It is time to re-evaluate the use of combined hormonal contraceptives in women who experience migraines with aura.
The CDC U.S. Medical Eligibility Criteria for Contraceptive Use, updated in 2024, rates combined hormonal contraceptives as Category 4, an unacceptable health risk and method not to be used. The prohibition of combined hormonal contraceptives for women who suffer from migraine with aura feels like gospel in the field of obstetrics and gynecology, and is rooted in the increased risk of ischemic stroke associated with both migraine with aura and exogenous estrogen use.
But a February 2023 study published in Headache calls this into question.
In a major shift from the standard dogma of our field, this study did not show an increased risk of stroke in women with migraine with aura. However, this evidence in support of a significant change in contraception restrictions failed to produce even a ripple in high impact gynecologic resources. As noted above, the highly referenced CDC Medical Eligibility Criteria revised in 2024, over a year after publication of this new data, continues the Category 4 designation for estrogen containing contraceptives for women experiencing migraines with aura. And within the gynecology-focused sources, there has been minimal work done to continue to evaluate this standard of care. The last published evaluation by The American Journal of Obstetrics and Gynecology was in 2017 and failed to evaluate the impact of different estrogen doses, which is essential to fully evaluating the safety of estrogen containing contraceptives. This lack of data fails to support the practice of evidence-based medicine, which should be centered on the findings of the best available current research.
So why isn’t this work being done in the field of gynecology?
One perspective is that further study puts women at risk of stroke, a risk that in otherwise healthy reproductive age women is found by many to be unacceptable. By this same reasoning, opening this treatment option up to a more individualized and patient-centered approach in gynecologic care without definitive evidence of safety is also too risky. Many physicians focus their practice updates on resources within their own field of practice, and the failure of this work to receive better recognition in gynecology is largely oversight.
Nevertheless, it is disappointing that gynecologists are not taking greater notice of data that may have a significant positive impact on the lives of a large number of patients. Estrogen-containing methods are an important class of contraceptives. While largely studied and approved for pregnancy prevention, they also provide unique therapeutic advantages for patients with PCOS, premenstrual dysphoric disorder, and endometriosis. For patients whose primary goal is contraception, combined contraceptive pills are one of the most popular and effective methods. For many women who value a predictable bleeding pattern, this is the only class of acceptable methods.
I would argue that to continue the prohibition, and to ignore good evidence that it is inappropriate to do so, treats contraception as though it is an optional lifestyle choice instead of the essential female health care that it is. Stroke is a serious medical complication, but an unplanned pregnancy can also have far reaching implications for a woman’s life. Now, in a time when effective contraception is more vital than ever due to growing numbers of women losing access to pregnancy options, it is essential that we ensure women receive the most effective and comprehensive contraceptive options. When physicians make the decision that the risks of this medication outweigh the benefits, women are placed at risk of being without adequate and personally acceptable contraceptive options. In addition to placing women at increased, and very possibly unnecessary, risk of pregnancy, this undermines women’s autonomy and the belief that they are the ones best qualified to direct their own reproductive health choices.
Gynecologists should not ignore important evidence and discussions in the field of neurology that may open up an important class of medications to women who would benefit. Providing women with the evidence-based medical care they deserve requires factoring this new data into our clinical practice and guidelines. At the very least, this new data should trigger further investigation. Ongoing work to establish the most accurate understanding of safety should include input from gynecologists, and receive more robust recognition in gynecology resources. However, unlike many conditions in obstetrics, ob/gyns aren’t the only ones with a point of view and expertise on this subject. Gynecologists are experts in the medical use of reproductive hormones. Neurologists also have expertise on the other side of this coin, as the specialists tasked with managing both migraine with aura and ischemic stroke. It is essential that neurologists and gynecologists collaborate to come to the answer that best serves women, by facilitating their reproductive choices and providing accurate and up-to-date information that allows them to make informed decisions.
How can ob/gyns work with other specialties? Share in the comments.
Dr. Erica Jacovetty is an ob/gyn practicing in Maine. She enjoys reading, pie making, and gardening. Dr. Jacovetty is a 2024-2025 Doximity Op-Med Fellow.
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