Reproductive · Year 2 · from Reproductive
Case 2: Contraindications to Combined Hormonal Contraceptives
Clinical Image
Source: Wikipedia - Aura (symptom) - CC BY-SA 3.0
Case Presentation
A 35-year-old G2P2 woman presents requesting oral contraceptives. She has been using condoms but wants more reliable contraception. Her medical history includes migraine headaches that began 10 years ago. On further questioning, she reports that her migraines are preceded by visual disturbances including flashing lights and zigzag lines that last about 20 minutes before the headache begins. She smokes half a pack of cigarettes daily and has been trying to quit. She has no history of blood clots, stroke, or heart disease. BMI is 26. The provider explains that she has two Category 4 contraindications to combined hormonal contraceptives (CHCs) per the US Medical Eligibility Criteria: migraine with aura (at any age) and smoking more than 15 cigarettes daily at age 35 or older. Migraine with aura increases ischemic stroke risk, and CHCs further elevate this risk. Alternative contraceptive options are discussed. She is counseled about progestin-only methods, which are safe for women with migraine with aura. She chooses the etonogestrel implant (Nexplanon), which is placed at the same visit. She is also provided with smoking cessation resources. At follow-up, she reports no change in her migraine pattern and is satisfied with the implant.
Key Learning Points
- Combined hormonal contraceptives are contraindicated (US MEC Category 4) in women with migraine with aura at any age due to significantly increased ischemic stroke risk
- Other Category 4 contraindications include history of VTE/PE, thrombogenic mutations, current or recent breast cancer, severe hypertension, and smoking 15+ cigarettes daily at age 35 or older
- Progestin-only methods (implant, injection, IUD, progestin-only pills) are safe alternatives for women with CHC contraindications
- The US Medical Eligibility Criteria (MEC) provides guidance on contraceptive safety based on medical conditions