Understanding Contraindications: Who Should Avoid the Combination Pill?

October 10, 2025 •

4 min read

In the United States, nearly half of all pregnancies are unintended [1.2.5]. While the combination birth control pill is a popular and effective contraceptive method, it's not safe for everyone. This guide details who should avoid the combination pill due to specific health factors.

Quick Summary

An in-depth look at the specific health conditions, lifestyle factors, and medications that are contraindications for using combination birth control pills, which contain both estrogen and progestin.

Key Points

Smokers Over 35: Individuals over 35 who smoke should not use combination pills due to a severely increased risk of heart attack and stroke [1.4.2, 1.4.4].
High Blood Pressure: Those with poorly controlled high blood pressure are at an unacceptable risk and should avoid combination pills [1.3.2, 1.3.4].
History of Blood Clots: A personal or family history of venous thromboembolism (VTE) is a major contraindication [1.2.2].
Migraine with Aura: People who experience migraines with neurological symptoms (aura) have a higher stroke risk and should avoid estrogen-containing pills [1.6.4].
Certain Cancers: A history of breast cancer or certain liver tumors makes combination pills unsafe [1.2.2, 1.3.4].
Complicated Diabetes: Diabetes with nerve, kidney, or eye damage is a contraindication [1.2.2, 1.3.4].
Postpartum Period: Use should be avoided for at least 21-42 days after giving birth, especially if breastfeeding [1.2.6].

The Dual-Hormone Approach: What is a Combination Pill?

Combination birth control pills are a type of oral contraceptive that contains two hormones: estrogen and progestin [1.2.1]. These hormones work together primarily by preventing ovulation, meaning no egg is released from the ovaries. They also thicken cervical mucus to make it harder for sperm to reach an egg and thin the uterine lining to prevent implantation. With typical use, about 9 out of 100 people taking these pills will get pregnant in the first year, but with perfect use, the rate is less than 1 in 100 [1.2.2]. While effective for many, the estrogen component in these pills is linked to an increased risk of certain serious health conditions, making them unsuitable for a significant portion of the population [1.5.6, 1.4.8].

Absolute and Relative Contraindications

Medical guidelines often categorize contraindications to determine the level of risk. An absolute contraindication means the method poses an unacceptable health risk and should not be used. A relative contraindication means the risks generally outweigh the benefits, but it may be considered in certain situations with careful monitoring [1.3.6]. A thorough medical history is crucial for identifying these risk factors before a prescription is written [1.3.6].

Cardiovascular Risks: A Primary Concern

The most significant reasons to avoid the combination pill are related to cardiovascular health. The estrogen in these pills can increase the risk of blood clots, heart attack, and stroke [1.2.2, 1.4.8].

Individuals with a History of Blood Clots

Anyone with a personal or family history of blood clots, such as deep vein thrombosis (DVT) in the legs or a pulmonary embolism (PE) in the lungs, should not use combination pills [1.2.2, 1.3.3]. This also extends to those with known genetic clotting disorders (thrombogenic mutations) like Factor V Leiden [1.2.6]. The risk of venous thromboembolism (VTE) is 3 to 9 per 10,000 woman-years for users, compared to 1 to 5 for non-users [1.2.6].

High Blood Pressure (Hypertension)

Combination pills can increase blood pressure [1.5.4]. For individuals with poorly controlled hypertension (systolic > 160mmHg or diastolic > 100mmHg), these pills are an absolute contraindication [1.3.4, 1.3.6]. Even those with well-controlled high blood pressure may be advised to seek alternatives, especially if other cardiovascular risk factors are present [1.5.5]. Progestin-only pills are often considered a safer option for those with hypertension [1.5.2].

Smokers, Especially Over 35

This is one of the most critical contraindications. Smoking hardens and restricts blood vessels, and the pill thickens the blood; the combination drastically increases the risk of heart attack and stroke [1.4.1]. The U.S. Food and Drug Administration (FDA) explicitly states that combination oral contraceptives are contraindicated in women over 35 who smoke [1.4.2]. The World Health Organization (WHO) classifies use for women over 35 who smoke 15 or more cigarettes a day as a category 4 risk (unacceptable health risk) [1.4.4].

Other Major Medical Contraindications

Beyond cardiovascular issues, several other conditions make combination pills a poor choice.

Migraine with Aura

Women who experience migraine with aura (focal neurological symptoms like flashing lights before or during a headache) should not use combination hormonal contraceptives [1.2.4, 1.6.6]. This is because both migraine with aura and combination pills independently increase the risk of ischemic stroke; together, they can increase the risk six-fold compared to those with neither risk factor [1.6.7, 1.6.4].

History of Certain Cancers

Due to the hormonal nature of the pill, it is contraindicated for individuals with a current or past history of breast cancer [1.2.2, 1.2.4]. Use is also restricted for those with liver tumors (adenoma or hepatoma) or severe cirrhosis [1.3.4].

Liver and Gallbladder Disease

Individuals with certain liver diseases, including acute viral hepatitis, severe cirrhosis, or benign or malignant liver tumors, should avoid the combination pill [1.4.2, 1.2.2]. The pill can also be a concern for those with current or medically treated gallbladder disease [1.3.8].

Diabetes with Complications

While uncomplicated diabetes doesn't automatically rule out the pill, those with diabetes-related complications affecting the kidneys (nephropathy), eyes (retinopathy), or nerves (neuropathy) should not use it [1.3.4, 1.2.2]. The same applies to those who have had diabetes for more than 20 years, as microvascular damage is assumed [1.3.6].


Condition	Risk with Combination Pill	Safer Alternatives Recommended
Smoker > 35 years old	Significantly increased risk of heart attack and stroke [1.4.2, 1.4.4].	Progestin-only pills, IUDs (hormonal or copper), implant, shot [1.4.3].
High Blood Pressure (uncontrolled)	Can further elevate blood pressure, increasing stroke and heart attack risk [1.5.4, 1.3.2].	Progestin-only methods, non-hormonal methods (e.g., copper IUD) [1.5.2].
History of Blood Clots (VTE)	High risk of recurrent blood clots [1.2.2, 1.2.6].	Progestin-only pills, implant, copper IUD [1.2.5].
Migraine with Aura	Increased risk of ischemic stroke [1.6.4, 1.6.7].	Progestin-only methods, non-hormonal methods [1.6.6].
Current or Past Breast Cancer	Hormones may promote cancer growth [1.2.2, 1.3.3].	Non-hormonal methods like the copper IUD or barrier methods [1.7.3].

Additional Considerations

Postpartum and Breastfeeding: Combination pills should be avoided for at least the first 21 days postpartum due to a higher risk of VTE. If breastfeeding, they should be avoided for the first 42 days as estrogen can impact lactation [1.2.6].
Prolonged Immobility: If you will be confined to bed for an extended period, such as after a major surgery, you should stop taking the pill at least four weeks prior to avoid clot formation [1.3.6, 1.3.2].
Certain Medications: Some drugs, including certain antibiotics (rifampin), epilepsy medications, and HIV medications, can make the pill less effective [1.2.4].

Conclusion: Prioritizing Safety in Contraceptive Choice

The combination birth control pill is a safe and highly effective contraceptive for many, but it is not a one-size-fits-all solution. The presence of estrogen creates significant health risks for individuals with specific pre-existing conditions, most notably those related to cardiovascular health like high blood pressure, a history of blood clots, and for smokers over the age of 35. Other conditions such as migraine with aura, certain cancers, and complicated diabetes also serve as absolute contraindications. A transparent and thorough discussion with a healthcare provider about your personal and family medical history is essential to determine if the combination pill is a safe choice for you. Fortunately, numerous effective estrogen-free and non-hormonal alternatives are available, ensuring that nearly everyone can find a suitable method of contraception [1.7.5, 1.7.3].

For more information on contraceptive eligibility, you can consult the U.S. Medical Eligibility Criteria for Contraceptive Use from the CDC.

Frequently Asked Questions

Smoking damages blood vessels, and the estrogen in combination pills increases the risk of blood clots. This combination significantly elevates the risk of serious cardiovascular events like heart attack and stroke in women over 35 [1.4.1, 1.4.2].

Migraine with aura involves temporary neurological symptoms like seeing flashing lights or blind spots before or during a headache. Both migraine with aura and combination pills independently increase the risk of ischemic stroke, so using them together is considered an unacceptable health risk [1.6.4, 1.6.7].

If you have poorly controlled high blood pressure, you should not take the combination pill [1.3.2]. If your blood pressure is well-controlled, a doctor may consider it if you have no other cardiovascular risk factors, but progestin-only methods are generally safer [1.5.5].

Yes, progestin-only pills, also known as the 'mini-pill', do not contain estrogen and are often a safe alternative for those with contraindications to the combination pill, such as high blood pressure or a history of migraines with aura [1.7.6, 1.5.2].

You should not use the combination pill if you have a close family member (first-degree relative) who had a blood clot under the age of 45 [1.2.7, 1.3.5]. This may indicate a genetic predisposition to clotting that the pill could dangerously exacerbate.

Yes, for major surgery that requires prolonged immobilization, it's recommended to stop taking combination pills at least four weeks beforehand to reduce the risk of developing blood clots [1.3.6].

You should wait at least 21 days after giving birth to avoid an increased risk of blood clots. If you are breastfeeding, you should wait at least 42 days, as the estrogen can affect your milk supply [1.2.6].