Association of Reproductive Health Professionals
Association of Reproductive Health Professionals
Reproductive Health Topics Publications & Resources Professional Education Newsroom Membership Policy & Advocacy About Us
Quick Reference Guide for Clinicians
Send To A Friend Send To A Friend Bookmark this Page Share this page
Choosing a Birth Control Method

(Updated June 2014)

Combined Hormonal Contraception: General Information

Benefits of Combined Hormonal Contraception

The term "combined hormonal contraception" refers to methods that include both an estrogen (often ethinyl estradiol) and a progestin (of which several are available). In addition to protecting women from pregnancy, combined hormonal contraceptives have some non-contraceptive benefits, which include:

  • Menstrual-related health benefits, such as:
    • Decreased dysmenorrhea9
    • Decreased menstrual blood loss and anemia10
    • Possible reduction of premenstrual syndrome (PMS) symptoms11
  • Other gynecological health benefits, such as decreased risk of:
    • Ectopic pregnancies
    • Endometrial and ovarian cancer12
    • Benign breast conditions
    • Pelvic inflammatory disease (PID)
  • Non-gynecological benefit:
    • Effective in reducing acne13

Risks

  • The risk of venous thromboembolism (VTE) is increased with use of combined oral contraceptives (COCs). However, the annual risk is low (1.0–3.0/10,000 women) and approximately half that associated with pregnancy (5.9/10,000).14
  • The CDC updated its recommendations in 2011 to state that postpartum women should not use combined hormonal contraceptives during the first 21 days after delivery because of high risk for VTE during this period. During days 21-42 postpartum, women without risk factors for VTE can generally initiate combined hormonal contraceptives. Women with risk factors for VTE, such as VTE or recent cesarean delivery, generally should not use these methods. After 42 days postpartum, no restrictions on the use of combined hormonal contraceptives based on postpartum status apply.15
  • COC use does NOT increase the risk of breast cancer.16
  • COC use does NOT increase the risk of cardiovascular events among healthy non-smokers less than age 35 who do not have other risk factors (see box).

 

Dispelling Myths About the COCs and Cardiovascular Events17

  • The incidence of cardiovascular events is low in reproductive-age women—whether or not they are COC users.
  • The additional mortality associated with COC use among healthy women ages 40 to 44 is only 31.8 per million users per year (3.6 per million users per year for women 20 to 24 years old).
  • The mortality rate associated with COC use is low among women who are less than 35 years old—whether they smoke or not.
  • Smoking has a greater effect on mortality and the incidence of cardiovascular events than does COC use—for women of all ages.

Side Effects

  • Breakthrough and/or unscheduled bleeding may occur with COC use.
  • Some women experience breast tenderness, nausea, or bloating.
  • Many side effects disappear after the first few cycles of use.

Contraindications and Precautions

Medical Eligibility Criteria for COC Pills, Ring, and Patch.

Category 4
(unacceptable health risk if the contraceptive method is used)

  • Postpartum (<21 days postpartum)
  • Smoking if age >35 years and >15 cigarettes a day
  • Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension; possibly designated category 3 if multiple major risk factors are not present)
  • Hypertension (systolic >160 mm Hg or diastolic >100 mm Hg or with vascular disease)
  • Deep venous thrombosis/pulmonary embolism (DVT/PE)
    • Acute
    • Previous, not currently on anticoagulant therapy, with risk factors for recurrence (designated category 3 if no risk factors for recurrence)
  • Known thrombogenic mutations (e.g., protein S deficiency)
  • Ischemic heart disease or stroke (current or history of)
  • Valvular heart disease (designated category 2 if uncomplicated)
  • Peripartum cardiomyopathy (designated as category 3 if <6 or more months previously AND free of moderately or severely impaired cardiac function)
  • Systemic lupus erythematosus (SLE) (designated as category 2 if known to be negative for antiphospholipid antibodies)
  • Migraine
    • With aura
    • Without aura if age >35 years—for continuing method (designated category 3 for initiating method)
  • Current breast cancer
  • Severe cirrhosis
  • Solid organ transplantation (designated category 2 if uncomplicated)
  • Malignant liver tumor
  • Benign liver tumor (i.e., hepatocelluar adenoma; designated category 2 if focal nodular hyperplasia)
  • Diabetes with nephropathy, retinopathy, neuropathy, other vascular disease, or duration of more than 20 years (possibly designated category 3, depending on the severity of the disease)
  • Acute viral hepatitis or exacerbation—for initiating method (possibly designated category 3 depending on severity)

Category 3
(theoretical or proven risks usually outweigh the advantages of using the method)

  • Breastfeeding (if < 1 month postpartum)
  • Postpartum, breastfeeding
    • 21 to <30 days postpartum, with or without other risk factors for VTE
    • 30 to 42 days, with other risk factors for VTE
  • Postpartum, not breastfeeding, with other risks for VTE (21 to 42 days postpartum)
  • Smoking if age >35 years and <15 cigarettes a day
  • For COCs only: History of bariatric surgery with a malabsorptive procedure (e.g., gastric bypass)
  • Hypertension (adequately controlled or mildly elevated)
  • Known hyperlipidemias (possibly designated as category 2, depending on severity)
  • Migraine without aura, if age <35 years—for continuing method (designated category 2 for initiating method)
  • Breast cancer in past; no evidence of disease for five years
  • Rifampin or rifabutin therapy
  • Certain antiretroviral and anticonvulsant medications (some are designated category 2)
  • Inflammatory bowel disease (IBD) (designated as category 2 if mild IBD and no other risk factors for VTE)
  • History of cholestasis (if COC-related; designated as category 2 if pregnancy-related)
  • Gallbladder disease (designated as category 2 if asymptomatic or treated by cholecystectomy)
 

Source: See Reference 5, 18

Advantages

  • Discreet
  • Very effective
  • Rapidly reversible
  • Easy to use, start, and stop

Disadvantages

  • Requires a prescription
  • No protection against STIs