Which of the following is an absolute contraindication to prescribing oral hormonal contraceptives?

• A. History of iron deficiency anemia
• B. History of dysmenorrhea since age 15
• C. Positive family history of ovarian cancer
• D. History of smoking in a patient older than age 35

Answer: (D)

The key idea is that estrogen-containing oral contraceptives have a risk of cardiovascular events that becomes absolute when a patient is older than 35 and also smokes. Estrogen increases clotting factor production and the risk of thrombosis, while smoking promotes endothelial injury and accelerates atherogenesis. Together, in someone over 35 who smokes, the chance of serious events like heart attack or stroke is high enough that estrogen-containing contraception is not considered safe. That’s why this scenario is an absolute contraindication.

The other factors listed aren’t absolute red flags. Iron deficiency anemia, nonspecific lower abdominal pain like dysmenorrhea in a long-standing pattern, or a family history of ovarian cancer don’t by themselves bar the use of combined hormonal contraceptives. If contraception is still needed, alternatives such as progestin-only methods or nonhormonal options (eg, copper IUD, nonhormonal methods) are considered safer for someone who smokes and is over 35.