PURLs

Prescribe This Combined OC With CV Safety in Mind

Clinician Reviews. 2017 August;27(8):36-38

References

1. Weill A, Dalichampt M, Raguideau F, et al. Low dose oestrogen combined oral contraception and risk of pulmonary embolism, stroke, and myocardial infarction in five million French women: cohort study. BMJ. 2016;353:i2002.
2. Lidegaard Ø, Løkkegaard E, Svendsen AL, et al. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ. 2009;339:b2890.
3. Lidegaard Ø, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. N Engl J Med. 2012;366:2257-2266.
4. Stegeman BH, de Bastos M, Rosendaal FR, et al. Different combined oral contraceptives and the risk of venous thrombosis: systematic review and network meta-analysis. BMJ. 2013;347:f5298.
5. FDA. Combined hormonal contraceptives (CHCs) and the risk of cardiovascular disease endpoints. www.fda.gov/downloads/drugs/drugsafety/ucm277384. Accessed July 5, 2017.
6. Seeger JD, Loughlin J, Eng PM, et al. Risk of thromboembolism in women taking ethinyl estradiol/drospirenone and other oral contraceptives. Obstet Gynecol. 2007;110:587-593.
7. European Medicines Agency. PhVWP monthly report on safety concerns, guidelines and general matters. 2012. www.ema.europa.eu/docs/en_GB/document_library/Report/2012/01/WC500121387.pdf. Accessed July 5, 2017.
8. FDA. FDA Drug Safety Communication: Updated information about the risk of blood clots in women taking birth control pills containing drospirenone. 2012. www.fda.gov/Drugs/DrugSafety/ucm299305.htm. Accessed July 5, 2017.
9. Tuppin P, de Roquefeuil L, Weill A, et al. French national health insurance information system and the permanent beneficiaries sample. Rev Epidemiol Sante Publique. 2010;58:286-290.
10. Moulis G, Lapeyre-Mestre M, Palmaro A, et al. French health insurance databases: what interest for medical research? Rev Med Interne. 2015;36:411-417.
11. Farmer RD, Lawrenson RA, Thompson CR, et al. Population-based study of risk of venous thromboembolism associated with various oral contraceptives. Lancet. 1997;349:83-88.
12. Lidegaard Ø, Nielsen LH, Skovlund CW, et al. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001-9. BMJ. 2011;343:d6423.
13. Zhang G, Xu X, Su W, et al. Smoking and risk of venous thromboembolism: a systematic review. Southeast Asian J Trop Med Public Health. 2014;45:736-745.
14. Akerlund M, Røde A, Westergaard J. Comparative profiles of reliability, cycle control and side effects of two oral contraceptive formulations containing 150 micrograms desogestrel and either 30 micrograms or 20 micrograms ethinyl oestradiol. Br J Obstet Gynaecol. 1993;100:832-838.

WHAT’S NEW?

Low-dose estrogen + levonorgestrel confer lowest risk

Prior studies have shown that COCs increase the risk for PE and may also increase the risks for ischemic stroke and MI.^3,11 Studies have also suggested that a higher dose of estrogen in COCs is associated with an increased risk for VTE.^11,12 This study shows that 20 µg of estrogen combined with levonorgestrel is associated with the lowest risks for PE, MI, and ischemic stroke.

CAVEATS

Cohort study, no start date, incomplete tobacco use data

This is an observational cohort study, so it is subject to confounding factors and biases. It does, however, include a very large population, which improves validity. The study did not account for COC start date, which may be confounding because the risk for VTE is highest in the first three months to one year of COC use.¹² Data on tobacco use, a significant independent risk factor for arterial but not venous thromboembolism, was incomplete; however, in other studies, it has only marginally affected outcomes.^3,13

CHALLENGES TO IMPLEMENTATION

Increased vaginal spotting

One potential challenge to implementing this practice changer may be the increased rate of vaginal spotting associated with low-dose estrogen. COCs containing 20 µg of estrogen are associated with spotting in approximately two-thirds of menstrual cycles over the course of a year.¹⁴ That said, women may prefer to endure the spotting in light of the improved safety profile of a lower-dose estrogen pill.

ACKNOWLEDGEMENT

The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice (2017;66[7]:454-456).

Prescribe This Combined OC With CV Safety in Mind

References

WHAT’S NEW?

Low-dose estrogen + levonorgestrel confer lowest risk

CAVEATS

Cohort study, no start date, incomplete tobacco use data

CHALLENGES TO IMPLEMENTATION

Increased vaginal spotting

ACKNOWLEDGEMENT

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