How would you counsel a woman with a strong family history of thrombosis about oral contraceptives?

This can be a complex question for which there are likely no specific data or guidelines upon which to base a recommendation. ASH has published guidelines on thrombophilia testing in VTE (Middeldorp et al., PMID 37195076). They specifically recommend against testing prior to COC prescription. The rationale/basis makes for very interesting reading. However, they focus on hereditary thrombophilia. There is no discussion on acquired thrombophilia, e.g., antiphospholipid antibodies. Hence, antiphosp...

First, does she have a rheumatic diagnosis? If not, she would have the same risk of thrombosis using combined hormonal contraceptives as any other patient.

The US CDC MEC, updated in 2024, makes no indication for choosing contraception based on family history.

This patient, however, may deserve a workup with hematology for thrombophilia, but perhaps her family member has already been through this to know any genetic diagnoses that would impact her contraceptive options.