History of Pulmonary Embolism is an Absolute Contraindication to Estrogen-Containing Oral Contraceptives
A history of pulmonary embolism represents an absolute contraindication to combined estrogen-containing oral contraceptives, making this the correct answer among the options provided. 1
Why Pulmonary Embolism is Contraindicated
Established Thrombotic Risk
Estrogen-containing oral contraceptives increase the risk of venous thromboembolism (VTE) by 3.5-fold compared to non-users (relative risk 3.5,95% CI 2.9-4.3), with combined oral contraceptives being well-documented risk factors for both deep venous thrombosis and pulmonary embolism 2
Oral contraceptives are listed as a secondary risk factor for venous thromboembolism in major cardiology guidelines, with the risk increasing from a baseline of 0.3 per 10,000 per year to 1-2 per 10,000 per year with third-generation formulations 1
Clinical Guidance on Prior VTE
The estrogen-containing oral contraceptive pill is explicitly not recommended for patients at risk of thromboembolism, including those with prior thromboembolic events 1
Guidelines specifically identify that estrogen-containing contraceptives should be avoided in patients with cyanotic congenital heart disease, Fontan procedure history, or pulmonary arterial hypertension due to increased thrombosis risk 3
Even in the context of hormone replacement therapy (HRT), most experts agree that recent VTE (less than one year) represents a contraindication, though this is somewhat less stringent than for contraceptive use 1
Mechanism and Severity
The thrombotic risk is dose-dependent for ethinylestradiol and varies by progestogen type, with third-generation progestogens (desogestrel, gestodene) and newer formulations (cyproterone acetate, drospirenone) carrying 50-80% higher risk than levonorgestrel-containing preparations 2
Case reports document pulmonary embolism occurring even in young, healthy women without additional risk factors after only 4 months of COC use, and even after single high-dose exposures 4, 5
Why Other Options Are NOT Contraindications
Asthma
- Asthma is not listed among contraindications to estrogen-containing contraceptives in any major guideline reviewed
- No thrombotic or hormonal mechanism links asthma to contraceptive safety concerns
Pre-Diabetes
- Pre-diabetes is not an absolute contraindication to combined oral contraceptives
- While diabetes and cardiovascular risk factors share some associations with VTE, pre-diabetes alone does not constitute a contraindication 1
Hypothyroidism
- Hypothyroidism is not mentioned as a contraindication in any guideline
- This condition does not significantly alter thrombotic risk related to hormonal contraception
Clinical Pitfall to Avoid
The absolute risk of death from pulmonary embolism in contraceptive users is 10.5 per million woman-years (95% CI: 6.2-16.6), which while low in absolute terms, represents an unacceptable risk in someone with prior VTE who has already demonstrated thrombotic tendency 6. Alternative contraceptive methods such as levonorgestrel IUD, copper IUD, or progestin-only pills should be offered instead 3.