Is the use of hormonal contraception safe for women older than 35 years?

Yes, in non-smoking, healthy women over 35, there appears to be no increased risk of heart attack or stroke. Perimenopausal women may benefit from the positive effects of estrogen on bone mineral density and vasomotor symptoms. In addition, women on oral contraceptives have a reduced risk for endometrial and ovarian cancers. Data on the impact of oral contraceptives on breast cancer risk in women in their late 40’s and 50’s are limited. However, these benefits must be weighed against the increase in risk for venous thrombosis which increases with age, particularly for women over the age of 40. Therefore, caution should be used for women who are obese or have other cardiovascular risk factors.

Is hormonal contraception safe for women who smoke cigarettes?

Studies carried out in the 1960s-1980s showed an increased rate of heart attack among women cigarette smokers who took oral contraceptives containing 50mcg of estrogen compared with women who did not smoke or did not take oral contraceptives. More recent large case-control studies in the U.S. with lower estrogen pills found no evidence that there was an increased risk for heart attack or stroke. However, few women were over 35 or smoked since fewer women in the US today smoke. A Dutch study found that oral contraceptive use combined with smoking carried twice the risk of heart attack as smoking alone. Thus, it is recommended that oral contraceptives not be prescribed to women over 35 who smoke.

What hormonal contraceptives are appropriate for postpartum and nursing women?

Postpartum women are in a hypercoagulable state and are at increased risk for thromboemoblic events, including stroke, for weeks postpartum. It is recommended that non-breastfeeding women defer use of an estrogen-containing hormonal contraceptive until 4 weeks postpartum. Progestin-only oral contraceptives (including the “mini-pill”) may be initiated safely immediately after delivery, however product inserts recommend waiting until 6 weeks for nursing mothers. Progestin-only pills do not impair lactation and may increase the quality of lactation. Very small amounts of progestin pass into the breast milk, and no adverse effects on infant growth have been observed.

Traditionally, combination oral contraceptives (containing both progesterone and estrogen) have not been recommended for breastfeeding women because of concerns that estrogens may reduce milk production and the caloric and mineral content of breast milk. However, use of combination oral contraceptives by well-nourished women does not appear to result in infant development problems.

Kimberly Pearson, MD

ACOG Practice Bulletin. Use of Hormonal Contraception in Women with Coexisting Medical Conditions. Obstet Gynecol 2006 Jun;107(6):1453-72.

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