Prescribing Combined Oral Contraceptives in Primary Care: What Every NP Should Know

Contraception counseling is one of the most common visits in primary care. For many women, combined oral contraceptives (COCs) are an accessible, effective, and familiar option. But safe prescribing requires knowing who can use them — and who should avoid them.

Here’s a streamlined guide based on the CDC U.S. Medical Eligibility Criteria (MEC, 2024) and clinical pearls from real-world practice.

Who Can Safely Use COCs?

The CDC MEC uses a 1–4 rating scale for contraceptive safety:

• Category 1: No restriction — safe to use.

• Category 2: Benefits generally outweigh risks.

• Category 3: Risks usually outweigh benefits.

• Category 4: Unacceptable risk — contraindicated.

For most healthy, nonsmoking women under age 35, COCs are Category 1.

Who Should Avoid COCs? (Absolute Contraindications)

COCs are Category 4 (do not use) in patients with:

• Age ≥35 and smoking ≥15 cigarettes/day

• Hypertension (uncontrolled or with vascular disease)

• History of stroke, DVT, or pulmonary embolism

• Known thrombophilia (e.g., Factor V Leiden)

• History of breast cancer (current)

• Migraines with aura

• Severe liver disease or hepatic adenoma

💡 Pearl: Even young women with migraine with aura should avoid estrogen-containing contraception due to stroke risk.

Relative Contraindications (Category 3)

Use caution and weigh risks vs. benefits in:

• Controlled hypertension

• Age ≥35 and smoking <15 cigarettes/day

• Diabetes with vascular complications

• Breastfeeding <6 weeks postpartum

Counseling Tips for NPs

• Start Method Today → If pregnancy can be reasonably excluded, patients can start immediately (Quick Start method).

• Adherence matters → Emphasize taking the pill at the same time daily.

• Missed pill protocol → If one pill is missed, take as soon as remembered and continue. If two or more missed, back-up contraception is needed.

• Drug interactions → Watch for anticonvulsants, rifampin, and certain HIV meds.

• Non-contraceptive benefits → COCs reduce risk of ovarian and endometrial cancer, help with acne, regulate cycles, and reduce dysmenorrhea.

Clinical Pearls

• Always screen for migraine with aura and smoking history — these are easy-to-miss red flags.

• For patients who can’t take estrogen, consider progestin-only pills, LARC (IUDs/implants), or non-hormonal options.

• Blood pressure check is essential before starting COCs.

• Reassess risk factors annually (age, smoking, new diagnoses).

Final Thoughts

Prescribing combined oral contraceptives is a bread-and-butter skill in primary care, but the details matter. Use the CDC MEC chart as your quick guide, and lean on your EMR + patient history to identify red flags.

With the right screening and counseling, COCs are safe, effective, and empowering for patients.

References

1. Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MEC Summary Chart .

2. UpToDate. Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use. Accessed September 2025. Link .

3. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.

4. American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin: Combined Hormonal Contraception. Obstet Gynecol. 2019;134(2):e91-e103.

5. The Menopause Society. Hormonal Contraception Use and Age at Discontinuation. 2023.

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