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Contraception : Prescribing oral contraceptives

When considering the use of birth control pills, absolute and relative contraindications must be considered. Absolute contraindications include :

  • Thrombophlebitis or thromboembolic disorders

  • Cerebro-vascular or coronary artery disease

  • Carcinoma of the breast or other estrogen-dependent neoplasia

  • Undiagnosed abnormal genital bleeding

  • Known or suspected pregnancy

  • Benign or malignant liver tumor

Relative contraindications to contraceptives include:

  • Age over 45

  • Diabetes

  • Hypertension

  • Smoking

  • Gallbladder disease

  • Gestational cholestasis

  • History of renal disease

  • Impaired liver function

  • Hyperlipidemia

Over the last 30 years we have seen a continuous reduction in the estrogen dose contained in combination birth control pills. Ethinyl estradiol is added to birth control pills to help in the suppression of the gonadotropin secretion and also to allow cycle control. Vascular events have been directly related to the dosage of ethinyl estradiol.

Estrogen Doses and Vascular Events Estrogen Doses and Vascular Events.
Credits: Meade, et al Brit. Med. J. 1980

Presently, all birth control pills contain 50 ug or less of ethinyl estradiol. In choosing a birth control pill, we recommend that patients be initiated on < 35 ug dose of ethinyl estradiol. Occasionally, patients may require a pill with more ethinyl estradiol to obtain adequate cycle control.

Smoking definitely increases the risk of cardiovascular events.

OC Use and Cardiovascular Disease OC Use and Cardiovascular Disease: Smoking/Nonsmoking.
Credits: TO RCOP, Lancet 1961

In women over age 35 who smoke, oral contraceptives are not an appropriate choice. The risk of cardiovascular events begins to increase at 30 years and becomes significant at age 35.

Once a patient is on birth control pills, development of any of the following conditions should cause the physician to re-evaluate the use of birth control pills. These contraindications include:

  • Elevated blood pressure

  • Benign liver tumor

  • Hepatitis

  • Pulmonary embolism

  • Thrombophlebitis

  • Gallbladder disease