Combined oral contraceptive use is absolutely contraindicated in which of these scenarios?

• A. Older than 35 years and smoke a pack of cigarettes/day
• B. Develop migraine headaches after starting oral contraceptives
• C. 6-12 weeks postpartum and breastfeeding
• D. Had breast cancer more than 5 years ago

Answer: (A)

The scenario where combined oral contraceptive use is absolutely contraindicated involves women who are older than 35 years and smoke a pack of cigarettes per day. This is due to the increased risk of serious cardiovascular events, such as thrombosis and stroke, which are significantly amplified by the combination of age and heavy smoking. The estrogen component of combined oral contraceptives can further elevate the risk of these adverse outcomes in this population.

In other scenarios, such as developing migraine headaches after starting oral contraceptives, it may be necessary to evaluate the severity and type of migraine. Additionally, while there are considerations for women who are postpartum and breastfeeding, especially regarding timing and type of contraceptive, it is not an absolute contraindication. Having had breast cancer more than five years ago may require careful consideration and monitoring, but it does not categorically prevent the use of combined oral contraceptives as long as the patient is deemed low risk and there is no current evidence of disease. Hence, the combination of being over 35 and smoking heavily presents a clear and established contraindication.