A 35-year-old woman who smokes 15 cigarettes/day requests combined oral contraceptive pills (COCPs). What is the MOST appropriate contraceptive counselling?
- A COCPs are safe in women over 35 who smoke <20 cigarettes/day
- B COCPs are absolutely contraindicated in women ≥35 years who smoke ✓
- C Progesterone-only pills are a suitable alternative with similar cardiovascular risk
- D Low-dose COCPs are safe as long as blood pressure is normal
Correct answer: B. COCPs are absolutely contraindicated in women ≥35 years who smoke
Explanation
Smoking ≥15 cigarettes/day in women ≥35 years is a WHO MEC Category 4 (absolute contraindication) for COCPs, as the combination dramatically increases the risk of arterial thrombosis, myocardial infarction, and stroke. Even 1–14 cigarettes/day in women ≥35 is Category 3 (relative contraindication). Progesterone-only pills (POPs) do not contain estrogen and do not carry the same thromboembolic risk, making them a suitable alternative. LNG-IUS, implants, or barrier methods are also appropriate choices.
Reference: Shaw's Textbook of Gynaecology, 17th ed.
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