Perfect health eludes many women in their reproductive years. And those who have medical problems may be at risk for significant maternal as well as fetal complications if they become pregnant. This doesn’t mean that they shouldn’t plan a future pregnancy; however, their underlying condition should be appropriately treated and once pregnant these women should be monitored by the right medical and prenatal team. Writing a prescription for a birth control pill, deciding on “just” barrier methods or inserting a form of long term contraception should not simply be tailored to a woman’s personal goals of when and if to get pregnant; contraceptive planning should also address her medical problems.
I have a mental check list of the do’s and don’ts for contraceptive prescriptions which I thought I might share with you in this website article. I’ve listed the medical problems that many women encounter and under each heading, what can, cannot (or maybe should not) be used to prevent conception. Obviously, there are myriad medical problems that women can develop during their reproductive years, I’ve tried to stick to the most frequent. (This is where I put in the “proclaimer” and disclaimer….if you have a medical condition that could impact your birth control methods speak to your doctor!)
There are multiple studies about diabetes and contraception, which I won’t list ….but the general consensus is that oral contraceptive pills (OCP’s) or the vaginal contraceptive ring are safe for women with diabetes. This “go for it seal” does have a few conditions, namely age less than 35, no kidney or eye disease and no smoking (smoking with diagnosed diabetes is truly stupid, but then smoking in general is ….OK I won’t start on this again). IUC’s (intrauterine contraception) such as the Paragard and Mirena, as well as progesterone-only-pills (POP’s), Depot Provera injections (DMPA) and progestin implants are safe and indeed they may be better choices for a diabetic woman who has any of the above mentioned risk factors.
Unfortunately, this includes 35% of adult women in the US. A recent review of all the evidence seems to indicate that the efficacy of OCP’s may be mildly reduced in overweight and obese women. They are, however, more effective than barrier methods. Obese women have a 3 fold increase in their risk for dangerous clot formation (venous thromboembolism or VTE) compared to their svelter counterparts. I know there are frequent claims of “class actions” for stroke and heart attack “due” to OCP’s. The risk of that VTE is still much less with OCP’s then with pregnancy. If an obese woman is interested in long term contraception I suggest an IUC, either the Paragard or Mirena. Their safety and effectiveness are not compromised by weight.
There is concern that the efficacy of oral contraceptive pills may decrease after gastric bypass (bariatric) surgeries due to limited absorption. For those patients, I suggest a contraceptive vaginal ring (NuvaRing) or an IUC.
We all get headaches, especially tension headaches. (I have one now as I contemplate all I have to do before the holiday.) Tension headaches do not increase our risk for stroke and have no impact on the safety of any of the contraceptive methods….the real headache will occur if birth control is not used or fails!
Migraines are another story…Women with simple migraines have a 2.5 to 3 fold increase in their risk of stroke regardless of whether they use OCP’s or other forms of birth control. I do prescribe OCP’s to my patients who suffer from “simple” migraines. (I am not denigrating their headaches; the word “simple” means there is no concomitant aura). Studies have shown that OCP’s don’t make a difference to their risk of stroke.
Most women of reproductive age who are migrainers experience their headaches during their periods. The hormonal decline that occurs before the menses (especially estrogen) may instigate the migraine. For those women who have menstrual migraines, I prescribe the active birth control pills (containing estrogen and progestin) continuously. If they experience frequent breakthrough bleeding I may suggest that they take the active pills just 3 weeks a month (which is the way most pills are packaged) and prescribe an estrogen patch for the days that they are on the placebo in their pill pack,when they get their “period”.
Migraine with aura carries a higher risk of stroke than a simple migraine. So in general, most physicians will not prescribe OCP’s if there is a history of aura and/or additional risk factors, such as smoking or age over 35. (Maybe this is the time to state that smokers are, in general, at risk for stroke and heart attack but even more so with OCP’s….and if a woman who smokes is also over 35, the Pill is a ‘No No”. I have often stated that OCP’s should be over-the-counter and cigarettes should be available by prescription only! I just can’t seem to stop my antismoking campaign.
There are no contraindications to using IUC’s, progestin-only methods and barrier methods in women with migraines.
Many of the antiepileptic drugs (AED’s) induce a hepatic enzyme system called P-450 which can increase the clearance of contraceptive hormones, causing them to be less effective. It may be necessary to use a somewhat higher dose of the Pill if a woman takes an AED. Injections of Depo-Provera, or an IUC might be a more secure form of contraception. It’s extremely important that reliable contraception be used, since some of the AED’s can cause fetal malformations if an inadvertent pregnancy occurs.
Women younger than 35 with well controlled hypertension can use OCP’s as long as they don’t smoke and have no known kidney or heart disease. Progestin-only meds are also fine, as are IUC’s.
OCP’s do not increase HIV progression. However, once a woman begins antiretroviral therapy this medication may alter the blood level of the hormones in the Pill. Moreover, the OCP’s can impact the level of the medication. This is when a consult with an HIV expert is needed. IUC’s are felt to be safe. (I just noticed that I am using a lot of initials, sorry but they do shorten the text.)
There is always concern about the risk of transmission to uninfected partners. So no matter what a woman who is HIV positive uses, she should use condoms.
Bottom line: In most instances, a medical problem does not “disenfranchise” our usual types of contraception. On the contrary, it makes use of appropriate birth control more important than ever!