Oral contraceptives in risk groups: exclusion or monitoring?

Careful consideration of absolute and relative contraindications, including newly appreciated factors such as past pregnancy-related hypertension, is essential to select what is termed the "safer women." A family history of either arterial or venous thrombosis indicates preliminary blood analysis to exclude atherogenic lipid states and thrombophilias. The goal then is to prescribe "safer pills." One should also allow for biologic variation in pharmacokinetics and end-organ responses. This can be done to a limited extent in clinical practice by using bleeding from the uterus as a "threshold bioassay." Namely, by identifying for each woman the lowest dose of a chosen estrogen-progestogen combination that is just sufficient to prevent breakthrough bleeding. Thereafter, monitoring requires attention to the development of new risk factors, regular blood pressure checks, and specific attention to the important side effects of headaches and migraines, especially if there are focal (cerebral ischemic) symptoms.