Use of Hormonal Contraception in Women With Coexisting Medical Conditions

Publication Date: January 31, 2019
Last Updated: March 14, 2022

Summary of Recommendations

The following recommendations are based on good and consistent scientific evidence.

  • Women with certain conditions associated with VTE should be counseled for nonhormonal or progestin-only contraceptives.
  • Gynecologic care providers should not perform routine screening for familial thrombotic disorders ating combined hormonal contraceptives.
  • Use of combined hormonal contraceptives is contraindicated in women with known familial thrombophilias (USMEC category 4). Progestin-only methods and LNG-IUDs are acceptable alternatives for individuals with known thrombogenic mutations (USMEC category 2).
  • Women with SLE should be tested for anti-phospholipid antibodies before initiating hormonal contraception. Combined hormonal contraception is contraindicated in women with SLE and positive antiphospholipid antibodies (USMEC category 4).
  • Regardless of breastfeeding status, combined hor-monal contraceptives are contraindicated during the first 21 days after giving birth because of the risk of VTE (USMEC category 4); therefore, health care providers should advise against initiating combined hormonal contraceptives during this time. Venous thromboembolism risk decreases postpartum day 21–42, although this risk continues to outweigh contraceptive benefits (USMEC category 3) in women with additional risk factors for VTE.
  • At the time of contraceptive initiation, the diagnosis of migraine with or without aura should be carefully considered in all women who present with a history of headache.
  • Combined hormonal contraceptives can be used in women who have migraine without aura and no other risk factors for stroke (USMEC category 2). Estrogen-containing contraceptives are not recommended for women who have migraine with aura because of the increased risk of stroke (USMEC category 4).
  • Women with blood pressure below 140/90 mm Hg may use any hormonal contraceptive method. In women with hypertension of systolic 140–159 mm Hg or diastolic 90–99 mm Hg, combined hormonal contraceptives should not be used unless no other method is appropriate for or acceptable to the patient (USMEC category 3). Women with hypertension of systolic 160 mm Hg or greater or diastolic 100 mg Hg or greater or with vascular disease should not use combined hormonal contraceptives (USMEC category 4).
  • For women with uncomplicated insulin or non-insulin dependent diabetes, no methods of hormonal contraception are contraindicated based on available data (USMEC category 2). However, for women with diabetes of more than 20 years of duration or evidence of microvascular disease (retinopathy, nephropathy, or neuropathy), combined hormonal contraceptives are contraindicated (USMEC category 3 or 4 depending on the severity of the condition).
(A)
574

The following recommendations are based on limited or inconsistent scientific evidence.

  • Combined hormonal contraceptives that contain older formulations of progestins (levonorgestrel and norethindrone) and newer progestins (desogestrel and drospirenone in oral contraception and etonogestrel in the vaginal ring) are associated with a comparable risk of VTE and can be recommended as equivalent options to women with a history of or at risk of VTE.
  • Progestin-only pills, the contraceptive implant, or an LNG-IUD are appropriate options to initiate in women with a history of or at risk of VTE, myo- cardial infarction, or stroke (USMEC category 2).
  • Breastfeeding women may use progestin-only contraceptives at any time during the postpartum period and may use combined hormonal methods at 4–6 weeks after giving birth depending on VTE risk factors.
  • Women with obesity can be offered all hormonal contraceptive method options with reassurance that the efficacy of hormonal contraception is not sig- nificantly affected by weight.
  • Women with depressive disorders can use all methods of hormonal contraception (USMEC cate- gory 1) because depressive symptoms do not appear to worsen with use of any method of hormonal contraception, including DMPA.
  • Gynecologic care providers need not restrict use of any hormonal contraception in women with a family his- tory of breast cancer (USMEC category 1) or women with identified mutations in breast cancer susceptibility genes (eg, BRCA1 and BRCA2) who have not per- sonally been diagnosed with breast cancer.
  • Women taking rifampin and liver-enzyme inducing antiepileptic and antiretroviral medications that interfere with contraceptive steroid efficacy can use DMPA and LNG-IUDs without concern for increased contraceptive failure (USMEC category 1). Combined hormonal contraception or progestin-only pills generally are not recom- mended because of the increased risk of contra- ceptive failure (USMEC category 3).
(B)
574

The following recommendations are based primarily on consensus and expert opinion.

  • Healthy, nonsmoking women without specific risk factors for cardiovascular disease can continue combined hormonal contraception until age 50–55 years (USMEC category 2).
  • Routine assessment of follicle-stimulating hormone when hormonal contraceptive users have become menopausal and, thus, no longer need contraception may be misleading and is not recommended.
  • Women who undergo bariatric surgery that may compromise the absorption of oral medications (Roux-en-Y gastric bypass or biliopancreatic diver- sion) should not use oral contraception (combined hormonal or progestin-only) because efficacy may be impaired (USMEC category 3). Nonoral methods of contraception can be used without restriction (USMEC category 1).
  • Gynecologic care providers can recommend the use of the copper IUD as an appropriate contraceptive option for women who have been treated for breast cancer (USMEC category 1).
  • Decisions regarding use of LNG-IUDs in breast cancer survivors should balance the unknown risk of recurrence against its potential benefit on a case-by- case basis. Consultation with the patient’s medical oncologist can be useful in these cases.
(C)
574

Recommendation Grading

Overview

Title

Use of Hormonal Contraception in Women With Coexisting Medical Conditions

Authoring Organization

American College of Obstetricians and Gynecologists

Publication Month/Year

January 31, 2019

Last Updated Month/Year

April 1, 2024

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Physician, nurse nurse midwife, nurse certified nurse midwife, nurse, nurse practitioner, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D000080066 - Contraceptive Agents, Hormonal, D015897 - Comorbidity, D003278 - Contraceptives, Oral, Hormonal, D003282 - Contraceptives, Postcoital, Hormonal, D000080282 - Hormonal Contraception

Keywords

coexisting conditions, hormonal contraception