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Patients should be counseled about the various types of long-term contraception, i.e., contraceptive methods that are effective and reversible and do not require daily application: for example, gestagen implants or copper or hormone spirals. Such methods were, at one time, mainly used by women over age 35 who did not want to have any more children. But women are now older on the average when they bear their first child (2017: 29 years and 10 months), and the period of time in which they want contraception before their first pregnancy has become correspondingly longer (e5). As a result, long-term contraception (intrauterine methods, gestagen implants and injections) has become a more commonly used option in younger patients. Depot medroxyprogesterone acetate (MPA) is not suitable for this purpose, because ovulation may not return for up to nine months after it is discontinued (e1).

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Long-term contraception was, at one time, mainly used by women over age 35 who did not want to have any more children. Because women are now older on the average when they bear their first child, long-term contraception has become a more common option for younger women as well.

Obesity is considered a risk factor for the use of combined oral contraceptives both in the WHO recommendations and in the German Red Hand Letter (2, 4). The WHO recommendations assign a score of 2 (=no contraindication) to the used of combined oral contraceptives in obese women who have no further risk factors, but this is only rarely the case, and meticulous history-taking is needed to determine which further risk factors these patients have. If hypertension, hyperlipidemia, or diabetes mellitus is present, then another contraceptive method should be chosen, e.g., gestagens (1). Obese women have a tenfold elevation of the thrombotic risk under treatment with combined oral contraceptives, compared to women of normal weight who are not taking combined oral contraceptives (5). The more obese the patient, the higher the risk (up to a 24-fold elevation) (6).

Smoking is the single most important risk factor; the factor V Leiden mutation, which is not uncommon, is a further one. The risk of thrombosis in women with the factor V Leiden mutation who take oral contraceptives is likewise influenced by the particular gestagen contained in the preparation.

The types of hepatic tumor include benign lesions, such as hemangioma, adenoma, and focal nodular hyperplasia (FNH), as well as malignant ones, such as hepatocellular carcinoma and hepatoblastoma. When combined oral contraceptives are taken, hemangiomas can develop, even in adolescents (1). FNH and adenomas can arise after many years of use of combined oral contraceptives (COC); there is a positive correlation with the dose of ethinyl estradiol. The long-term use of COC has been found to be associated with an elevated risk of hepatic disease, although the evidence for this comes mainly from older studies in which the COC that were used contained 50 µg of ethinyl estradiol (1). More recent studies have shown that, in women with focal nodular hyperplasia, the use of low-dose COC does not lead to any progression or regression of the hepatic findings (28, 29). According to a meta-analysis, the evidence regarding malignant tumors, such as hepatocellular carcinoma, is mix