Guidelines for Prescribing Oral Contraceptives

Pre-Prescription Screening and Contraindications

The World Health Organization recommends assessing for absolute contraindications using the WHO Medical Eligibility Criteria (Category 4 conditions where contraceptive use represents unacceptable health risk) 2, 3
The American Academy of Dermatology states that absolute contraindications for oral contraceptives include current pregnancy, age ≥35 years AND heavy smoking (≥15 cigarettes/day), hypertension with systolic ≥160 mm Hg or diastolic ≥100 mm Hg, history of or current deep vein thrombosis or pulmonary embolism, ischemic heart disease (history or current), history of cerebrovascular accident, migraine with focal neurologic symptoms at any age, or migraine without aura if age ≥35 years, current breast cancer, active viral hepatitis, severe decompensated cirrhosis, or liver tumor, and diabetes with end-organ damage or ≥20 years duration 4
The World Health Organization recommends that breastfeeding women <6 weeks postpartum should not use oral contraceptives 2, 3

The American College of Obstetricians and Gynecologists recommends initiating a combined oral contraceptive containing 20-30 μg ethinyl estradiol with levonorgestrel or norethisterone, taken daily for 21 days followed by 7 hormone-free days 1
The Stroke journal reports that the estrogen dose directly correlates with stroke risk - for every 10 μg increase in ethinyl estradiol, there is a 19% increased odds of stroke (OR 1.19, 95% CI 1.16-1.23) 5

The Stroke journal recommends that for women with specific stroke risk factors (age >35 years, tobacco use, hypertension, or migraine with aura), progestin-only contraception or non-hormonal methods are preferred to avoid estrogen-related stroke risk 5
The Blood Reviews journal recommends that for women with premature ovarian insufficiency requiring contraception, the first choice is 17β-estradiol-based combined oral contraceptives with nomegestrol acetate or dienogest 6

The Centers for Disease Control and Prevention recommends that if one pill is late (<24 hours), take the late pill immediately and continue regular schedule (may take 2 pills same day) 7, 1
The Centers for Disease Control and Prevention recommends that if one pill is missed (24-48 hours late), take the most recent missed pill immediately (discard other missed pills) and use backup contraception (condoms) or avoid intercourse for 7 consecutive days 7, 1
The Centers for Disease Control and Prevention recommends that if two or more consecutive pills are missed (≥48 hours late), take the most recent missed pill immediately (discard other missed pills) and use backup contraception for 7 consecutive days 7, 1

The Centers for Disease Control and Prevention recommends that higher-dose pills (30 μg) provide better ovulation suppression than 20 μg formulations when pills are missed, though this must be balanced against increased stroke risk with higher estrogen doses 7, 1, 5
The American College of Obstetricians and Gynecologists recommends monitoring blood pressure during routine follow-up visits and no routine follow-up visits are required, but women should return for side effects or method change 1