Best Oral Contraceptive for Mood Swings with Lowest Thrombosis Risk

Thrombosis Risk Hierarchy

The American College of Cardiology recommends levonorgestrel IUD and progestin-only pills as the lowest risk options for thrombosis, with no increase in VTE risk (RR 0.61 and 0.90 respectively) 1
The American Academy of Dermatology suggests that combined oral contraceptives with levonorgestrel have a lower VTE risk than newer progestins, but still 3-9 per 10,000 woman-years 2
Blood Reviews indicate that low-dose ethinyl estradiol (≤20 mcg) with levonorgestrel shows a safer coagulation profile, with a lower VTE risk 3, 4

The American College of Cardiology recommends assessing thrombosis risk factors, including high-risk conditions such as cyanosis, Fontan physiology, mechanical valves, prior thrombotic events, pulmonary arterial hypertension, and antiphospholipid antibodies, and using levonorgestrel IUD or progestin-only pill if any high-risk factor is present 6, 1
For standard-risk patients with mood swings, the first choice is levonorgestrel IUD, which addresses both concerns optimally, followed by progestin-only pill, and then combined pill with ≤20 mcg ethinyl estradiol and levonorgestrel 1, 3, 4

The American College of Cardiology absolutely contraindicates estrogen-containing contraceptives in patients with antiphospholipid antibodies, cyanotic congenital heart disease, prior thrombotic events, Fontan physiology, and pulmonary arterial hypertension 1, 6, 7
The American College of Cardiology also contraindicates DMPA in patients with thrombosis risk factors, antiphospholipid antibodies, chronic coronary disease, or previous stroke 5, 1