For women with prior myocardial infarction, COCs should not be considered. Also, in women with multiple cardiovas cular risk factors, which include smoking, hypertension, older age, and diabetes, the risk for myocardial infarction outweighs the beneits of this method. However, for those without these risks, low-dose oral contraceptives are not associated with an increased risk of myocardial infarction (Margolis, 2007; World
Health Organization, 1997).
The risks for deep-vein thrombosis and pulmonary embolism are increased in women who use COCs (Stadel, 1981). These clearly are estrogen-dose related, and rates have substantively declined with lower-dose formulations containing 10 to 35 �g of ethinyl estradiol. he general-population risk of venous thromboembolism (VTE) is 4 to 5 events per 100,000 woman-years. he incidence ofVTE with COC use increases three-to fivefold compared with nonusers (Shaw, 2013; van Hylckama Vlieg, 2009). Obesity raises the VTE risk, which is compounded by COCs (Horton, 2016; Suchon, 2016). Accordingly, in an obese woman, COCs are considered a US MEC category 2. VTEs are signiicantly increased in women older than 35 years who smoke, and COCs are not recommended. Those most at risk for VTE include women with thrombophilias (ESHRE Capri Workshop Group, 2013). Nloreover, COC use during the month before a major operative procedure appears to double the risk for postoperative VTE (Robinson, 1991). Thus, the merican College of Obstetricians and Gynecologists (2016d) recommends balancing the risks ofVTE and the degree of postoperative immobility with the risk of unintended pregnancy during the 4 to 6 weeks required to reverse the thrombogenic efects of COCs before surgery. In the early puerperium, VTE risks are also increased, and COCs are not recommended for women within the irst 4 weeks after delivery.
Certain progestins within COC are linked with greater rates of thromboembolism. A slightly higher VTE risk with drospirenone-containing COCs has been shown in two studies. In response, an assessment of benefits and VTE risks in users of these pills has been emphasized (Food and Drug Administration, 2012; Jick, 2011; Parkin, 2011). Desogestrel and gestodene are also implicated and carry similarly elevated risks (Stegeman, 2013; Vinogradova, 2015).
Most studies indicate that COCs overall are not associated with an increased risk of cancer (Cibula, 2010). In fact, a protective efect against ovarian and endometrial cancer has been shown (Collaborative Group on Epidemiological Studies of Ovarian Cancer, 2008; Tsilidis, 201r1). As an exception, the relative risk of cervical dysplasia and cervical cancer is higher in current COC users, but this declines after use is discontinued. Following 10 or more years, risk returns to that of never users (International Collaboration of Epidemiological Studies of Cervical Cancer, 2007). It is unclear whether COCs contribute to breast cancer development. Major studies show no risk or a small risk among current users, which drops with time following cessation (Collaborative Group on Hormonal Factors in Breast Cancer, 1996; Hannaford, 2007; Marchbanks, 2002).