Oral contraceptives are among the most prescribed medications in the world. In the United States alone, roughly one in four women between the ages of 15 and 44 who use contraception rely on the Pill as their method of choice [1]. The Pill is widely available, heavily marketed, and perhaps most importantly, often prescribed with minimal medical scrutiny.
But here’s what doesn’t get talked about nearly enough: for a significant subset of women, the combined oral contraceptive pill is not simply a neutral fertility management tool. It gets quite complicated when the medical evidence suggests, sometimes quite strongly, that the risques of taking it outweigh any potential benefit—and that for these women, something else should be recommended instead.
For a significant subset of women, the combined oral contraceptive pill is not simply a neutral fertility management tool. It gets quite complicated when the medical evidence suggests, sometimes quite strongly, that the risks of taking it outweigh any potential benefit.
A 2026 cross-sectional survey publié dans Contraception examined the prevalence of medical contraindications among women obtaining oral contraceptives over-the-counter (OTC) versus by prescription in the United States. The results were striking: among women in the prescription group, 15.5% reported at least one category 3 or 4 condition (meaning a relative or absolute contraindication) to combined oral contraceptive (COC) use [2]. And yet, many of these women were prescribed them anyway. This study, and others like it, raise an uncomfortable question: how often are birth control contraindications genuinely screened for and taken seriously in routine practice?
The WHO framework: A useful roadmap
Before diving into the specific conditions, it helps to understand the framework clinicians are supposed to be using. The World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) have both developed Medical Eligibility Criteria (MEC) for contraceptive use, most recently updated by the CDC in 2024 [3]. These criteria classify conditions on a scale of 1 to 4:
- Category 1: No restriction; method can be used.
- Category 2: Advantages generally outweigh the risks.
- Category 3: Risks generally outweigh the advantages (relative contraindication).
- Category 4: Unacceptable health risk; method should not be used (absolute contraindication).
The 2024 update expanded these criteria significantly, adding new recommendations for chronic kidney disease, solid organ transplantation, and revised guidance on thrombophilia, systemic lupus erythematosus, and liver disease [3]. This is a living framework instead of a static checklist, and it reflects an evolving body of evidence that deserves far more attention in public-facing conversations about the role of contraceptives in reproductive health.
Venous thromboembolism and clotting disorders
The relationship between combined oral contraceptives and blood clotting is perhaps the most well-documented risk in the literature. Research indicates a three- to sevenfold increase in the risk of venous thromboembolism (VTE) among COC users compared to non-users [4]. The mechanism is largely estrogen-driven: synthetic estrogens in COCs alter coagulation factors in ways that shift the balance toward a prothrombotic state.
For women who already have clotting vulnerabilities; such as known thrombophilias such as Factor V Leiden mutation, antiphospholipid syndrome, or a personal or family history of deep vein thrombosis or pulmonary embolism, combined oral contraceptives represent a category 4 contraindication [3]. The same applies to women recovering from oncologic treatment, whose residual hypercoagulability makes estrogen-containing contraceptives particularly dangerous [3].
Not all COC formulations carry equal thrombotic risk. Research comparing progestin types has found variation in thrombotic profiles across different formulations, with pills containing lower estrogen doses and certain progestins carrying a more favorable safety profile [5]. This is not a reason to dismiss the risk, however, but a reason to have a genuinely individualized conversation with your healthcare professional about your personal safety profile.
Hypertension: The most common contraindication
Among women with documented contraindications to COCs, hypertension consistently emerges as the most prevalent [2] [6]. This is not incidental. Recherche has shown that estrogen-containing contraceptives are associated with elevated blood pressure in a meaningful proportion of users, adding to an already complex cardiovascular risk profile [7].
For women with well-controlled hypertension, this sits at a category 3: a relative contraindication. For those with severe or uncontrolled hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg), it becomes category 4 [3]. The concern here is compounded: hypertension is itself a risk factor for stroke and cardiovascular events, and adding exogenous estrogen can amplify that risk considerably.
The good news (and this is genuinely good news!) is that the cardiovascular effects associated with COC use, including changes in blood pressure, are generally reversible upon discontinuation [7]. But that normalization depends on catching the problem in the first place, which requires monitoring that is not always provided.
Migraine with aura: A frequently overlooked red flag
Migraine with aura is associated with cortical spreading depression and transient ischemic events; adding estrogen-driven coagulation changes and vasoconstrictive effects from COCs to this picture substantially raises ischemic stroke risk [3]. Current guidelines from both the WHO and CDC place migraine with aura firmly in category 4 for estrogen-containing contraceptives [3]. It is generally thought that progestin-only methods including the progestin-only pill, IUDs, and implants remain safe alternatives for this population. (However, it’s worth noting, as Natural Womanhood has previously reported, that a 2025 study published in the British Medical Journal found that while heart attack and stroke risks for progestin-only pill users weren’t comme high as the same risks from combined estrogen-progestin oral contraceptives, they were still markedly higher compared to women who didn’t use any hormonal birth control.)
A 2025 study in Pharmacoepidemiology and Drug Safety examined real-world use of combined oral contraceptives among women diagnosed with migraine with aura. The findings revealed that COC use declined but did not fully cease after a migraine-with-aura diagnosis. In a UK cohort of over 142,000 reproductive-age individuals, 15% continued using COCs after their diagnosis [8]. This suggests that in practice, some women value the convenience of COC over the risks—or that they were unaware of the risks altogether. That in itself is clinically significant and worth a deeper dive.
In a UK cohort of over 142,000 reproductive-age individuals, 15% continued using COCs after their migraine-with-aura diagnosis. This suggests that in practice, some women value the convenience of COC over the risks—or that they were unaware of the risks altogether. That in itself is clinically significant and worth a deeper dive.
Liver disease and hepatic tumors
The liver is central to the metabolism of synthetic hormones. It is unsurprising, then, that liver conditions feature prominently among COC contraindications. Active viral hepatitis, decompensated cirrhosis, hepatic adenomas, and hepatocellular carcinoma are all classified as category 3 or 4 contraindications for combined oral contraceptives [3].
The concern is twofold: estrogen can impair hepatic function in women with already-compromised livers, and hepatic adenomas have been documented to grow in response to exogenous estrogen exposure [3]. The 2024 CDC update revised guidance in this area in light of new evidence, emphasizing the importance of distinguishing between benign and malignant liver pathology when advising patients [3]. Women with benign liver tumors or well-managed viral hepatitis may be candidates for progestin-only or non-hormonal methods, which carry a considerably lower hepatic burden.
Breast cancer and hormone-sensitive cancers
Current or recent breast cancer is an absolute contraindication (category 4) to all hormonal methods, including both combined and progestin-only pills [3]. This is because many breast cancers are hormone-receptor-positive, meaning estrogen and progesterone/progestins can actively stimulate tumor growth. Expanding reproductive medicine guidelines from the Society of Family Planning, updated in 2025, underscore the importance of individualized risk assessment for cancer survivors, noting that contraceptive decisions should be made in close collaboration with oncology teams [9].
Women with a personal history of breast cancer who require contraception are best served by non-hormonal methods such as les méthodes de sensibilisation à la fertilité (FAM), none of which carry the hormonal concerns relevant to this population.
Cardiovascular disease, diabetes with vascular involvement, and smoking over 35
A cluster of conditions that compound cardiovascular risk round out the major contraindications list for hormonal contraception. Ischemic heart disease, prior stroke, complicated valvular heart disease, and peripartum cardiomyopathy are all category 4 conditions for COC use [3]. Diabetes with vascular complications (including nephropathy, retinopathy, or neuropathy) sits at category 3 or 4 depending on severity, as does diabetes of more than 20 years’ duration [3].
Perhaps most widely known but still worth repeating, is the interaction between smoking, age, and estrogen-containing contraceptives. Women over the age of 35 who smoke more than 15 cigarettes per day face a significantly elevated risk of cardiovascular events, including deep vein thromboembolism, on combined oral contraceptives [1]. This is not a minor concern dressed up in statistical language, it is a genuine and preventable harm.
The self-screening problem
As the landscape of contraceptive access continues to shift, with progestin-only pills now available over-the-counter in the United States and pressure growing for COC OTC approval, the question of who screens for these contraindications becomes urgent. The 2025 study referenced above found that OTC users reported a higher rate of category 3/4 conditions for COC use (25.1%) compared to the prescription group (15.5%) [2]. In an environment of reduced clinical oversight, this gap matters.
Self-screening tools and checklists can be useful; research has shown that, with proper labeling, most women can accurately identify contraindications for progestin-only pills [2]—however, as Natural Womanhood has previously reported, the Opill manufacturer’s study showed that women may still take OTC contraceptive pills inappropriately. And while COCs generally carry a more complex risk profile, and the stakes of missed contraindications are higher, progestin-only contraceptives are not without risks.
Research has shown that, with proper labeling, most women can accurately identify contraindications for progestin-only pills—however, as Natural Womanhood has previously reported, the Opill manufacturer’s study showed that women may still take OTC contraceptive pills inappropriately. And while COCs generally carry a more complex risk profile, and the stakes of missed contraindications are higher, progestin-only contraceptives are not without risks.
What this means for you
If you are currently taking or considering a combined oral contraceptive, this article is not written to alarm you. Instead, this is an invitation to pause and learn about the conditions that place a woman at elevated risk, since these conditions are not always rare nor exotic diagnoses. Hypertension, migraine, family history of clotting disorders, insulin-dependent diabetes: these are all fairly common conditions. They deserve to be taken seriously in the prescribing conversation.
Ask your healthcare professional which eligibility criteria framework they are using. Ask about your individual risk factors. Ask whether a non-hormonal method, such as an evidence-based method of fertility awareness, might serve you just as well. You deserve a treatment plan that is built around your biology, not issued by default.
Références
[1] Danielle B. Cooper and Preeti Patel. Oral contraceptive pills. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024.
[2] Rodriguez MI, Burns H, Edelman AB. Contraindications to combined hormonal oral contraceptives among over-the-counter users in the United States. Contraception. 2026 Mar 6:111434. doi: 10.1016/j.contraception.2026.111434. Epub ahead of print. PMID: 41796951.
[3] Nguyen AT, Curtis KM, Tepper NK, et al.. U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR Recomm Rep. 2024;73(4):1–126.
[4] Khizroeva J, Bitsadze V, Sukhikh G, Tretyakova M, Gris JC, Elalamy I, Gerotziafas G, Kapanadze D, Kvaratskheliia M, Tatarintseva A, Khisamieva A, Hovancev I, Yakubova F, Makatsariya A. Combined Oral Contraceptives and the Risk of Thrombosis. Int J Mol Sci. 2025 Nov 14;26(22):11010. doi: 10.3390/ijms262211010. PMID: 41303494; PMCID: PMC12652158.
[5] Li B, Xu X, Xu K, et al. Comparative effectiveness and safety of different progestins in combined oral contraceptives: a systematic review and network meta-analysis. Arch Gynecol Obstet. 2025;312:351–362. doi:10.1007/s00404-025-08050-2
[6] Grossman D, White K, Hopkins K, et al. Contraindications to combined oral contraceptives among over-the-counter compared with prescription users. Obstet Gynecol. 2011;117(3):558–565.
Références suite
[7] Bhullar SK, Rabinovich-Nikitin I, Kirshenbaum LA. Oral hormonal contraceptives and cardiovascular risks in females. Can J Physiol Pharmacol. 2024 Oct 1;102(10):572-584. doi: 10.1139/cjpp-2024-0041. Epub 2024 May 23. PMID: 38781602.
[8] Gibbs SN, Jick S. Utilization of oral contraceptives and hormone therapy for menopause among female individuals with migraine with aura: a descriptive study. Pharmacoepidemiol Drug Saf. 2025;34(11):e70266. doi:10.1002/pds.70266
[9] Society of Family Planning. Contraceptive considerations for individuals with cancer and cancer survivors — Part 2: Breast, ovarian, uterine, and cervical cancers. Clinical Recommendations. 2025.
