12 MMWR June 18, <strong>2010</strong> TABLE. (Continued) Classifications <strong>for</strong> combined hormonal contraceptives, including pill, patch, and ring* † Condition Category Clarifications/Evidence/Comments Postpartum (in nonbreastfeeding women) a.
Vol. 59 / RR-4 Recommendations and Reports 13 TABLE. (Continued) Classifications <strong>for</strong> combined hormonal contraceptives, including pill, patch, and ring* † Condition Category Clarifications/Evidence/Comments i. Systolic 140–159 mm Hg or diastolic 90–99 mm Hg ii. Systolic ≥160 mm Hg or diastolic 3 4 Evidence: Among women with hypertension, COC users were at higher risk than nonusers <strong>for</strong> stroke, acute myocardial infarction, and peripheral arterial disease (142,144,151–153,155,171–186). Discontinuation of COCs in women with hypertension might improve blood pressure control (187). ≥100 mm Hg § c. Vascular disease 4 History of high blood pressure during pregnancy (where current blood pressure is measurable and normal) 2 Evidence: Women with a history of high blood pressure in pregnancy, who also used COCs, had a higher risk <strong>for</strong> myocardial infarction and VTE than did COC users who did not have a history of high blood pressure during pregnancy. The absolute risks <strong>for</strong> acute myocardial infarction and VTE in this population remained small (153,172,184–186,188–193). Deep venous thrombosis (DVT)/ Pulmonary embolism (PE) a. History of DVT/PE, not on anticoagulant therapy i. Higher risk <strong>for</strong> recurrent DVT/PE (≥1 risk factors) • History of estrogen-associated DVT/PE • Pregnancy-associated DVT/PE • Idiopathic DVT/PE • Known thrombophilia, including antiphospholipid syndrome • Active cancer (metastatic, on therapy, or within 6 mos after clinical remission), excluding non-melanoma skin cancer • History of recurrent DVT/PE ii. Lower risk <strong>for</strong> recurrent DVT/PE 3 (no risk factors) b. Acute DVT/PE 4 c. DVT/PE and established on anticoagulant therapy <strong>for</strong> at least 3 mos i. Higher risk <strong>for</strong> recurrent DVT/PE (≥1 risk factors) • Known thrombophilia, including antiphospholipid syndrome • Active cancer (metastatic, on therapy, or within 6 mos after clinical remission), excluding non-melanoma skin cancer • History of recurrent DVT/PE ii. Lower risk <strong>for</strong> recurrent DVT/PE (no risk factors) 4 4 Clarification: Women on anticoagulant therapy are at risk <strong>for</strong> gynecologic complications of therapy, such as hemorrhagic ovarian cysts and severe menorrhagia. Hormonal contraceptive methods can be of benefit in preventing or treating these complications. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio might differ and should be considered on a case-bycase basis. 3 Clarification: Women on anticoagulant therapy are at risk <strong>for</strong> gynecologic complications of therapy, such as hemorrhagic ovarian cysts and severe menorrhagia. Hormonal contraceptive methods can be of benefit in preventing or treating these complications. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio may differ and should be considered on a case-bycase basis. d. Family history (first-degree relatives) 2 Comment: Some conditions that increase the risk <strong>for</strong> DVT/PE are heritable. e. Major surgery i. With prolonged immobilization 4 ii. Without prolonged immobilization 2 f. Minor surgery without immobilization 1 Known thrombogenic mutations § (e.g., factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies) 4 Clarification: Routine screening is not appropriate because of the rarity of the conditions and the high cost of screening. Evidence: Among women with thrombogenic mutations, COC users had a 2-fold to 20-fold higher risk <strong>for</strong> thrombosis than did nonusers (159,194–216). Superficial venous thrombosis a. Varicose veins 1 Comment: Varicose veins are not risk factors <strong>for</strong> DVT/PE b. Superficial thrombophlebitis 2 Current and history of ischemic heart 4 disease § Stroke § (history of cerebrovascular 4 accident)
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