Birth Control Pills and Thrombotic Risks: Differences of Contraception Methods with and without Estrogen

In Germany one-third of the women in fertile age use combined oral contraceptives (COCs), which consist mostly of ethinylestradiol (EE) and a synthetic progestin. Older COCs with norethisterone or levonorgestrel have a lower risk for venous thromboembolism (VTE) than newer COCs with desogestrel, drospirenone, or gestodene. This is also true for nonoral combined hormonal contraceptives. The risk of newer COCs containing estradiol instead of EE is not clear due to missing data. Progestin-only hormonal contraception is not associated with a significant increase of the risk for VTE with the exception of depot medroxyprogesterone acetate. Emergency contraceptions, which do not contain EE, but only levonorgestrel or ulipristal acetate, do not result in a higher risk for VTE. Oral desogestrel- or levonorgestrel-only contraceptives, intrauterine device, and etonogestrel implants are the contraception of choice in women with a history of VTE and/or suffering from thrombophilia. These safe contraceptives should be offered to women with high risk of VTE due to the much higher VTE risk in pregnancy and postpartum. The screening for thrombophilia is not indicated in every woman with the wish for contraception. This should be restricted to certain cases, for example to women with a positive history for VTE or with close relatives suffering from VTE in younger than 50 years.