Counseling women with coexisting medical conditions regarding contraception should balance the potential risk of using contraceptive methods against the potential risk of an unintended pregnancy, according to guidance from a recent Practice Bulletin from the American College of Obstetricians and Gynecologists (ACOG). The bulletin is a published guidance based on the best available evidence and expert opinion to help healthcare providers better care for women with chronic medical problems who need contraception. Among the ACOG recommendations (Level A):
- 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 before initiating 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 antiphospholipid 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 hormonal contraceptives are contraindicated during the first 21 days after giving birth because of the risk of VTE (USMEC category 4); therefore, healthcare providers should advise against initiating combined hormonal contraceptives during this time.
- 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.
- Women with blood pressure <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 diastolic ≥100 mg Hg or with vascular disease should not use combined hormonal contraceptives (USMEC category 4).
- For women with uncomplicated insulin or noninsulin dependent diabetes, no methods of hormonal contraception are contraindicated.
Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin No. 206. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2019;133:e128–50.