contraceptives

  • Lamotrigine levels decrease significantly with combined hormonal contraceptives, potentially reducing seizure control (category 3 contraindication) 1
  • Lamotrigine can be used safely with progestin-only methods 1

Common Pitfalls and How to Avoid Them

Misconception: Pelvic Exam Required Before Prescribing

A pelvic examination is NOT needed before prescribing oral contraceptives, patches, rings, implants, or DMPA injections 1, 3. This outdated requirement creates unnecessary barriers to contraception. Only IUD placement requires bimanual exam and cervical inspection 1, 2.

Misconception: Antibiotics Reduce Pill Effectiveness

Broad-spectrum antibiotics do NOT reduce contraceptive effectiveness (category 1—no restriction) 1. The only exception is rifampin/rifabutin 1. A 2011 case-crossover study of 1,330 combined oral contraceptive failures found no definitive evidence of decreased effectiveness with any antibiotic except rifampin 1.

Misconception: Age Alone Contraindicates Combined Methods

No contraceptive method is contraindicated based solely on age 5. However, cardiovascular risk factors that accumulate with age (hypertension, smoking in women ≥35 years, diabetes with complications) may contraindicate combined hormonal methods 1. Progestin-only methods remain safe alternatives 2, 5.

Misconception: Obesity Contraindicates Hormonal Contraception

All contraceptive methods can be used without restriction in patients with obesity (BMI ≥30) according to CDC Medical Eligibility Criteria 2. Obesity does not reduce contraceptive effectiveness of implants, IUDs, or other methods 2.

Venous Thromboembolism Risk Counseling

Baseline venous thromboembolism risk in adolescents and young women is 1 per 10,000 woman-years 1. Combined hormonal contraceptives increase this risk three to fourfold, to approximately 4 per 10,000 woman-years 1. For comparison, pregnancy-associated venous thromboembolism risk is substantially higher than contraceptive-associated risk 1.

When to Screen for Sexually Transmitted Infections

Routine STI screening is recommended in all sexually active patients regardless of contraceptive method chosen 1. However, STI screening should not delay contraceptive initiation 1, 2. For IUD placement specifically, do not delay insertion to await STI results unless purulent cervicitis is visible on exam 1, 2.

Special Populations Requiring Enhanced Screening

Cardiovascular Risk Factors

  • Measure blood pressure before combined hormonal contraceptive initiation 1, 2
  • Screen for personal or family history of thromboembolism 1
  • Assess for migraines with aura (absolute contraindication to combined methods) 1
  • Smoking in women ≥35 years contraindicates combined hormonal contraceptives 1

Diabetes

  • Uncomplicated diabetes is not a contraindication to any method 1
  • Diabetes with vascular complications (nephropathy, retinopathy, neuropathy) contraindicates combined hormonal contraceptives 1

Liver Disease

  • Active hepatitis or cirrhosis contraindicates all hormonal methods 1, 4
  • History of resolved hepatitis without ongoing dysfunction does not contraindicate hormonal contraception 1

Quick-Start Protocol Safety

Combined oral contraceptives can be started the same day as the visit ("quick-start") in healthy, non-pregnant patients 1. Backup contraception (condoms or abstinence) should be used for 7 days if starting more than 5 days after menses began 1. This approach increases continuation rates without increasing pregnancy risk when pregnancy is reasonably excluded 1.

Follow-Up Requirements

A routine follow-up visit 1-3 months after initiating combined oral contraceptives is useful for addressing persistent adverse effects or adherence issues 1. Blood pressure should be rechecked at follow-up for patients on combined hormonal methods 6. No routine follow-up is required for IUDs, implants, or DMPA unless the patient has concerns 2, 6.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Contraception Guidance

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Guideline

Initial Gynecologic Visit Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

6
Guideline

Management of Heavy Menstrual Bleeding in Adolescents

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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