Hormonal contraception itself increases the risk of developing thromboembolic disease 3-4 times. Both estrogenic and progestogen component of hormonal contraceptive, are involved at increased risk.
Contraindications of hormonal contraception
Women with inherited thrombophilia are at higher risk of developing thromboembolic disease, especially with the use of estrogenic-progestin contraception and during pregnancy. When deciding on contraceptive, women with thrombophilia must consider the risk of thromboembolism formation in connection with various types of hormonal contraception and the health complications related to an unplanned pregnancy caused by less effective contraceptive methods. Also with regard to psychosocial problems in the event of an unwanted pregnancy – especially for young girls and women – as well as with respect to a significantly higher risk of thromboembolic disease potentially cause by hormonal contraception. In any case, it must be done by individual decisions with a thorough discussion of the risks and benefits.
Patients with their own or a family history of thromboembolism or thrombophilia should be tested on thrombophilias. However, the laboratory results itself reveal little about an individual’s risk.
The following constellations thrombophilia is an absolute contraindication for combined hormonal contraception, although the history of the patient and family are negative
- Factor V Leiden homozygous
- Homozygous prothrombin G20210A
- Factor V Leiden heterozygous + Prothrombine 20210
- Factor V Leiden homozygous + Prothrombine 20210
- Antithrombin deficiency (reduced level)
- Protein C deficiency – resistance to activated protein C
- Protein S deficiency
The following pathological outcome should be consulted with a specialist in internal medicine or hematologist specializing in thrombophilia:
- The presence of antiphospholipid antibodies
No data confirm that combination hormonal contraceptive is safer for patients with a history of thrombosis associated with the effects of other risk factors than for patients with idiopathic thrombosis developed spontaneously. The decision on whether the risk of recurrence of thrombosis or thromboembolism is small, should not be determined by a gynaecologist. Instead, the decision should be made in cooperation with angiologist and haematologist. In any case, such decisions can only be determined after careful analysis of the benefits and risks for the patient. Even for women with a negative family history and no laboratory-confirmed thrombophilia, who suffered thrombosis in relation to the impact of external risk factors should not be prescribed hormonal contraceptives containing estrogen, because currently there is no data showing that combined hormonal contraception containing estrogen does not increase the risk of thrombosis recurrence.
According to the World Health Organization (WHO), the first choice of contraception should be copper intrauterine device (IUD) or – if no more children are planned, sterilization of men or women. As a less preferred alternative could be considered a classic mini-pill with norethindrone or levonorgestrel or IUD containing levonorgestrel. The possible use of a depot injection with progesterone or desogestrel should be viewed with caution. Another possible method is to use condom with spermicidal gels.