Using Clinical Judgment in Special Cases

Usually, a woman with any of the conditions listed below should not use COCs. In special circumstances, however, when other, more appropriate methods are not available or acceptable to her, a qualified provider who can carefully assess a specific woman’s condition and situation may decide that she can use COCs. The provider needs to consider the severity of her condition and, for most conditions, whether she will have access to follow-up.

• Not breastfeeding and less than 3 weeks since giving birth
• Not breastfeeding and between 3 and 6 weeks postpartum with additional risk that she might develop a blood clot in a deep vein (VTE)
• Primarily breastfeeding between 6 weeks and 6 months since giving birth
• Age 35 or older and smokes fewer than 15 cigarettes a day
• High blood pressure (systolic blood pressure between 140 and 159 mm Hg or diastolic blood pressure between 90 and 99 mm Hg)
• Controlled high blood pressure, where continuing evaluation is possible
• History of high blood pressure, where blood pressure cannot be taken (including pregnancy-related high blood pressure)
• History of jaundice while using COCs in the past
• Gall bladder disease (current or medically treated)
• Age 35 or older and has migraine headaches without aura
• Younger than age 35 and has migraine headaches without aura that have developed or have gotten worse while using COCs
• Had breast cancer more than 5 years ago, and it has not returned
• Diabetes for more than 20 years or damage to arteries, vision, kidneys, or nervous system caused by diabetes
• Multiple risk factors for arterial cardiovascular disease such as older age, smoking, diabetes, and high blood pressure
• Taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, rifampicin, rifabutin, or ritonavir or ritonavir-boosted protease inhibitors. A backup contraceptive method should also be used because these medications reduce the effectiveness of COCs.
• Taking lamotrigine. Combined hormonal methods may make lamotrigine less effective.