Contraception

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Contraindications

The World Health Organization (WHO) has developed a list of absolute and relative contraindications to the use of combined OCs. Contraindications to use of the transdermal contraceptive patch and the vaginal contraceptive ring are similar to those for the combined OC. The following are absolute contraindications to combined hormonal contraceptive use:

• up to 6 weeks post delivery
  
• Hypertension
• Venous thromboembolism (current/past)
• Personal history of breast cancer
• Known thrombophilia
• Cerebrovascular accident
• Migraine with focal neurological symptoms
• Migraine without aura over age 35
• Ischemic heart disease
• Complicated valvular heart disease
• Diabetes with retinopathy/nephropathy/neuropathy
• Liver disease: Severe cirrhosis, liver tumor, active viral hepatitis
• Smoking over the age of 35 (> 15 cigarettes/day)

Elevated blood pressure:

• Elevated blood pressure (systolic ≥ 160mm Hg or diastolic ≥ 100mm Hg is an absolute contraindication. A systolic BP 140–159mm Hg and diastolic BP 90–99mm Hg is a relative contraindication. Adequately controlled hypertension is also a relative contraindication.

Venous thromboembolism:

• The risk of venous thromboembolism (VTE) is 3-4 times higher in women taking combined OCs as compared to women not using them. Current or past history of venous thromboembolism is an absolute contraindication. Progestin-only (non-combination) contraceptives should be considered and used with caution in patients with thrombophilia. In women who are at risk for MI and stroke, non-hormonal options should be considered.

Smoking:

• An absolute contraindication to OCs is a smoker >35 years old, smoking ≥15 cigarettes/day, while a relative contraindication is smoker aged >35 years smoking <15>

Liver disease:

• Severe cirrhosis is an absolute contraindication; mild cirrhosis is a relative contraindication. A liver tumour is an absolute contraindication.

Diabetes:

• Diabetes with retinopathy/nephropathy/neuropathy is an absolute contraindication.

Contraindications for DMPA

• Absolute:
  • Known or suspected pregnancy
  • Current diagnosis of Breast Cancer
• Relative:
  • Unexplained vaginal bleeding (before investigation)
  • History of ischemic heart disease or stroke
  • Severe cirrhosis, active viral hepatitis, and liver tumors

Cancer Risk:

• The risk of breast cancer in combined OC users remains controversial. Two case control studies, in 1986 and 2002, found no association between combined OC’s and the risk of breast cancer. A 1996 meta-analysis suggested that there was a small but significant increase in risk of breast cancer in women who were currently taking the combined OC (relative risk [RR], 1.24; 95% CI, 1.15–1.33) up to 10 years after discontinuing. There was no significant excess risk of having breast cancer 10 or more years after stopping the COC. Two published studies in 2005 found that there was a decrease in the risk of breast cancer for women who had a family history of breast cancer and used the combined OC.
>Whether any potential small increase in breast cancer risk is associated with the combined OC itself or other factors such as delaying the first full-term birth is not known.
• The role of contraceptives and the development of cervical cancer is uncertain. Studies have failed to adequately control for HPV, which is known to be associated with squamous cell carcinoma of the cervix. One study found that OC use did not increase the risk of cervical cancer in a group of HPV positive women followed for 10 years. Other studies have shown a slight increase in women who take an OC, therefore, all OC users should have a yearly Pap.
• Use of the combined OC is associated with a decrease in the risk of ovarian and endometrial cancer. The risk of ovarian cancer is decreased by up to 50% in combined OC users and the risk of endometrial cancer can be decreased by as much as 70%, depending on the duration of use.