At this year’s KHM congress, one of the topics discussed was the problem of cardiovascular risks associated with combined contraceptive pills. Based on the current research situation, PD Dr. med. Sibil Tschudin, Basel, referred to the possibilities in the preliminary clarification, whereby in particular the family history, age and nicotine consumption should be taken into account. Finally, she mentioned advantages and disadvantages of newer alternatives to combined oral contraception (COC).
The most frequent question PD Dr. med. Sibil Tschudin, Head Physician of the Department of Gynecological Social Medicine and Psychosomatics, Basel, is confronted with is the one about the risks of the pill. More precisely, it is about the risk of thrombosis with the so-called “combined oral contraception” (COC), the combined pill. Different generations can be distinguished here, based on when the product came onto the market. “Third-generation progestins in particular are suspected of increasing the likelihood of thrombosis,” Dr. Tschudin said. “Large epidemiological studies confirm this. Nevertheless, it is important to keep in mind that if the overall risk for thrombosis is low, the increase in risk is only slight. Other factors play a more important role.” In any case, age, family history of cardiovascular disease, nicotine use, weight, and BMI and blood pressure should be clarified. In those over 35 years of age, it is recommended to determine lipid status, liver function, fasting blood glucose, and thyroid-stimulating hormone (TSH). “In healthy nonsmoking women without risk factors, administration of low-dose COC is feasible up to age 50,” Dr. Tschudin emphasized.
Frequency of cardiovascular events
According to the Swiss Society of Gynecology and Obstetrics (SGGG), ovulation inhibitors with cyproterone acetate (CPA) in particular have a slightly higher thromboembolic risk than those with second-generation progestins (especially levonorgestrel). CPA preparations may still be prescribed for otherwise untreatable or insufficiently treatable androgenization symptoms, such as severe acne or hirsutism. Of course, only after a careful family history and an exact risk assessment. According to SGGG, the sole desire for contraception without androgenization symptoms is not an indication for ovulation inhibitors with CPA.
The World Health Organization (WHO) points to two additional factors: Overall, the risk of venous thrombosis increases with age, even without the pill. Nicotine use, on the other hand, exerts no significant influence in either young or older women using COC for contraception. The figures for myocardial infarction, ischemic insult, and hemorrhagic insult are quite different: here, too, the probability increases with age. However, if the COC-taking women are also smokers, the risk increases significantly. “I therefore generally do not prescribe COC to older women who smoke. Nor should patients suffering from migraine with aura take the pill,” says Dr. Tschudin.
Alternatives to COC
In addition to the combined pill, there are progestogen preparations such as the three-month injection or the implant. The disadvantage here is that the cycle cannot be controlled. “The irregular bleeding between periods can become a problem,” Dr. Tschudin knows. “Many people don’t like injections and don’t feel like going to the doctor every third month.” In addition, there are results from research that attest to products such as Depoprovera® (DMPA) having a negative effect on bone density, especially when used early in adolescence. DMPA should therefore only be prescribed for adults.
Implanon®, on the other hand, appears to have no effect, or at least a lesser effect, on bone density. Recently, a radiopaque model has been launched on the market, where correct insertion is better ensured thanks to a new applicator.
In conclusion, Dr. Tschudin once again summarized the most important requirements for a contraceptive: “It should be safe, reversible, have few side effects, be STI-safe, simple, convenient and inexpensive.” New forms and modes of application offer interesting alternatives here. The patch (Evra®) or the vaginal ring (NuvaRing®), for example, have the advantage that they work independently of gastrointestinal absorption (most pills have lactose in them). Furthermore, there is no first-pass effect with either of them.
Source: “Contraception – News and Worth Knowing for the Practice”, Seminar at the 15th Continuing Education Conference of the College of Family Medicine (KHM), June 20-21, 2013, Lucerne.
