The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations."
The following recommendations are based on good and consistent scientific evidence (Level A):
- A history of benign breast disease or a positive family history of breast cancer should not be regarded as contraindications to oral contraceptive use.
- Combination oral contraceptives are safe for women with mild lupus who do not have antiphospholipid antibodies.
- Combination contraceptives are not recommended for women with a documented history of unexplained venous thromboembolism or venous thromboembolism associated with pregnancy or exogenous estrogen use, unless they are taking anticoagulants.
- Combination oral contraceptives should be prescribed with caution, if ever, to women who are older than 35 years and are smokers.
- Use of the levonorgestrel intrauterine system is appropriate for women with diabetes without retinopathy, nephropathy, or other vascular complications.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Healthy, nonsmoking women doing well on a combination contraceptive can continue their method until the ages of 50 to 55 years, after weighing the risks and benefits.
- Progestin-only oral contraceptives and depot medroxyprogesterone (DMPA) can be initiated safely at 6 weeks postpartum in lactating women and immediately postpartum in nonbreastfeeding women.
- Combination contraceptives are not recommended as the first choice for breastfeeding women because of the possible negative impact of contraceptive doses of estrogen on lactation. However, use of combination contraceptives by well-nourished breastfeeding women does not appear to result in infant development problems; therefore, their use can be considered once milk flow is well established.
- Women with well-controlled and monitored hypertension who are aged 35 years or younger are appropriate candidates for a trial of combination contraceptives, provided they are otherwise healthy, show no evidence of end-organ vascular disease, and do not smoke.
- The use of combination contraceptives by women with diabetes should be limited to such women who do not smoke, are younger than 35 years, and are otherwise healthy with no evidence of hypertension, nephropathy, retinopathy, or other vascular disease.
- The use of combination contraceptives may be considered for women with migraine headaches if they do not have focal neurologic signs, do not smoke, are otherwise healthy, and are younger than 35 years. Although cerebrovascular events rarely occur among women with migraines who use combination oral contraceptives, the impact of a stroke is so devastating that clinicians should consider the use of progestin-only, intrauterine, or barrier contraceptives in this setting.
- Because of the increased risk of venous thrombotic embolism, combination contraceptives should be used with caution in women older than 35 years who are obese.
- In women with depressive disorders, symptoms do not appear to worsen with use of hormonal methods of contraception.
- If oral contraceptives are continued before major surgery, heparin prophylaxis should be considered.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Most women with controlled dyslipidemia can use combination oral contraceptives formulated with 35 micrograms or less of estrogen. In women with uncontrolled low-density lipoprotein (LDL) cholesterol greater than 160 mg/dL, a triglyceride level greater than 250 mg/dL, or multiple additional risk factors for coronary artery disease, alternative contraceptives should be considered.
- DMPA has noncontraceptive benefits and is appropriate for women with sickle cell disease.
- Progestin-only contraceptives may be appropriate for women with coronary artery disease, congestive heart failure, or cerebrovascular disease. However, combination oral contraceptives are contraindicated in these women.
- Short- or long-term use of DMPA in healthy women should not be considered an indication for dual-energy X-ray absorptiometry (DXA) or other tests that assess bone mineral density. In adolescents, the advantages of DMPA likely outweigh the theoretical safety concerns regarding bone mineral density and fractures. However, in the absence of long-term data in this population, consideration of long-term use should be individualized.
Definitions:
Grades of Evidence
I: Evidence obtained from at least one properly designed randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Levels of Recommendations
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.
