Editing Combined oral contraceptive pill (section)

==Contraindications==
While combined oral contraceptives are generally considered to be a relatively safe medication, they are contraindicated for those with certain medical conditions. The [[World Health Organization]] and the US [[Centers for Disease Control and Prevention]] publish guidance, called [[Medical Eligibility Criteria for Contraceptive Use|medical eligibility criteria]], on the safety of birth control in the context of medical conditions.<ref name="who mec" /><ref name="pmid27467196" />

In terms of protection in [[sexual intercourse]], a sole reliance on hormonal oral contraceptives does not defend one from [[sexually transmitted infection]]s such as [[HPV]].<ref name=":0a" /><ref name=":4a" /> Additionally, [[breakthrough bleeding]] and spotting are exceptionally prevalent in the early stage of using hormonal oral contraceptives.<ref name=":0a" /><ref name=":2a" /><ref name=":4a" /> Although most reported side effects including [[nausea]], [[headache]], or [[mood swing]]s will disappear as the therapy progresses or upon switching formulation, [[elevated blood pressure]] or [[blood clots]] in patients with [[cardiovascular conditions]] are documented side effects that requires medical attention if not termination of hormonal oral contraceptives.<ref name=":0a" /><ref name=":2a" /><ref name=":4a" /> It is because combined oral contraceptives uses have been found to be related to an increased risk of [[Stroke|ischemic stroke]] or [[myocardial infarction]], especially in combined oral contraceptives with >50 μg Oestrogen.<ref>{{cite journal |last1=Roach |first1=Rachel E. J. |last2=Helmerhorst |first2=Frans M. |last3=Lijfering |first3=Willem M. |last4=Stijnen |first4=Theo |last5=Algra |first5=Ale |last6=Dekkers |first6=Olaf M. |title=Combined oral contraceptives: the risk of myocardial infarction and ischemic stroke |journal=The Cochrane Database of Systematic Reviews |date=27 August 2015 |volume=2015 |issue=8 |pages=CD011054 |doi=10.1002/14651858.CD011054.pub2 |pmid=26310586 |pmc=6494192 |issn=1469-493X}}</ref>
Besides, some ongoing studies giving evidence on the association between hormonal oral contraceptive use and escalated [[breast cancer]] risks cannot be neglected.<ref>{{Cite journal |last1=Fitzpatrick |first1=Danielle |last2=Pirie |first2=Kirstin |last3=Reeves |first3=Gillian |last4=Green |first4=Jane |last5=Beral |first5=Valerie |date=March 2023 |title=Combined and progestagen-only hormonal contraceptives and breast cancer risk: A UK nested case-control study and meta-analysis |journal=PLOS Medicine |volume=20 |issue=3 |pages=e1004188 |doi=10.1371/journal.pmed.1004188 |doi-access=free |issn=1549-1676 |pmid=36943819|pmc=10030023 }}</ref><ref>{{Cite journal |last1=Anastasiou |first1=Elle |last2=McCarthy |first2=Katharine J. |last3=Gollub |first3=Erica L. |last4=Ralph |first4=Lauren |last5=van de Wijgert |first5=Janneke H. H. M. |last6=Jones |first6=Heidi E. |date=March 2022 |title=The relationship between hormonal contraception and cervical dysplasia/cancer controlling for human papillomavirus infection: A systematic review |journal=Contraception |volume=107 |pages=1–9 |doi=10.1016/j.contraception.2021.10.018 |issn=1879-0518 |pmc=8837691 |pmid=34752778}}</ref><ref name=":5a">{{Cite journal |last1=Huber |first1=D. |last2=Seitz |first2=S. |last3=Kast |first3=K. |last4=Emons |first4=G. |last5=Ortmann |first5=O. |date=April 2020 |title=Use of oral contraceptives in BRCA mutation carriers and risk for ovarian and breast cancer: a systematic review |journal=Archives of Gynecology and Obstetrics |volume=301 |issue=4 |pages=875–884 |doi=10.1007/s00404-020-05458-w |issn=1432-0711 |pmc=8494665 |pmid=32140806}}</ref><ref name=":6a">{{Cite journal |last1=van Bommel |first1=Majke H. D. |last2=IntHout |first2=Joanna |last3=Veldmate |first3=Guus |last4=Kets |first4=C. Marleen |last5=de Hullu |first5=Joanne A. |last6=van Altena |first6=Anne M. |last7=Harmsen |first7=Marline G. |date=2023-03-01 |title=Contraceptives and cancer risks in BRCA1/2 pathogenic variant carriers: a systematic review and meta-analysis |journal=Human Reproduction Update |volume=29 |issue=2 |pages=197–217 |doi=10.1093/humupd/dmac038 |issn=1460-2369 |pmc=9976973 |pmid=36383189}}</ref>

According to [[World Health Organization|WHO]] Medical Eligibility Criteria for Contraceptive Use 2015, Category 3 implies that the use of such contraception is usually not recommended, unless other more appropriate methods are neither available nor acceptable and with good resources of clinical judgment; Category 4 implies that the contraceptive method should not be used even with good resources of clinical judgment.<ref name=":13a">{{Cite web |title=Medical eligibility criteria for contraceptive use |url=https://www.who.int/publications-detail-redirect/9789241549158 |access-date=2024-02-28 |website=[[World Health Organization]] (WHO) }}</ref> Both categories suggest that the contraceptive method should not be used with limited resources for clinical judgment.<ref name=":13a" /> The tables below summarise conditions of category 3 and 4 from [[World Health Organization]] Medical Eligibility Criteria for Contraceptive Use 2015.

=== Precautions and contraindications for combined oral contraceptives ===
{| class="wikitable"
|+
!Condition
!Category
|-
| colspan="2" |[[Breastfeeding]]
|-
|''for < 6 weeks postpartum''
|4
|-
|''for ≥  6 weeks to < 6 months postpartum''
|3
|-
| colspan="2" |[[Postpartum period|Postpartum]] (non-breastfeeding)
|-
|''< 21 days postpartum without other risk factors for [[Venous thromboembolic disease|VTE]]''
|3
|-
|''< 21 days postpartum with other risk factors for VTE''
|4
|-
|''≥  21 days to 42 days postpartum with other risk factors for VTE''
|3
|-
| colspan="2" |Smoking
|-
|''age ≥ 35 years and smoking < 15 cigarettes/day''
|3
|-
|''age ≥ 35 years and smoking ≥ 15 cigarettes/day''
|4
|-
|Multiple risk factors for [[Vascular disease|arterial cardiovascular disease]]
|3/4*
|-
| colspan="2" |[[Hypertension]]
|-
|''history of hypertension, where blood pressure CANNOT be evaluated''
|3
|-
|''adequately controlled hypertension, where blood pressure CAN be evaluated''
|3
|-
|''elevated blood pressure levels (properly taken measurements)''
''with systolic 140–159 or diastolic 90–99 mm Hg''
|3
|-
|''elevated blood pressure levels (properly taken measurements)''
''with systolic ≥ 160 or diastolic ≥ 100 mm Hg''
|4
|-
|''elevated blood pressure levels (properly taken measurements) with [[Vascular disease]]''
|4
|-
| colspan="2" |[[Deep vein thrombosis]] (DVT) / [[Pulmonary embolism]] (PE)
|-
|''with History of DVT/PE''
|4
|-
|''with acute DVT/PE''
|4
|-
|''with DVT/PE and established on [[anticoagulant]] therapy''
|4
|-
|''with Major surgery with prolonged immobilization''
|4
|-
|Known thrombogenic mutations
|4
|-
|Current and history of [[Coronary artery disease|ischemic heart disease]]
|4
|-
|[[Stroke]] (history of cerebrovascular accident)
|4
|-
|Complicated [[valvular heart disease]]
|4
|-
|Positive (or unknown) antiphospholipid antibodies [[Systemic lupus erythematosis|Systemic Lupus Erythematous]]
|4
|-
| colspan="2" |Headache
|-
|''migraine without aura of age ≥  35 years (for initiation of combined oral contraceptives)''
|3
|-
|''migraine without aura of age < 35 years (for continuation of combined oral contraceptives)''
|3
|-
|''migraine without aura of age ≥ 35 years (for continuation of combined oral contraceptives)''
|4
|-
|''migraine with aura, at any age (for initiation and continuation of combined oral contraceptives)''
|4
|-
|Breast cancer
|
|-
|''current Breast cancer''
|4
|-
|''past Breast Cancer and no evidence of current disease for 5 years''
|3
|-
|[[Kidney disease|Nephropathy]]/[[retinopathy]]/[[Peripheral neuropathy|neuropathy]]
|3/4*
|-
|Other vascular disease or [[diabetes]] of > 20 years’ duration
|3/4*
|-
|Medically treated symptomatic [[Gallbladder disease|gall bladder disease]]
|3
|-
|Current symptomatic gall bladder disease
|3
|-
|Past-combined oral contraceptive related history of [[Cholestasis]]
|3
|-
|Acute or flare [[viral hepatitis]] (for initiation of combined oral contraceptives)
|3/4*
|-
|Severe [[cirrhosis]] (decompensated)
|4
|-
| colspan="2" |Liver tumors
|-
|''[[hepatocellular adenoma]]''
|4
|-
|''malignant (hepatoma)''
|4
|-
| colspan="2" |On [[anticonvulsant]] therapy
|-
|''with [[phenytoin]], [[carbamazepine]], [[barbiturate]]s, [[primidone]], [[topiramate]], [[oxcarbazepine]]''
|3
|-
|''with [[Lamotrigine]]''
|3
|-
|On [[antimicrobial]] therapy with [[Rifampicin]] or [[rifabutin]] therapy
|
|}
<nowiki>*</nowiki>The category should be assessed according to the severity of the condition.

===Hypercoagulability===

Estrogen in high doses can increase risk of blood clots. All combined oral contraceptive pill users have a small increase in the risk of venous thromboembolism compared with non-users; this risk is greatest within the first year of combined oral contraceptive pill use.<ref name=":6">{{cite journal | vauthors = Black A, Guilbert E, Costescu D, Dunn S, Fisher W, Kives S, Mirosh M, Norman WV, Pymar H, Reid R, Roy G, Varto H, Waddington A, Wagner MS, Whelan AM | title = No. 329-Canadian Contraception Consensus Part 4 of 4 Chapter 9: Combined Hormonal Contraception | journal = Journal of Obstetrics and Gynaecology Canada | volume = 39 | issue = 4 | pages = 229–268.e5 | date = April 2017 | pmid = 28413042 | doi = 10.1016/j.jogc.2016.10.005 }}</ref> Individuals with any pre-existing medical condition that also increases their risk for blood clots have a more significant increase in risk of thrombotic events with combined oral contraceptive pill use.<ref name=":6" /> These conditions include but are not limited to high blood pressure, pre-existing [[cardiovascular disease]] (such as [[valvular heart disease]] or [[Coronary artery disease|ischemic heart disease]]<ref name=":4">{{cite book|vauthors=Cooper DB, Patel P, Mahdy H|chapter=Oral Contraceptive Pills|date=2019|chapter-url=http://www.ncbi.nlm.nih.gov/books/NBK430882/|title=StatPearls|publisher=StatPearls Publishing|pmid=28613632|access-date=5 August 2019|archive-date=3 May 2019|archive-url=https://web.archive.org/web/20190503071035/https://www.ncbi.nlm.nih.gov/books/NBK430882/|url-status=live}}</ref>), history of thromboembolism or pulmonary embolism, cerebrovascular accident, and a familial tendency to form blood clots (such as familial [[factor V Leiden]]).<ref name="webmdbcp2">{{cite web|url=http://www.webmd.com/sex/birth-control/birth-control-pills?page=5#1|title=Can Any Woman Take Birth Control Pills?|website=WebMD|access-date=8 May 2016|archive-date=3 May 2016|archive-url=https://web.archive.org/web/20160503120843/http://www.webmd.com/sex/birth-control/birth-control-pills?page=5#1|url-status=live}}</ref> There are conditions that, when associated with combined oral contraceptive pill use, increase risk of adverse effects other than thrombosis. For example, women with a history of [[migraine]] with aura have an increased risk of [[stroke]] when using combined oral contraceptive pills, and women who [[Tobacco smoking|smoke]] over age 35 and use combined oral contraceptive pills are at higher risk of [[myocardial infarction]].<ref name="who mec" />

===Pregnancy and postpartum===

Women who are known to be pregnant should not take combined oral contraceptive pills. Those in the postpartum period who are [[breastfeeding]] are also advised not to start combined oral contraceptive pills until 4 weeks after birth due to increased risk of blood clots.<ref name=":22" /> While studies have demonstrated conflicting results about the effects of combined oral contraceptive pills on lactation duration and milk volume, there exist concerns about the transient risk of combined oral contraceptive pills on breast milk production when breastfeeding is being established early postpartum.<ref>{{cite journal | vauthors = Lopez LM, Grey TW, Stuebe AM, Chen M, Truitt ST, Gallo MF | title = Combined hormonal versus nonhormonal versus progestin-only contraception in lactation | journal = The Cochrane Database of Systematic Reviews | issue = 3 | pages = CD003988 | date = March 2015 | volume = 2015 | pmid = 25793657 | doi = 10.1002/14651858.CD003988.pub2 | collaboration = Cochrane Fertility Regulation Group | pmc = 10644229 }}</ref> Due to the stated risks and additional concerns on lactation, women who are breastfeeding are not advised to start combined oral contraceptive pills until at least six weeks postpartum, while women who are not breastfeeding and have no other risks factors for blood clots may start combined oral contraceptive pills after 21 days postpartum.<ref>{{cite web|date=9 April 2020|title=Classifications for Combined Hormonal Contraceptives|url=https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixd.html|access-date=7 December 2020|website=U.S. [[Centers for Disease Control and Prevention]] (CDC)|archive-date=27 November 2020|archive-url=https://web.archive.org/web/20201127184611/https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixd.html|url-status=live}}</ref><ref name="who mec">{{cite book|url=https://www.who.int/publications/i/item/9789241549158|title=Medical eligibility criteria for contraceptive use|publisher=World Health Organization|year=2015|isbn=978-92-4-154915-8|edition=Fifth|location=Geneva, Switzerland|oclc=932048744|hdl=10665/181468|hdl-access=free|vauthors=((World Health Organization))|author-link=World Health Organization|access-date=11 February 2024|archive-date=11 February 2024|archive-url=https://web.archive.org/web/20240211070350/https://www.who.int/publications/i/item/9789241549158|url-status=live}}</ref>

===Breast cancer===

The [[World Health Organization]] (WHO) does not recommend the use of combined oral contraceptive pills in women with breast cancer.<ref name="pmid27467196">{{cite journal |vauthors=Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG, Zapata LB, Simmons KB, Pagano HP, Jamieson DJ, Whiteman MK |date=July 2016 |title=U.S. Medical Eligibility Criteria for Contraceptive Use, 2016 |url=https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf |journal=MMWR. Recommendations and Reports |volume=65 |issue=3 |pages=1–103 |doi=10.15585/mmwr.rr6503a1 |pmid=27467196 |issn=1057-5987 |doi-access=free |title-link=doi |access-date=11 February 2024 |archive-date=16 October 2020 |archive-url=https://web.archive.org/web/20201016231003/https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf |url-status=live }}</ref><ref>{{cite journal | vauthors = Tepper NK, Curtis KM, Cox S, Whiteman MK | title = Update to U.S. Medical Eligibility Criteria for Contraceptive Use, 2016: Updated Recommendations for the Use of Contraception Among Women at High Risk for HIV Infection | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 69 | issue = 14 | pages = 405–410 | date = April 2020 | pmid = 32271729 | pmc = 7147901 | doi = 10.15585/mmwr.mm6914a3 | url = https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6914a3-H.pdf | doi-access = free | title-link = doi | access-date = 11 February 2024 | archive-date = 9 June 2023 | archive-url = https://web.archive.org/web/20230609055201/https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6914a3-H.pdf | url-status = live }}</ref> Since combined oral contraceptive pills contain both estrogen and progestin, they are not recommended to be used in those with hormonally-sensitive cancers, including some types of breast cancer.<ref>{{cite web |title=Is There a Link Between Birth Control Pills and Higher Breast Cancer Risk? |url=https://www.breastcancer.org/research-news/study-questions-birth-control-and-risk |access-date=18 September 2022 |website=www.breastcancer.org |archive-date=20 September 2022 |archive-url=https://web.archive.org/web/20220920171723/https://www.breastcancer.org/research-news/study-questions-birth-control-and-risk |url-status=live }}</ref>{{Unreliable medical source|date=February 2024}}<ref>{{cite web |last=Pernambuco-Holsten |first=Christina |title=Birth Control and Cancer Risk: 6 Things You Should Know |url=https://www.mskcc.org/news/birth-control-and-cancer-risk |access-date=18 September 2022 |website=Memorial Sloan Kettering Cancer Center |date=25 September 2018 |archive-date=20 September 2022 |archive-url=https://web.archive.org/web/20220920173430/https://www.mskcc.org/news/birth-control-and-cancer-risk |url-status=live }}</ref> Non-hormonal contraceptive methods, such as the Copper IUD or condoms,<ref>{{cite web |title=What are the best birth control options that aren't hormonal? |url=https://www.plannedparenthood.org/learn/ask-experts/what-are-the-best-birth-control-options-that-arent-hormonal |access-date=18 September 2022 |website=Planned Parenthood |archive-date=20 September 2022 |archive-url=https://web.archive.org/web/20220920171208/https://www.plannedparenthood.org/learn/ask-experts/what-are-the-best-birth-control-options-that-arent-hormonal |url-status=live }}</ref> should be the first-line contraceptive choice for these patients instead of combined oral contraceptive pills.<ref>{{cite web |title=Do Hormonal Contraceptives Increase Breast Cancer Risk? |url=https://www.breastcancer.org/research-news/do-hormonal-contraceptives-increase-risk |access-date=18 September 2022 |website=www.breastcancer.org |archive-date=20 September 2022 |archive-url=https://web.archive.org/web/20220920172638/https://www.breastcancer.org/research-news/do-hormonal-contraceptives-increase-risk |url-status=live }}</ref>{{Unreliable medical source|date=February 2024}}

===Other===

Women with known or suspected [[endometrial cancer]] or unexplained uterine bleeding should also not take combined oral contraceptive pills to avoid health risks.<ref name=":4" /> Combined oral contraceptive pills are also contraindicated for people with advanced diabetes, liver tumors, [[hepatic adenoma]] or severe [[cirrhosis]] of the liver.<ref name="pmid27467196" /><ref name="webmdbcp2" /> Combined oral contraceptive pills are metabolized in the liver and thus liver disease can lead to reduced elimination of the medication. Additionally, severe [[hypercholesterolemia]] and [[hypertriglyceridemia]] are also contraindications, but the evidence showing that combined oral contraceptive pills lead to worse outcomes in this population is weak.<ref name=":13" /><ref name=":22" /> [[Obesity]] is not considered to be a contraindication to taking combined oral contraceptive pills.<ref name=":22" />