PocketGuide: Combined Contraceptives - Conditions Requiring Precautions

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PocketGuide for Family Planning Service Providers

Combined (Estrogen/Progestin) Contraceptives

Conditions Requiring Precautions

CONDITION	Pregnancy (known or suspected)
PRECAUTION	COCs and CICs should not be used during pregnancy and should be stopped if intrauterine pregnancy is confirmed and will be carried to term. (WHO class 4) If the possibility of pregnancy cannot be excluded by examination or pregnancy testing, use of COCs or CICs should be delayed until the next menstrual period. In the interim, help the client choose another method (e.g., condoms and spermicide).
RATIONALE	There is no reported harm to the woman or developing fetus from the small amount of estrogen and progestin in CICs or current (low-dose) COCs. It is, however, unwise for a woman to take any drugs in early pregnancy unless absolutely necessary.

CONDITION	Breastfeeding
PRECAUTION	Breastfeeding mothers fewer than 6–8 weeks postpartum should not use COCs or CICs. (WHO class 4) Fully breastfeeding mothers (6 weeks to 6 months postpartum) should avoid using COCs or CICs unless other more appropriate methods (e.g., IUD or POCs) are not available or acceptable. (WHO class 3)
RATIONALE	COCs and CICs decrease the amount of breastmilk and may affect the healthy growth of the infant. Waiting at least 6 to 8 weeks postpartum also permits breastfeeding to be better established. Fully breastfeeding mothers whose menses have not returned (amenorrhea) and who are less than 6 months postpartum are at low risk for pregnancy (< 2% failure rate; see LAM chapter).

CONDITION	Nonbreastfeeding
PRECAUTION	Nonbreastfeeding mothers fewer than 3 weeks postpartum should avoid using COCs or CICs unless other more appropriate methods are not available or acceptable. (WHO class 3)
RATIONALE	Until after 3 weeks postpartum, women are at increased risk for pregnancy-related blood clotting problems. Use of COCs or CICs during this time may further increase the risk. (Because even nonbreastfeeding women less than 6–8 weeks postpartum are at low risk for conception, neither COCs nor CICs need to be started prior to the third week following delivery.)

CONDITION	Unexplained vaginal bleeding (only if serious problem suspected)
PRECAUTION	Women with unexplained vaginal bleeding, which could be due to pregnancy or caused by a serious problem, should avoid using COCs or CICs until the cause is determined and treated, if possible. (WHO class 3)
RATIONALE	Because COCs and CICs can cause intermenstrual spotting or bleeding, an underlying problem (e.g., normal or ectopic pregnancy, cervicitis, other pelvic pathology and, rarely, cancer of the genital tract) may be masked. None of the above conditions, however, are worsened—and some are prevented—by use of COCs or CICs.

CONDITION	Jaundice (symptomatic viral hepatitis, gall bladder disease or cirrhosis)
PRECAUTION	COCs should not be used until clients have fully recovered from hepatitis (i.e., until either 3 months after becoming asymptomatic or normal liver function returns). Help client choose another method. (WHO class 4) Use of CICs should be avoided unless other more appropriate methods are not available or acceptable. (WHO class 3) Women with symptomatic gall bladder disease should avoid using COCs unless other more appropriate methods are not available or acceptable. (WHO class 3)
RATIONALE	The hormones in COCs and CICs, especially the estrogen, may be poorly metabolized in women with impaired liver function; therefore, their use may affect the health of these women. In addition, COCs and CICs may accelerate development of symptoms of gall bladder disease in asymptomatic women. The concern with CICs, however, is less than that with COCs. The hormones in CICs initially pass directly from the injection site to the heart without first passing through the liver (no first-pass effect).

CONDITION	Smoker and age 35 years or older
PRECAUTION	Client should not use COCs or CICs if heavy (WHO class 4) or light smoker. (WHO class 3)¹ Use of CICs should be avoided unless other more appropriate methods are not available or acceptable. (WHO class 3)
RATIONALE	Women 35 years or older who smoke (heavily or lightly) already are at increased risk of heart attack, stroke and other blood clotting problems. Use of COCs or CICs by these women poses an additional risk of blood clotting problems (estrogen effect). Women 35 years or older who stop smoking and have no other risk factors may use COCs or CICs.

CONDITION	Ischemic heart disease or Stroke (current or history of)
PRECAUTION	Women with underlying arterial vascular disease should not use COCs or CICs. (WHO class 4)
RATIONALE	In women with documented arterial vascular disease (heart attack or stroke), use of COCs or CICs may pose an additional risk (estrogen effect).

CONDITION	Blood clotting disorders (deep vein thrombophlebitis or pulmonary embolus)
PRECAUTION	Women with blood clotting disorders (current, history of or recovering from major surgery with prolonged bed rest) should not use COCs or CICs. (WHO class 4)
RATIONALE	While COCs and CICs only slightly increase the risk of blood clotting problems in healthy women, this increased risk may have substantial impact on women already at risk. Preliminary results suggest that users of COCs containing the new progestins desogestrel and gestodene have a higher risk of venous blood clotting problems than those using COCs containing leconorgestrel or norethindrone. WHO advises that until further information is available, COCs containing progestins other than desogestrel and gestodene are preferred.

CONDITION	Diabetes (> 20 years duration; vascular problems, or CNS, kidney or visual disease)
PRECAUTION	Women with advanced or long-standing diabetes should not use COCs or CICs. (WHO class 3/4) Insulin- and noninsulin-dependent diabetics without serious problems generally can use COCs or CICs. (WHO class 2)
RATIONALE	Use of COCs or CICs by women with advanced or long-standing (> 20 years) diabetes may worsen venous vascular problems and possibly increase the risk of blood clotting problems (estrogen effect).

CONDITION	Headaches (migraine)
PRECAUTION	Women with migraine headaches that cause focal neurologic symptoms should not use COCs or CICs. (WHO class 4)
RATIONALE	In women with severe, recurrent vascular (migraine) headaches who also have focal neurologic symptoms (e.g., unable to speak for short intervals, temporary weakness or blurred vision), use of COCs or CICs may pose an additional risk for stroke (estrogen effect).

CONDITION	High blood pressure (with or without vascular problems)
PRECAUTION	Women with BP: > 180/110 should not use COCs or CICs. (WHO class 4) > 160/100 but < 180/110 should avoid using COCs or CICs unless other more appropriate methods are not available or acceptable. (WHO class 3) Women with vascular disease as well as high BP should not use either COCs or CICs. (WHO class 4)
RATIONALE	Although use of COCs or CICs causes only small changes in the BP of healthy women, in hypertensive women, use poses an additional risk for venous blood clotting problems (estrogen effect). Use should be stopped if monitoring during the first few months reveals a marked increase in BP or arterial vascular disease develops.

CONDITION	Breast cancer
PRECAUTION	Women with breast cancer should not use COCs or CICs. (WHO class 4) Women with a history of breast cancer and no evidence of current disease should avoid using COCs or CICs unless other more appropriate methods are not available or acceptable. (WHO class 3)
RATIONALE	There is no evidence that COCs or CICs cause breast cancer. Because it is a hormonally-sensitive tumor, there is concern that the risk of progression may be increased among women with a past history or current breast cancer. Note: Clients with suspicious breast lumps (firm, nontender or fixed and which do not change during the menstrual cycle) need to be evaluated before using COCs or CICs.

CONDITION	Liver tumors (adenoma and hepatoma)
PRECAUTION	Women with liver tumors should not use COCs. (WHO class 4) Women with liver tumors should avoid using CICs unless other more appropriate methods are not available or acceptable. (WHO class 3)
RATIONALE	The hormones in COCs and CICs, especially the estrogen, are metabolized by the liver and their use may alter the course of existing disease. Because liver tumors (benign and malignant) are rare in women of reproductive age, routine screening (e.g., ultrasound) is not needed. The concern with CICs is less than that with COCs because the first-pass effect on the liver is eliminated. The hormones in CICs initially pass directly from the injection site to the heart without first passing through the liver.

CONDITION	Major surgery with prolonged bed rest
PRECAUTION	Women who are to undergo major elective surgery should switch to another more appropriate method. (WHO class 4)
RATIONALE	Prolonged bed rest increases the rsk of venous blood clotting problems in healthy women. If possible, COCs should be stopped for 4 weeks before and 2 weeks after major elective surgery requiring prolonged bed rest.

CONDITION	Taking drugs for epilepsy (phenytoin or barbiturates) or tuberculosis (rifampin)
PRECAUTION	Clients taking drugs for these disorders should be counseled about the potential reduction in the effectiveness of COCs and CICs. Use of COCs or CICs should be avoided unless other more appropriate methods are not available or acceptable. (WHO class 3)
RATIONALE	Long-term use of drugs for epilepsy (except valproic acid) and tuberculosis causes the liver to metabolize estrogens and progestins more rapidly and may decrease the effectiveness of COCs or CICs.² Overall, COCs and CICs do not appear to alter seizure activity and can be provided with caution. Development of intermenstrual spotting or bleeding may indicate a decreased level of sex steroid hormones (estrogen and progestin). If this occurs, consider switching to a COC with a higher estrogen level (50 Fg EE) or help client choose another method (COC or CIC).

^{1 Definitions of heavy smoking vary internationally.
Throughout this PocketGuide the WHO definition, 20 cigarettes or more per day, is
used.
2
Because
griseofulvin, which increases estrogen and progestin metabolism, usually is used only for
a short period of time (2–4 weeks), women taking it for fungal infections can
continue to use COCs or CICs. They should use a backup method while taking griseofulvin
and until the start of the next menstrual period after stopping the antibiotic.

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