Medical contraindications to estrogen and contraceptive use among women veterans

Abstract: Background: Women Veterans have high rates of medical comorbidities and may be particularly vulnerable to adverse health outcomes associated with unintended pregnancy. Objectives: To estimate the prevalence of medical contraindications to estrogen-containing combined hormonal contraception among women Veterans of reproductive age, and to evaluate the relationship between contraindications and contraceptive use. Study design: This is a secondary analysis of data from a cross-sectional, telephone-based survey with a national sample of 2,302 female Veterans, ages 18–45, who use the Veterans Administration Healthcare System for primary care. This analysis includes women at risk of unintended pregnancy, defined as heterosexually active, not pregnant or trying to conceive, and with no history of hysterectomy or infertility. Seven contraindications to combined hormonal contraception were identified using survey data or medical diagnosis codes: hypertension, coronary artery disease, active migraine in women over 35 or migraine with aura, smoking in women over 35, and history of thromboembolism, stroke or breast cancer. Outcomes were current use of combined hormonal contraception and contraceptive method type (combined hormonal contraception, other prescription methods, non-prescription methods or no method). Multivariable logistic and multinomial regression were used to assess the relationship between contraindications and combined hormonal contraception use and method type, respectively. Results: Among 1,169 women Veterans at risk of unintended pregnancy, 339 (29%) had at least one contraindication to combined hormonal contraception. The most prevalent conditions were hypertension (14.9%) and migraine (8.7%). In adjusted analyses, women with contraindications were less likely than women without contraindications to report use of combined hormonal contraception (aOR:0.54, 95% CI:0.37–0.79). Relative to use of combined hormonal contraception, women with contraindications were more likely than women without contraindications to use other prescription methods (aOR:1.74, 95%CI:1.17–2.60), non-prescription methods (aOR:1.96, 95%CI:1.19–3.22) and no method (aOR:2.29, 95%CI:1.35–3.89). Conclusion: Women Veterans at risk of unintended pregnancy have a high burden of medical contraindications to estrogen. Women with contraindications were less likely to use combined hormonal contraceptive methods, but were more likely to use no method, suggesting unmet need for contraception in this medically vulnerable population.