Ask the client the questions below about known medical conditions.
Examinations and tests are not necessary. If she answers “no” to all of the questions, then she can start COCs if she wants.
If she answers “yes” to a question, follow the instructions. In some cases she can still start COCs. These questions also apply for the combined patch and the combined vaginal ring.
1. Are you breastfeeding a baby less than 6 months old?
No.
Yes - if fully or nearly fully breastfeeding: give her COCs and tell her to start taking them 6 months after giving birth or when breast milk is no longer the baby’s main food—whichever comes first (see Fully or nearly fully breastfeeding).
If partially breastfeeding: she can start COCs as soon as 6 weeks after childbirth (see Partially breastfeeding).
2. Have you had a baby in the last 3 weeks that you are not breastfeeding?
No.
Yes - give her COCs now and tell her to start taking them 3 weeks after childbirth (see not breastfeeding)
3. Do you smoke cigarettes?
No.
Yes - if she is 35 years of age or older and smokes, do not provide COCs. Urge her to stop smoking and help her choose another method.
4. Do you have cirrhosis of the liver, a liver infection, or liver tumor? (Are her eyes or skin unusually yellow? [signs of jaundice]) Have you ever had jaundice when using COCs?
No
Yes - if she reports serious active liver disease (jaundice, active hepatitis, mild or severe cirrhosis, liver tumor) or ever had jaundice while using COCs, do not provide COCs.
Help her choose a method without hormones. (She can use monthly injectables if she has had jaundice only with past COC use.)
5. Do you have high blood pressure?
No.
Yes - if you cannot check blood pressure and she reports a history of high blood pressure, or if she is being treated for high blood pressure, do not provide COCs.
Refer her for a blood pressure check if possible or help her choose a method without estrogen.
Check blood pressure if possible:
(One blood pressure reading in the range of 140–159/90–99 mm Hg is not enough to diagnose high blood pressure. Give her a backup method* to use until she can return for another blood pressure check, or help her choose another method now if she prefers.
If her blood pressure at next check is below 140/90, she can use COCs.)
6. Have you had diabetes for more than 20 years or damage to your arteries, vision, kidneys, or nervous system caused by diabetes?
No.
Yes - do not provide COCs. Help her choose a method without estrogen but not progestin-only injectables.7. Do you have gallbladder disease now or take medication for gallbladder disease?
No.
Yes - do not provide COCs. Help her choose another method but not the combined patch or combined vaginal ring.
8. Have you ever had a stroke, blood clot in your legs or lungs, heart attack, or other serious heart problems?
No.
Yes - if she reports heart attack, heart disease due to blocked or narrowed arteries, or stroke, do not provide COCs. Help her choose a method without estrogen but not progestin-only injectables.
If she reports a current blood clot in the deep veins of the legs or lungs (not superficial clots), help her choose a method without hormones.
9. Do you have or have you ever had breast cancer?
No.
Yes - do not provide COCs. Help her choose a method without hormones.
10. Do you sometimes see a bright area of lost vision in the eye before a very bad headache (migraine aura)? Do you get throbbing, severe head pain, often on one side of the head, that can last from a few hours to several days and can cause nausea or vomiting (migraine headaches)? Such headaches are often made worse by light, noise, or moving about.
No.
Yes - if she has migraine aura at any age, do not provide COCs. If she has migraine headaches without aura and is age 35 or older, do not provide COCs.
Help these women choose a method without estrogen. If she is under 35 and has migraine headaches without aura, she can use COCs (see Identifying Migraine Headaches and Auras).
11. Are you taking medications for seizures? Are you taking rifampicin for tuberculosis or other illness?
No.
Yes - if she is taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, or rifampicin, do not provide COCs. They can make COCs less effective.
Help her choose another method but not progestin-only pills or implants.
12. Are you planning major surgery that will keep you from walking for one week or more?
No.
Yes - if so, she can start COCs 2 weeks after the surgery. Until she can start COCs, she should use a backup method.
13. Do you have several conditions that could increase your chances of heart disease (coronary artery disease) or stroke, such as older age, smoking, high blood pressure, or diabetes?
No.
Yes - do not provide COCs. Help her choose a method without estrogen but not progestin-only injectables.
For complete classifications, see medical eligibility criteria for contraceptive use.
Be sure to explain the health benefits and risks and the side effects of the method that the client will use.
Also, point out any conditions that would make the method inadvisable, when relevant to the client.
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.
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Not breastfeeding and less than 3 weeks since giving birth
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Primarily breastfeeding between 6 weeks and 6 months since giving birth
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Age 35 or older and smokes fewer than 15 cigarettes a day
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High blood pressure (systolic blood pressure between 140 and 159 mm
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Hg or diastolic blood pressure between 90 and 99 mm Hg)
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Controlled high blood pressure, where continuing evaluation is possible
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History of high blood pressure, where blood pressure cannot be taken
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(including pregnancy-related high blood pressure)
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Mild cirrhosis of the liver or history of jaundice while using COCs in the past
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Gall bladder disease (current or medically treated)
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Age 35 or older and has migraine headaches without aura
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Younger than age 35 and has migraine headaches without aura that have
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developed or have gotten worse while using COCs
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Had breast cancer more than 5 years ago, and it has not returned
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Taking barbiturates, carbamazepine, oxcarbazepine, phenytoin, primidone,
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topiramate, or rifampicin. A backup contraceptive method should also be
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used because these medications reduce the effectiveness of COCs.
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Diabetes for more than 20 years or damage to arteries, vision, kidneys, or
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nervous system caused by diabetes
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Multiple risk factors for arterial cardiovascular disease such as older age,
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smoking, diabetes, and high blood pressure
Combined oral contraceptives for women with HIV
Women who are infected with HIV, have AIDS, or are on antiretroviral (ARV) therapy can safely use COCs.
Urge these women to use condoms along with COCs. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs.
Condoms also provide extra contraceptive protection for women on ARV therapy. It is not certain whether ARV medications reduce the effectiveness of COCs.
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