Acute porphyrias p. 1120.
gallstones. heart disease associated with pulmonary
hypertension or risk of embolus. history during pregnancy
of cholestatic jaundice. history during pregnancy of
chorea. history during pregnancy of pemphigoid
gestationis. history during pregnancy of pruritus. history
of breast cancer (but can be used after 5 years if no
evidence of disease and non-hormonal methods
unacceptable). history of haemolytic uraemic syndrome.
migraine with aura. personal history of venous or arterial
thrombosis. sclerosing treatment for varicose veins.
severe or multiple risk factors for arterial disease. severe
or multiple risk factors for venous thromboembolism.
systemic lupus erythematosus with (or unknown)
antiphospholipid antibodies. transient cerebral ischaemic
attacks without headaches. undiagnosed vaginal bleeding
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Active trophoblastic disease (until return to
normal of urine- and plasma-gonadotrophin
concentration)—seek specialist advice. Crohn’s disease.
gene mutations associated with breast cancer (e.g. BRCA
1). history of severe depression especially if induced by
hormonal contraceptive. hyperprolactinaemia (seek
specialist advice). inflammatory bowel disease. migraine.
personal or family history of hypertriglyceridaemia
(increased risk of pancreatitis). risk factors for arterial
disease. risk factors for venous thromboembolism. sickle-
cell disease. undiagnosed breast mass
CAUTIONS, FURTHER INFORMATION
▶Risk of venous thromboembolism There is an increased risk of
venous thromboembolic disease in users of combined
hormonal contraceptives particularly during the first year
and possibly after restarting combined hormonal
contraceptives following a break of four weeks or more.
This risk is considerably smaller than that associated with
pregnancy (about 60 cases of venous thromboembolic
disease per 100 000 pregnancies). In all cases the risk of
venous thromboembolism increases with age and in the
presence of other risk factors, such as obesity. The risk also
varies depending on the type of progestogen.
Provided that women are informed of the relative risks
of venous thromboembolism and accept them, the choice
of oral contraceptive is for the woman together with the
prescriber jointly to make in light of her individual medical
history and any contra-indications.
Combined hormonal contraceptives also slightly
increase the risk of arterial thromboembolism; however,
there is no evidence to suggest that this risk varies
between different preparations.
▶Risk factors for venous thromboembolism Use with caution if
any of following factors present but avoid if two or more
factors present:
. family history of venous thromboembolism in first-degree
relative aged under 45 years (avoid contraceptive
containing desogestrel or gestodene, or avoid if known
prothrombotic coagulation abnormality e.g. factor V
Leiden or antiphospholipid antibodies (including lupus
anticoagulant));
. obesity; body mass index 30 kg/m2 (avoid if body mass
index 35 kg/m2 unless no suitable alternative); (in
adolescents, caution if obese according to BMI (adjusted
for age and gender); in those who are markedly obese,
avoid unless no suitable alternative);
. long-term immobilisation e.g. in a wheelchair (avoid if
confined to bed or leg in plaster cast);
. history of superficial thrombophlebitis;
. age over 35 years (avoid if over 50 years);
. smoking.
Combined Hormonal Contraception and Risk of
Venous Thromboembolism
Estimated incidence per 10 000
Progestogen in Combined
Hormonal Contraceptive
women per year of use
Non-pregnant, not using
combined hormonal
contraception
Levonorgesterol1
5–7
Norgestimate1
5–7
Norethisterone1
5–7
Etonogestrel1
6–12
Norelgestromin1
6–12
Gestodene1
9–12
Desogestrel1
9–12
Drospirenone1
9–12
Dienogest2
Not known—insufficient data
Nomegestrol2
Not known—insufficient data
1 Combined with ethinylestradiol 2 Combined with estradiol
▶Risk factors for arterial disease Use with caution if any one of
following factors present but avoid if two or more factors
present:
. family history of arterial disease in first degree relative
aged under 45 years (avoid if atherogenic lipid profile);
. diabetes mellitus (avoid if diabetes complications
present);
. hypertension; blood pressure above systolic 140 mmHg or
diastolic 90 mmHg (avoid if blood pressure above systolic
160 mmHg or diastolic 95 mmHg); (in adolescents, avoid
if blood pressure very high);
. smoking (avoid if smoking 40 or more cigarettes daily);
. age over 35 years (avoid if over 50 years);
. obesity (avoid if body mass index 35 kg/m2 unless no
suitable alternative); (in adolescents, caution if obese
according to BMI (adjusted for age and gender); in those
who are markedly obese, avoid unless no suitable
alternative);
. migraine without aura (avoid if migraine with aura (focal
symptoms), or severe migraine frequently lasting over
72 hours despite treatment, or migraine treated with
ergot derivatives).
▶Migraine Women should report any increase in headache
frequency or onset of focal symptoms (discontinue
immediately and refer urgently to neurology expert if focal
neurological symptoms not typical of aura persist for more
than 1 hour).
Combined hormonal contraceptives should be stopped
(pending investigation and treatment), if serious
neurological effects occur, including unusual severe,
prolonged headache especially if first time or getting
progressively worse or sudden partial or complete loss of
vision or sudden disturbance of hearing or other
perceptual disorders or dysphasia or bad fainting attack or
collapse or first unexplained epileptic seizure or weakness,
motor disturbances, very marked numbness suddenly
affecting one side or one part of body.
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