Anticonvulsant drugs used to treat epilepsy have been linked to an increased risk of birth defects among infants of epileptic mothers. Thus, effective contraception for epileptic women is especially important. Copper IUDs, voluntary sterilization, and correct use of barrier methods have been suggested. Most hormonal methods raise concerns, however. Some antiepileptic drugs (e.g., phenytoin, phenobarbital, carbamazepine, and paramethadione) may cause more rapid metabolism of the progestin or estrogen component of combined oral contraceptives. This, in turn, may reduce contraceptive effectiveness, resulting in pregnancy and exposure of the fetus to the potential teratogenic properties of the anti-seizure drug. Since anticonvulsant drugs also speed the metabolism of levonorgestrel, Norplant is not recommended for epileptic women. Depo-Provera is an appropriate method for epileptic women and may reduce seizure frequency.
When counseling women with chronic health conditions about their contraceptive method options, providers must strike a careful balance between the risks and benefits, safety, effectiveness, and acceptability of various methods and the risk of pregnancy. For many women with chronic medical conditions, the risk of an unintended pregnancy exceeds that related to contraception. Intensive counseling is especially important for women with a chronic disease that would be exacerbated by pregnancy. It is not uncommon for such women to have more than one chronic condition, such as diabetes plus hypertension or ischemic heart disease. The family planning provider must take into account the separate risks and contraceptive contraindications of each condition.
Family planning practitioners tend to be unaware of the reproductive health needs of disabled people. In many developing countries, disabled women are not taken for routine gynecologic examinations because it is assumed they will not have children. Even in developed countries, women with paralysis, impaired motor function, and other obvious physical disabilities are rarely offered counseling on sexuality or contraception. With proper education and counseling, disabled men and women may finally be in a position to make a truly informed decision about their reproductive lives. The selection of a contraceptive method for a disabled woman depends on consideration of factors such as the quality of circulation, abnormal clotting, the degree of physical sensation, manual dexterity, possible interactions with other medications, the effect of contraceptives on the disease process, problems with menstrual hygiene, and depression. For example, oral contraceptives are contraindicated in women with impaired circulation, a history of cerebrovascular accident, and immobility of the extremities. Methods than increase menstrual bleeding (e.g., copper IUDs) can cause hygiene problems for women with compromised manual dexterity. Although use of a barrier method may be difficult for women with poor coordination or upper-extremity disabilities, sexually transmitted disease (STD) prevention is especially important for women with pelvic sensory impairments that could allow STD symptoms to go unrecognized. Also in need of assessment in patients with physical disabilities are the impact of the disability on sexual expression and the possibility that sexual abuse is occurring.
In both developed and developing countries, women with high blood pressure who use oral contraceptives (OCs) face at least three times the relative risk of heart attack or ischemic stroke and 10 times the risk of hemorrhagic stroke than OC users without hypertension. A hypertensive OC user who smokes is at even greater risk. In general, combined OC use is contraindicated in women with severe hypertension (180/110 mm Hg or greater), hypertension with related vascular disease, or moderate hypertension (160-179/100-109 mm Hg). However, any contraception-related risks in hypertensive women must be weighed against those of pregnancy. Hypertensive pregnancies are associated with increased risks of pre-eclampsia, intrauterine growth retardation, premature delivery, and fetal death.
Women with tension headaches or migraine headaches without aura can use oral contraceptives (OCs) and other hormonal methods without concern. The use of combined OCs by women with severe, recurrent headaches with focal neurologic symptoms (including migraine headaches with aura) is contraindicated, however. It has been suggested that women with migraine headaches are at increased risk of stroke while taking OCs, but no data have been collected to support this contention.
