Contraception Guidelines for Women with Endometriosis and Migraine with Aura

Introduction to Contraceptive Options

The American Heart Association/American Stroke Association recommends progestin-only contraceptives or copper IUD as safe options for women with endometriosis and migraine with aura, due to the significantly elevated stroke risk associated with estrogen-containing contraceptives 1, 2, 3

Age >35 years increases baseline stroke risk, as stated by the American Heart Association 1, 2
Migraine with aura independently increases stroke risk 2.5-fold (RR 2.51; 95% CI 1.52-4.14) 4
Endometriosis increases stroke risk by 11-34% (RR 1.11; 95% CI 1.02-1.20), according to the American Heart Association 1, 2

Progestin-only contraceptives carry no increased stroke risk and are recommended for patients with multiple stroke risk factors, as stated by the American Heart Association 1, 2, 3
The levonorgestrel IUD is the optimal choice for women with endometriosis, as it addresses both contraception and endometriosis-related pain simultaneously 3

Irregular bleeding patterns are common with progestin-only methods, and can be managed with NSAIDs or short courses of low-dose estrogen, as recommended by the Centers for Disease Control and Prevention 5
Screening for and aggressively managing hypertension is crucial, as endometriosis patients have higher rates of hypertension, according to the American Heart Association 1, 2
Absolute prohibition of tobacco use is necessary, as smoking combined with migraine and any hormonal contraception creates catastrophic stroke risk, as stated by the American Heart Association 4

The 2024 AHA/ASA guidelines mandate shared decision-making for patients with stroke risk factors considering contraception, including discussion of absolute contraindication to estrogen-containing methods and presentation of progestin-only options, as recommended by the American Heart Association 1, 2, 3