Contraception Guidelines for Women ≥ 35 Years Who Smoke

Contraindications to Combined Estrogen‑Progestin Contraception

Combined estrogen‑progestin pills, patches, or vaginal rings are absolutely contraindicated in all women ≥ 35 years who smoke, especially those smoking > 15 cigarettes per day【1】【2】【4】【5】【6】【7】.
The contraindication applies to all routes of administration (oral, transdermal, vaginal)【2】【8】.
In smokers > 20 cigarettes per day using combined contraception, the relative risk of myocardial infarction rises to ≈ 12.5【6】【7】【8】.
Estrogen‑containing contraception combined with smoking creates a synergistic thrombotic risk mediated by increased PAI‑1 and altered hepatic estrogen metabolism【6】【7】【8】.
The majority of coronary and cerebrovascular events in this population occur in women aged 35‑40 years, with smoking as a key contributor【2】【4】【5】【7】.

Progestin‑only pills (e.g., desogestrel 0.075 mg or norethindrone) show no increase in stroke or myocardial infarction; the relative risk for venous thromboembolism is 0.90 (95 % CI 0.57‑1.45)【3】【8】.
Levonorgestrel intrauterine device (IUD) carries no thrombosis risk, has a pregnancy rate < 1 % per year, and additionally reduces heavy menstrual bleeding【1】【3】【8】.
Etonogestrel subdermal implant provides > 99 % efficacy without estrogen‑related cardiovascular risks【3】【8】.
Depot medroxyprogesterone acetate (DMPA) does not increase stroke risk, though patients require careful follow‑up【3】【8】.
Copper IUD offers > 99 % efficacy with no hormonal or cardiovascular risk, serving as an appropriate alternative to all hormonal methods【1】【2】【5】【3】【8】.

Any smoking in women ≥ 35 years mandates exclusion of combined hormonal contraception【1】【3】.
Offer progestin‑only pills, levonorgestrel IUD, etonogestrel implant, or copper IUD as equally effective options that carry no increased cardiovascular risk【3】【8】.
If a patient quits smoking, combined hormonal contraception remains Category 2 (generally usable with careful follow‑up) for women > 45 years due to age‑related baseline cardiovascular risk【9】【3】.

Low‑dose estrogen formulations (e.g., 20 µg ethinyl estradiol) are still contraindicated for smokers ≥ 35 years【8】.
Patches and vaginal rings share the same contraindication as oral combined pills and should not be considered safer alternatives【2】【8】.
Do not delay switching from combined to progestin‑only methods when smoking continues or resumes【8】.
Light smoking (< 15 cigarettes/day) does not make combined contraception acceptable; it remains a relative contraindication【1】【2】.

Progestin‑only and non‑hormonal methods are associated with no increase in cardiovascular mortality compared with combined estrogen‑progestin products【3】【8】.

Continue contraception until menopause or age 50‑55 years (median menopause ≈ 51 years)【9】【3】.
No reliable laboratory test (e.g., follicle‑stimulating hormone) can definitively confirm loss of fertility【9】.
Pregnancy in women of advanced reproductive age carries higher maternal complications (hemorrhage, venous thromboembolism, death) and higher fetal complications (spontaneous abortion, stillbirth, congenital anomalies)【9】【3】.