ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions

Hormonal Contraception and Risk of Cardiometabolic Disease in Women with HIV

Objective: We sought to determine the association of hormonal contraception (HC) and cardiometabolic outcomes among women with human immunodeficiency virus (HIV). Methods: We included women with HIV aged 18-45 years in clinical care in the Southeastern United States between 1998 and 2018. Oral and injectable HC use was captured from medication records. Our outcomes included incident cardiovascular/thrombotic disease (CVD) (atherosclerosis, hypertension, cerebrovascular disease, thrombosis, and heart failure) and incident metabolic disorders (diabetes, dyslipidemia, obesity, and non-alcoholic steatohepatitis). We excluded women with prevalent conditions. We used multivariable marginal structural models to examine time-varying current and cumulative HC use and cardiometabolic outcomes in separate analyses, adjusting for age, race, smoking, time-varying comorbidities, CD4 cell count, HIV RNA, and antiretroviral use. Women with HC exposure were compared with women without HC exposure. Results: Among the 710 women included, 201 women (28%) used HC. CVD analyses included 603 women without prevalent CVD and 93 incident events; metabolic analyses included 365 women without prevalent metabolic disease and 150 incident events. Current and cumulative oral HC use was associated with increased odds of CVD, though this was not statistically significant (adjusted odds ratio [aOR] = 2.08, [95% confidence interval (CI): 0.80-5.43] and aOR = 1.24 [95% CI: 0.96-1.60] per year of use, respectively). Oral HC was not associated with risk of incident metabolic disorders. Depot medroxyprogesterone acetate (DMPA) was not associated with risk of incident CVD. Current and cumulative DMPA use was significantly associated with decreased odds of incident metabolic disorders (aOR = 0.48 [95% CI: 0.23, 1.00] and aOR = 0.65 [95% CI: 0.42-1.00] per year of use, respectively). Conclusion: Our results suggest that cardiovascular risk should be considered when selecting contraception for women with HIV.

The Impact of Regular Screening and Lifestyle Modification on Cardiovascular Disease Risk Factors in South African Women Living With HIV

BACKGROUND

The Integration of cardiovascular disease SCreening and prevention in the HIV MAnagement plan for women of reproductive age study set out to determine the effectiveness of screening and lifestyle modification in modifying cardiovascular disease (CVD) risk factors in women living with HIV (WLHIV).

METHODS

In this prospective, quasiexperimental, intervention study, WLHIV aged 18-<50 years were enrolled from 2 clinics (intervention [I-arm]) and (control arms [C-arm]) in Umlazi, South Africa, between November 2018 and May 2019. Women in the I-arm received lifestyle modification advice on diet, physical activity, alcohol use, and smoking cessation and underwent annual screening for CVD risk. The CVD risk factors were assessed through standardized questionnaires and clinical and laboratory procedures at baseline and at end of 3 years of follow-up. Prevalence of metabolic syndrome and other CVD indices were compared between arms at end-of-study (EOS).

RESULTS

Total of 269 WLHIV (149 I-arm and 120 C-arm) with a mean ± SD age of 36 ± 1 years were included in the EOS analyses after 32 ± 2 months of follow-up. The metabolic syndrome prevalence at EOS was 16.8% (25/149) in the I-arm and 24% (24/120) in the C-arm (risk ratio 0.9; 95% CI: 0.5 to 1.1; P 0.86). Proportion of women with fasting blood glucose >5.6 mmol/L in the I-arm and C-arm were 2.7% (4/149) and 13.3% (16/120) respectively (risk ratio 0.2; 95% CI: 0.069 to 0.646; P < 0.01). High-density lipoprotein improved with the intervention arm from baseline to EOS (95% CI: -0.157 to -0.034; P < 0.05).

CONCLUSIONS

Although there was no significant difference in the prevalence of metabolic syndrome between study arms, we observed decreased blood glucose levels in the I-arm compared with the C-arm and improved high-density lipoprotein within the I-arm, following lifestyle modification and regular screening for CVD risk factors in WLHIV.

Developing practical recommendations for drug-disease interactions in patients with hypertension

Background

Hypertension, a significant risk factor for cardiovascular diseases, demands proactive management as cardiovascular diseases remain the leading cause of death worldwide. Reducing systolic and diastolic blood pressure levels below recommended reference values of <140/90 mmHg can lead to a significant reduction of the risk of CVD and all-cause mortality. However, treatment of hypertension can be difficult and the presence of comorbidities could further complicate this treatment. Drugs used to manage these comorbidities may inadvertently have an impact on blood pressure, resulting in a phenomenon known as drug-disease interaction. This study aims to assess the safety of medication that can affect blood pressure in patients with hypertension and provide practical recommendations for healthcare professionals.

Methods

For the development of recommendations for the drug-disease interaction (DDSI) hypertension, a six-step plan that combined literature selection and multidisciplinary expert opinion was used. The process involved (1) defining the scope of the DDSI and selecting relevant drugs, (2) collecting evidence, (3) data-extraction, (4) reaching of expert consensus, (5) publication and implementation of the recommendations in healthcare systems and (6) updating the information.

Results

An increase of 10 mmHg in systolic blood pressure and 5 mmHg in diastolic blood pressure was defined as clinically relevant. Corticosteroids, danazol, and yohimbine caused a clinically relevant DDSI with hypertension. Several other drugs with warnings for hypertension in the official product information were assessed to have no clinically relevant DDSI due to minor influence or lack of data on blood pressure. Drugs with evidence for a relevant change in blood pressure which are prescribed under close monitoring of blood pressure according to clinical guidelines, were deemed to be not clinically relevant for signalling.

Conclusion

This study provides specific recommendations that can be implemented directly in clinical practice, for example, in clinical decision support systems, potentially resulting in safer drug use in patients with hypertension and better healthcare by reducing alert fatigue. Future research should focus on evaluating the effectiveness of implementation strategies and their impact on reducing unsafe use of medication in patients with hypertension.

Hormonal Contraception and Menstrual Cycle Control at High Altitude: A Scoping Review-UIAA Medical Commission Recommendations

Horakova, Lenka , Susi Kriemler, Vladimír Študent, Jacqueline Pichler Hefti, David Hillebrandt, Dominique Jean, Kastė Mateikaitė-Pipirienė, Peter Paal, Alison Rosier, Marija Andjelkovic, Beth Beidlemann, Mia Derstine, and Linda E. Keyes. Hormonal contraception and menstrual cycle control at high altitude: a scoping review-UIAA Medical Commission recommendations. High Alt Med Biol. 00:00-00, 2024. Background: Women who use hormonal contraception (HC) may have questions about their use during travel to high altitude. This scoping review summarizes current evidence on the efficacy and safety of HC and cycle control during high-altitude travel. Methods: We performed a scoping review for the International Climbing and Mountaineering Federation (UIAA) Medical Commission series on Women's Health in the Mountains. Pertinent literature from PubMed and Cochrane was identified by keyword search combinations (including contraception) with additional publications found by hand search. Results: We identified 17 studies from 7,165 potentially eligible articles. No articles assessed the efficacy of contraception during a short-term high-altitude sojourn. Current data show no advantage or disadvantage in HC users for acclimatization or acute mountain sickness (AMS). Use of HC during high-altitude travel is common and safe for menses suppression. A potential concern of estrogen-containing HC is the increased thrombotic risk, which theoretically could be compounded in hypobaric hypoxia. Conclusions: Evidence is limited for the interaction of HC and high altitude on performance, thrombosis, and contraceptive efficacy. HC does not affect the risk of AMS. The most efficacious and safest method at high altitude is generally the one women are most familiar with and already using.

Contraceptive Recommendations for Women with Immune-Mediated Inflammatory Diseases: A Delphi Consensus

INTRODUCTION

Immune-mediated inflammatory diseases (IMID) are a group of disorders characterized by chronic inflammation caused by an altered immune regulation in targeted organs or systems. IMID itself could have an implied increased risk of venous thromboembolism (VTE) and this risk varies throughout the course of the disease as well as with some contraceptive methods and treatments. The aim of this study was to present some key considerations in relation to contraception in women with IMID.

METHODS

This was an exploratory study conducted in Spain following the online modified Delphi methodology with two rounds of participation. Four questionnaires were designed for each medical specialty: gastroenterology, rheumatology, dermatology, and gynecology. Each questionnaire was divided in three domains: general recommendations about IMID, specific recommendations, and contraceptive methods for patients with IMID. A 5-point Likert scale measured agreement with each statement, with an 80% agreement threshold. Following the first round, the percentage of each response was calculated for every item. Subsequently, a second round was conducted to reach a consensus on the items for which discrepancies were observed.

RESULTS

A total of 52 and 50 experts participated in the first and second round, respectively. Participants agreed on the existence of a higher risk of VTE in inflammatory bowel diseases, psoriasis, and rheumatoid arthritis diseases. Regarding recommendations for contraceptive methods in patients with IMID, experts considered the hormonal intrauterine device (IUD) as a first-line contraceptive (80.0%) and low doses of progesterone-only pills if the latter is not recommended (88.0%). Most of the interviewees concurred on the importance of the patients' contraceptive needs during the disease course (98.1%).

CONCLUSION

Raising awareness and promoting a multidisciplinary relationship among the physicians involved in the therapeutic decisions by considering all the risk factors when prescribing a contraceptive method is important to prevent VTE in women with IMID.

[Diabetes and women, why are we different?]

Diabetes affects men and women differently and the mistaken assumption of equality in its clinical expression can lead to errors and delays in the diagnostic process and the therapeutic strategy adopted. The objective is to show the gender differences that influence the approach to this pathology and what the role of the family doctor is in the monitoring of women with diabetes. It is a review of the impact of diabetes at different stages of a woman's life, how hormonal changes affect glycemic control, gestational diabetes, how diabetes affects the development of chronic complications in women and their consequences, the existing differences in the control of cardiovascular risk factors and the differential aspects by sex of the different families of drugs used in the treatment of diabetes.

Cerebral venous sinus thrombosis due to desogestrel intake in a young lady: A case report

Cerebral Venous Sinus Thrombosis (CVST) is a subtype of venous thromboembolism, which occurs in the dural venous sinuses. Blockage of the venous drainage of the brain leads to the development of hemorrhages. Strokes can hence develop in any individual, irrespective of age or sex. CVST is a very serious condition requiring immediate thrombolysis to prevent residual neurological deficits. We report the case of a lady aged 25 years, who presented to the emergency department with a severe diffuse headache for 4 days, associated with vomiting. This was followed by multiple episodes of seizures and altered sensorium the previous day. She had been taking desogestrel for the past 2 months. On examination, the patient was unconscious and febrile (102.8 F). On admission, Glasgow Coma Scale score of E2V2M3 and bilateral extensor plantar response were noted. Signs of meningeal irritation were absent. Her pupils were mid-dilated, sluggishly reactive to light, and papilledema was present bilaterally. Based on imaging studies, she was diagnosed with a case of CVST. Her homocysteine levels were elevated. She recovered on appropriate treatment and was discharged on Ryle's feeding tube after 26 days of hospital stay with a Glasgow Coma Scale score of E4V5M6 and a flexor plantar response. The case emphasizes the need to rule out CVST in young adult females on oral contraceptive pills (OCP) presenting with severe neurological dysfunction. Vigilant screening, clinical suspicion and timely management can help cut down the associated mortality and morbidity in such cases.

Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

Management of Friedreich Ataxia-Associated Cardiomyopathy in Pregnancy: A Review of the Literature

A major manifestation of Friedreich ataxia (FRDA) is cardiomyopathy, caused by mitochondrial proliferation in myocytes. Because the lifespan for patients with FRDA improves with better treatment modalities, more patients are becoming pregnant, meaning that more medical providers must know how to care for this population. This report provides a review of the literature on multidisciplinary management of pregnant patients with FRDA and cardiomyopathy from preconception through lactation. A cardio-obstetrics team, including cardiology, anesthesiology, and obstetrics, should be involved for this entire period. All patients should be counseled on pregnancy risk using elements of existing stratification systems, and contraception should be discussed, highlighting the safety of intrauterine devices. Electrocardiogram should be obtained at baseline and each trimester, looking for atrial arrhythmias and ST-segment changes, as should transthoracic echocardiogram, with a focus on left ventricular ejection fraction-which is typically normal in FRDA cardiomyopathy-and relative wall thickness and global longitudinal strain-which tend to decrease as cardiomyopathy progresses. Brain natriuretic peptide is also a helpful marker to detect adverse events. If heart failure develops, it should be treated like any other etiology of heart failure during pregnancy. Atrial arrhythmias should be treated with β blockers or electrical cardioversion and anticoagulation, as necessary. Most patients with FRDA can deliver vaginally, and neuraxial analgesia is recommended during labor because of the risks associated with general anesthesia. Breastfeeding is encouraged, even for those taking cardiac medications.

Cardiovascular diseases in women - Consensus document of the Sociedade Portuguesa de Cardiologia, Sociedade Portuguesa de Ginecologia, Sociedade Portuguesa de Obstetrícia e Medicina Materno-Fetal, Sociedade Portuguesa de Contraceção e Associação Portuguesa de Medicina Geral e Familiar

The main objective of this consensus statement from the Portuguese Society of Cardiology, the Portuguese Society of Gynecology, the Portuguese Society of Obstetrics and Maternal-Fetal Medicine, Portuguese Society of Contraception, Portuguese Association of General Practice and Family Medicine is to improve cardiovascular care for women. It includes a brief review of the state-of-the-art of cardiovascular diseases in women and of the links to other fields such as Gynaecology, Obstetrics and Endocrinology. It also provides final recommendations to help clinicians working in care of women's health.

The potential impact of tobacco use on female fertility and pregnancy outcomes: An invited scientific review by EBCOG

Tobacco use in pregnant women remains prevalent with an estimated prevalence of 8.1 % in the European region. In whatever form it is partaken, tobacco use is associated with significant short- and long-term consequences for both the mother and the progeny thus making the habit an important obstetric and public health concern. It is recommended that an active intervention policy should be adopted by healthcare providers to promote preconception smoking cessation and provide services for counselling with behavioural modification support, and the provision of smoking cessation pharmaceutical services. Women who continue to smoke should have closer antenatal surveillance throughout the whole of pregnancy.

Predicted Pharmacokinetic Interactions Between Hormonal Contraception and Single or Intermittently Dosed Rifampicin

The scale-up of rifampicin-based prevention regimens is an essential part of the global leprosy strategy. Daily rifampicin may reduce the effectiveness of the oral contraceptive pill (OCP), but little is known about the effects of rifampicin at the less frequent dosing intervals used for leprosy prophylaxis. As many women of reproductive age rely on OCP for family planning, evaluating the interaction with less-than-daily rifampicin regimens would enhance the scalability and acceptability of leprosy prophylaxis. Using a semi-mechanistic pharmacokinetic model of rifampicin induction, we simulated predicted changes in OCP clearance when coadministered with varying rifampicin dosing schedules. Rifampicin given as a single dose (600 or 1200 mg) or 600 mg every 4 weeks was not predicted to result in a clinically relevant interaction with OCP, defined as a >25% increase in clearance. Simulations of daily rifampicin were predicted to increase OCP clearance within the range of observed changes previously reported in the literature. Therefore, our findings suggest that OCP efficacy will be maintained when coadministered with rifampicin-based leprosy prophylaxis regimens of 600 mg once, 1200 mg once, and 600 mg every 4 weeks. This work provides reassurance to stakeholders that leprosy prophylaxis can be used with OCP without any additional recommendations for contraception prevention.

Breastfeeding and Hormonal Contraception: A Scoping Review of Clinical Guidelines, Professional Association Recommendations, and the Literature

Background: Postpartum contraceptive use can help prevent short-interval pregnancies, which have been associated with adverse neonatal and maternal health outcomes. Many contraceptive methods are safe for postpartum use, but patients and providers may be confused as to what impact hormonal contraception has on lactation. We performed a scoping review of the most recent U.S.-based guidelines regarding hormonal contraception on lactation to provide synthesis and recommendations to aid providers in counseling their patients. Methods: We conducted a scoping review by identifying the most recent clinical recommendations and guidelines from the Centers for Disease Control and Prevention (CDC) and three maternal and child health professional associations (American College of Obstetricians and Gynecologists [ACOG], Society for Maternal-Fetal Medicine [SMFM], and Academy of Breastfeeding Medicine [ABM]). We also reviewed the citations in these guidelines used in their development. We then conducted an updated literature review to capture studies published since the most recent systematic reviews were conducted. Results: We reviewed 1 clinical guideline from the CDC and 2 systematic reviews cited in its references, 6 professional association recommendations, and 28 publications identified through the updated literature review. Progestin-only contraceptive methods continue to demonstrate safety in breastfeeding patients, while low-quality evidence supports concerns of decreased milk supply with combined hormonal contraception. Discussion: Organizations should consider updating counseling recommendations regarding progestin-only contraceptives and lactation. Further research is needed to examine new contraceptive methods as well as the effect of hormonal contraception on lactation in the setting of preterm birth.

Norethindrone dosing for adequate menstrual suppression in adolescents

OBJECTIVES

We sought to study factors predictive of achieving menstrual suppression with norethindrone vs. norethindrone acetate in adolescents, as optimal dosing is unknown. Secondary outcomes included analyzing prescriber practices and patient satisfaction.

METHODS

We performed a retrospective chart review of adolescents ages <18 years presenting to an academic medical center from 2010 to 2022. Data collected included demographics, menstrual history, and norethindrone and norethindrone acetate use. Follow-up was measured at one, three, and 12 months. Main outcome measures were starting norethindrone 0.35 mg, continuing norethindrone 0.35 mg, achieving menstrual suppression, and patient satisfaction. Analysis included Chi-square and multivariate logistic regression.

RESULTS

Of 262 adolescents initiating norethindrone or norethindrone acetate, 219 completed ≥1 follow-up. Providers less often started norethindrone 0.35 mg for patients with body mass index ≥25 kg/m2, prolonged bleeding, or younger age at menarche, but more often for patients who were younger, had migraines with aura, or were at risk of venous thromboembolism. Those with prolonged bleeding or older age at menarche were less likely to continue norethindrone 0.35 mg. Obesity, heavy menstrual bleeding, and younger age were negatively associated with achieving menstrual suppression. Patients with disabilities reported greater satisfaction.

CONCLUSIONS

While younger patients more often received norethindrone 0.35 mg vs. norethindrone acetate, they were less likely to achieve menstrual suppression. Patients with obesity or heavy menstrual bleeding may achieve suppression with higher doses of norethindrone acetate. These results reveal opportunities to improve norethindrone and norethindrone acetate prescribing practices for adolescent menstrual suppression.

Migraine and the Gender Divide

Migraine is a global neurologic disease that is highly prevalent, especially in women. Studies have observed a predisposition for the development of migraine in women, although the mechanisms involved have yet to be fully elucidated. This review aimed to summarize the recent evidence regarding the epidemiology, pathophysiology, and treatment of migraine and highlight key sex differences. We also identify gaps in care for both women and men living with migraine and discuss the presence of migraine-related stigma and how this may impact the efficacy of clinical care.

Oral Contraceptive Pills and Hypertension: A Review of Current Evidence and Recommendations

Oral contraceptive pills (OCPs) have been used as effective and popular forms of contraception since the middle of the last century. By 2019, over 150 million reproductive-aged individuals were using OCPs to prevent unintended pregnancies worldwide. Safety concerns regarding the effects of OCPs on blood pressure were reported soon after these pills gained approval. Although OCP doses were subsequently reduced, epidemiologic evidence continued to support a smaller, but significant association between OCPs and hypertension. Given the rising prevalence of hypertension, as well as the adverse effects of cumulative exposure to blood pressure elevations on cardiovascular disease risk, understanding the nature of the association between OCPs and hypertension is important for clinicians and patients to assess the risks and benefits of use, and make individualized decisions regarding contraception. Therefore, this review summarizes the current and historical evidence describing the association between OCP use and blood pressure elevations. Specifically, it identifies the pathophysiologic mechanisms linking OCPs to hypertension risk, describes the magnitude of the association between OCPs and blood pressure elevations, and distinguishes the effects of various OCP types on blood pressure. Finally, it describes current recommendations regarding hypertension and OCP use, as well as identifies strategies, such as over-the-counter OCP prescribing, to safely and equitably improve access to oral contraception.

Considerations for Contraceptive Use Among Patients with Migraines

Purpose of Review

There is an overlap in the populations of patients who suffer from migraine headaches and patients who seek contraception. The purpose of this review is to present recent studies on contraception among patients with migraines and provide clinical recommendations.

Recent Findings

Migraine with aura and combined hormonal contraceptive (CHC) use are associated with increased ischemic stroke risk. The use of CHCs in patients with migraine with aura produces a higher risk of ischemic stroke than either factor individually; therefore, CHC is contraindicated in this population by certain guidelines. However, recent studies suggest that oral contraceptive may reduce migraine days, pain scores, and migraine medication use.

Summary

Certain guidelines recommend against use of CHCs in patients with migraine with aura. CHC use is acceptable among patient with migraines without aura. In patients with menstrual-related migraines, there may be benefit from continuous use of oral contraceptives. Further studies are needed on migraine and specific formulations of CHC, if the frequency of migraines with aura impacts ischemic stroke risk and the impact of oral and non-oral contraceptives on menstrual headaches.

Hypertension across a Woman's lifespan

Hypertension is a leading risk factor for cardiovascular disease in women. Both traditional and sex-specific risk modifiers occurring from menarche to pregnancy to menopause modulate the risk of hypertension and adverse cardiovascular events. This review provides a narrative summary of risk and treatment of hypertension in women across the lifespan, from adolescence to the post-menopausal period, where each period represents a potential window for risk assessment, diagnosis, and appropriate treatment. Management of hypertension throughout a woman's life must be included in a holistic cardiovascular prevention approach for women in order to prevent future cardiovascular complications.

Evaluating Shared Decision-Making in Postpartum Contraceptive Counseling Using Objective Structured Clinical Examinations

BACKGROUND

Shared decision-making (SDM) may support widespread uptake of progestin-containing long-acting reversible contraceptives in the immediate postpartum period. We piloted an Objective Structured Clinical Examination (OSCE) to evaluate first-year obstetrics and gynecology resident physicians' use of SDM in postpartum contraception counseling.

METHODS

As part of their 2015 and 2016 OSCEs, first-year OB/GYN residents were instructed to provide contraceptive counseling to a Standardized Patient (SP) portraying a 29-year-old postpartum patient seen during rounds on the morning following her delivery. Three investigators independently scored each resident encounter using a 10-item rubric adapted from a 9-item SDM measure and assigned scores of 0 (absent), 1 (partial), or 2 (complete). Each encounter was video and audio recorded, then transcribed for qualitative analysis. Descriptive statistics was produced using SPSS version 24.

RESULTS

Eighteen residents participated. The majority (78%) discussed contraceptive options and timing of initiation. Nearly 33% elicited factors most important to the SP in influencing her preference. Only 6% discussed the benefits of exclusive breastfeeding, and few addressed the uncertainty of progesterone on milk supply and production.

CONCLUSION

Although residents conveyed ample clinical information, the vast majority did not discuss elements of SDM, such as her preferences, values, and goals for future fertility and breastfeeding. Our work revealed that critical elements of SDM are often not explored and deliberated by resident physicians. Trainings (e.g., OSCEs) are needed to equip residents with effective communication skills to facilitate more SDM in postpartum contraceptive care.

Smoking and combined oral contraceptives should be considered as an independent variable in sex and gender-oriented studies

The influence of sex combined with smoking and combined oral contraceptives (COC) use on atherogenic indexes is scarcely studied. Thus, traditional lipid parameters were measured, and non-traditional atherogenic indexes were calculated in a young and healthy population of men, COC-free women, and COC users. Total cholesterol (TChol), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and HDL/LDL ratio were lower in men, while triglycerides (TG)/HDL ratio, atherogenic index of plasma (AIP), Castelli's Risk Index I (CRII) and CRI-II, atherogenic coefficient (AC), creatinine, creatinine clearance, and estimated glomerular filtration rate (eGFR) were higher in men. The use of COC modified TChol, HDL, TG, TG/HDL, and AIP which had significantly higher values in COC users. In addition, TG were also increased in COC users in comparison with men. Smoking reduced sexually divergent parameters: BMI, TG, HDL/LDL, TG/HDL, AIP, CRII, CRI-II, and AC became similar among the three cohorts, losing the reported sex differences. Smoking also reduced differences in TChol, HDL, TG, and AIP between COC-free women and COC users, but it does not affect CRII, CRI-II, creatinine, creatinine clearance, and eGFR, underlining that COC users and COC-free women have to be considered two different populations. Our results represent a complex landscape suggesting that for both sexes smoking should be an independent variable in medical studies. Moreover, in women, the use of COC evidenced two different cohorts. Thus, more variables should be considered during a single study indicating that sex, smoking, and COC should be studied together to get a picture of the real-life context.

Hypertension Across a Woman's Life Cycle

PURPOSE OF REVIEW

We reviewed the effects of hypertension and the means to prevent and treat it across the spectrum of a woman's lifespan and identified gaps in sex-specific mechanisms contributing to hypertension in women that need to be addressed.

RECENT FINDINGS

Hypertension continues to be an important public health problem for women across all life stages from adolescence through pregnancy, menopause, and older age. There remain racial, ethnic, and socioeconomic differences in hypertension rates not only overall but also between the sexes. Blood pressure cutoffs during pregnancy have not been updated to reflect the 2017 ACC/AHA changes due to a lack of data. Additionally, the mechanisms behind hypertension development in menopause, including sex hormones and genetic factors, are not well understood. In the setting of increasing inactivity and obesity, along with an aging population, hypertension rates are increasing in women. Screening and management of hypertension throughout a women's lifespan are necessary to reduce the burden of cardiovascular disease, and further research to understand sex-specific hypertension mechanisms is needed.

Contraceptive Use in Premenopausal Women With Early Breast Cancer

IMPORTANCE

As life span has increased among patients with cancer, survivorship has become an important component of breast cancer care. Among survivorship concerns, adequate contraceptive counseling is needed for premenopausal patients who are not seeking to become pregnant.

OBJECTIVE

To examine contraceptive use and chosen methods and to assess factors associated with contraceptive use over time in patients with early breast cancer.

DESIGN, SETTING, AND PARTICIPANTS

The Cancer Toxicity (CANTO) study was a multicenter nationwide prospective cohort study that enrolled women diagnosed with stage I to stage III breast cancer in France between March 2012 and December 2017. This analysis included 2900 premenopausal women who were 50 years of age or younger at diagnosis. Data were analyzed from July 2020 to July 2022.

EXPOSURES

Contraceptive use and method at diagnosis, shortly after the end of primary treatment (year 1), and during follow-up (year 2).

MAIN OUTCOMES AND MEASURES

Contraceptive use and methods were longitudinally evaluated at diagnosis, year 1, and year 2 after breast cancer diagnosis. Multivariable logistic regression models were used to assess the associations of clinical, socioeconomic, treatment, adverse effect, and patient-reported outcome variables with contraceptive use after diagnosis.

RESULTS

A total of 2900 patients (mean [SD] age, 43.1 [5.6] years) were included in the analysis; 2050 of 2894 women (70.8%) received chemotherapy, and 2305 of 2880 women (80.0%) received endocrine therapy. After diagnosis, 1182 of 2625 patients (45.0%) at year 1 and 1553 of 2363 patients (65.7%) at year 2 reported consulting with a gynecologist in the previous year. At diagnosis, 1487 of 2744 patients (54.2%) reported contraceptive use, with most patients (921 of 1470 women [62.7%]) using hormonal methods. The use of contraception significantly decreased after diagnosis (911 of 2342 patients [38.9%] at year 1 and 808 of 1961 patients [41.2%] at year 2; P < .001 for trend), when most patients (848 of 900 women [94.2%] at year 1 and 767 of 805 women [95.3%] at year 2) reported use of nonhormonal methods; these methods were primarily reversible mechanical approaches (copper intrauterine devices: 656 of 848 patients [77.4%] at year 1 and 577 of 767 patients [75.2%] at year 2; male condoms: 115 of 848 patients [13.6%] at year 1 and 110 of 767 patients [14.3%] at year 2). In the multivariable model, factors significantly associated with contraceptive use at year 1 included using contraception at diagnosis (adjusted odds ratio [aOR], 4.02; 95% CI, 3.15-5.14), being younger (aOR, 1.09; 95% CI, 1.07-1.13 per decreasing year), having better sexual function (aOR, 1.13; 95% CI, 1.07-1.19 per 10-point increment), having children (aOR, 4.21; 95% CI, 1.80-9.86), reporting the presence of leukorrhea (aOR, 1.32; 95% CI, 1.03-1.70), receiving tamoxifen treatment alone (aOR, 1.39; 95% CI, 1.01-1.92), and consulting with a gynecologist in the previous year (aOR, 1.29; 95% CI, 1.02-1.63). Similar factors were associated with contraceptive use at year 2, with the addition of partnered status (aOR, 1.61; 95% CI, 1.07-2.44).

CONCLUSIONS AND RELEVANCE

Findings from this study support the importance of raising awareness and improving targeted contraceptive counseling for premenopausal women with early breast cancer.

Sex differences in hypertension. Do we need a sex-specific guideline?

Hypertension is the most prevalent cardiovascular disorder and the leading cause of death worldwide in both sexes. The prevalence of hypertension is lower in premenopausal women than in men of the same age, but sharply increases after the menopause, resulting in higher rates in women aged 65 and older. Awareness, treatment, and control of hypertension are better in women. A sex-pooled analysis from 4 community-based cohort studies found increasing cardiovascular risk beginning at lower systolic blood pressure thresholds for women than men. Hormonal changes after the menopause play a substantial role in the pathophysiology of hypertension in postmenopausal women. Female-specific causes of hypertension such as the use of contraceptive agents and assisted reproductive technologies have been identified. Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality, as well as with a greater risk of developing cardiovascular disease later in life. Hypertension-mediated organ damage was found to be more prevalent in women, thus increasing the cardiovascular risk. Sex differences in pharmacokinetics have been observed, but their clinical implications are still a matter of debate. There are currently no sufficient data to support sex-based differences in the efficacy of antihypertensive treatment. Adverse drug reactions are more frequently reported in women. Women are still underrepresented in large clinical trials in hypertension, and not all of them report sex-specific results. Therefore, it is of utmost importance to oblige scientists to include women in clinical trials and to consider sex as a biological variable.

Recent advances in targeting calcitonin gene-related peptide for the treatment of menstrual migraine: A narrative review

Menstrual migraine (MM) has a longer duration and higher drug resistance than non-perimenstrual migraine. Calcitonin gene-related peptide (CGRP) and CGRP receptors are expressed in the peripheral and central nervous systems throughout the trigeminovascular system. The CGRP/CGRP receptor axis plays an important role in sensory physiology and pharmacology. CGRP receptor antagonists and anti-CGRP monoclonal antibodies (mAbs) have shown consistent efficacy and tolerability in the prevention of chronic or episodic migraine and are now approved for clinical use. However, few studies have reported the use of these drugs in MM, and no specific treatment for MM has been approved. This review aimed to shed light on the recent advances in targeting calcitonin gene-related peptides for the treatment of menstrual migraines in PubMed. In this review, we first discuss the axis of the CGRP/CGRP receptor. We then discuss the role of CGRP receptor antagonists and anti-CGRP mAbs in MM treatment. Finally, we discuss the role of the combination of anti-CGRP mAbs and CGRP receptor antagonists in migraine treatment and the drugs that inhibit CGRP release. Altogether, the anti-CGRP mAbs or CGRP receptor antagonists showed good efficacy and safety in the treatment of MM.

Society of Family Planning Clinical Recommendation: Extended Use of Long Acting Reversible Contraception

In this clinical recommendation, we review the evidence supporting the use of the copper intrauterine device, levonorgestrel intrauterine devices and etonogestrel subdermal implant beyond the Food and Drug Administration approved duration of use for contraception (extended use). Clinicians should discuss effectiveness as well as other clinical considerations with patients to allow them to make contraceptive decisions that support their reproductive goals and clinical needs. Extended use of long acting reversible contraception may be a safe, effective and desirable option for many patients.

Contraceptive decisions among individuals with medical conditions in Michigan, USA: A qualitative explanatory model informed by the Health Belief Model and the principle of respect for patient autonomy

OBJECTIVE

We aimed to qualitatively describe the contraceptive experiences of individuals with medical conditions and develop an explanatory model of contraceptive decision-making in this context.

STUDY DESIGN

We conducted 41 interviews with pre-menopausal patients with a range of medical conditions from Michigan, USA. We identified themes through open coding and comparative analysis until we reached theoretical saturation. We analyzed the themes in the context of the Health Belief Model constructs and patient autonomy. To develop the explanatory model, we qualitatively mapped out relationships between constructs and how they informed contraceptive-decision making.

RESULTS

The model posits that contraceptive decisions are affected by the perceived impact of chronic disease on pregnancy, parenting, and contraceptive options. These perceptions were strongly affected by others, particularly health care providers (HCPs). Most worried that pregnancy could threaten their health, fetal health, or ability to parent. Active symptoms of chronic disease (e.g., pain, fatigue) amplified this perceived threat. Patients appreciated when their HCPs acknowledged, rather than dismissed, their concerns about contraceptive side effects that affected their chronic disease symptoms and management (e.g., headaches, worsening mood). Patients with medical contraindications to hormonal contraception and preferred to use coital-dependent methods (e.g. condoms) did not feel supported to do so by their HCPs. Patients who were Black, young, living on low-incomes, or considered medically "high risk" felt discriminated against by HCPs who limited or coerced their contraceptive decisions.

CONCLUSIONS

This explanatory model synthesizes factors that underlie, constrain, or promote reproductive and contraceptive decisions and autonomy for individuals with medical conditions.

IMPLICATIONS

This new explanatory model can guide the development and evaluation of interventions that support the contraceptive decisions and autonomy of individuals with medical conditions.

Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease

Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.

Women's Cardiovascular Health: Selecting the Best Contraception

Basic knowledge about contraceptive types, efficacy, and indications is absolutely necessary for cardiologists caring for reproductive-age women for whom pregnancy could cause significant morbidity or mortality and for those on teratogenic medications. This summary provides a comprehensive overview of contraception options.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

Contraceptive use in women with inherited metabolic disorders: a retrospective study and literature review

BACKGROUND

Reproductive planning is an emerging concern for women with inherited metabolic disease (IMD). Anticipatory guidance on contraception is necessary to prevent unintended pregnancies in this population. Few resources exist to aid informed decision-making on contraceptive choice. A retrospective case-control study was performed to examine trends in reproductive planning for adolescent and adult women seen at the Children's Hospital of Philadelphia (CHOP). Literature review on contraception and IMD was performed to assess global use.

RESULTS

In a cohort of 221 reproductive-aged female IMD patients, 29.4% reported routine contraceptive use. Anticipatory guidance on contraception was provided by metabolic physicians to 36.8% of patients during the study period. Contraception discussion was more likely to occur in women older than 21 years, who lived independently and were followed by gynecology. Women who received contraception counseling from their metabolic physician were 40-fold more likely to use regular contraception. Use of combined hormonal contraceptives was most commonly reported, but contraception choice varied by age and IMD.

CONCLUSION

Metabolic physicians are ideally suited to provide guidance on contraception to women with IMD. Reproductive planning should be addressed routinely using shared decision-making. Contraceptives should be selected for their efficacy, effects on metabolism, and likelihood of patient adherence.

A Review of Venous Thromboembolism Risk Assessment and Prophylaxis in Plastic Surgery

BACKGROUND

Venous thromboembolism is a significant cause of postoperative death and morbidity. While prophylactic and treatment regimens exist, they usually come with some risk of clinically relevant bleeding and, thus, must be considered carefully for each individual patient.

METHODS

This special topic article represents a review of current evidence regarding venous thromboembolism risk, biology, and prevention in plastic surgery patients. The specific types and duration of available prophylaxis are also reviewed. The balance of venous thromboembolism risk must be weighed against the risk of hemorrhage.

RESULTS

Though alternatives exist, the most validated risk assessment tool is the 2005 modification of the Caprini Risk Assessment Model. Controversies remain regarding recommendations for outpatient and low risk cosmetic patients. The authors additionally make recommendations for high-risk patients regarding the use of tranexamic acid, estrogen therapy, anesthesia, and prophylaxis regimens.

CONCLUSION

Our profession has made great strides in understanding the science behind venous thromboembolism, risk stratification for patients, and prophylactic regimens; yet, continued studies and definitive data are needed.

Contraceptive use and counseling in patients with systemic lupus erythematosus

OBJECTIVES

(1) Describe contraception use in women with systemic lupus erythematosus (SLE); (2) characterize the types of contraception used by this population; (3) determine factors affecting the documentation of contraception use; (4) identify if contraception counseling was received in this population at risk for adverse pregnancy outcomes.

STUDY DESIGN

This cross-sectional study analyzed data from clinic visits from 2016 - 2018 among 453 women of reproductive age who have SLE. Documentation of contraception use, contraception method, contraception counseling, and other medication use were abstracted from the medical record and analyzed with percentage based statistics, chi-squared test, t-test, and logistic regression.

RESULTS

Of the 453 women included in the analysis, 71% had a method of contraception documented within 2 years of the study period. Only 37% were using highly effective contraception. 78% had documentation of contraception counseling. Half (50%) were using teratogenic medications; patients on teratogenic medications had higher odds of having a contraceptive method documented (OR 1.56, 95% CI 1.04 - 2.36) however 24% did not have any contraception documented. 28% of patients were using contraception for which they had a possible or absolute contraindication.

CONCLUSIONS

Given a substantial proportion of women with SLE did not have any contraception or contraceptive counseling documented, these findings suggest the need to improve universal reproductive health counseling in patients with SLE.

IMPLICATIONS

There is room to improve reproductive health care in patients with SLE through provider training to help optimize pregnancy outcomes in this high-risk population.

Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are collectively referred to as "venous thromboembolic events" (VTE). Despite advances in prophylaxis, diagnosis, and treatment, VTE remains a leading cause of cost, disability, and death in postoperative and hospitalized patients (1, 2). Beyond the acute sequelae of leg pain, edema, and respiratory distress, VTE may result in chronic conditions, including postthrombotic syndrome (3), venous insufficiency, and pulmonary hypertension. This Practice Bulletin has been revised to reflect updated literature on the prevention of VTE in patients undergoing gynecologic surgery and the current surgical thromboprophylaxis guidelines from the American College of Chest Physicians (4). Discussion of gynecologic surgery and chronic antithrombotic therapy is beyond the scope of this document.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Hypertension in Women Across the Lifespan

PURPOSE OF REVIEW

We will highlight the biological processes across a women's lifespan from young adulthood through menopause and beyond that impact blood pressure and summarize women's representation in hypertension clinical trials.

RECENT FINDINGS

Throughout their lifetime, women potentially undergo several unique sex-specific changes that may impact their risk of developing hypertension. Blood pressure diagnostic criteria for pregnant women remains 140/90 mmHg and has not been updated for concordance with the 2017 ACC/AHA guideline due to a lack of data. Although on a population level, women develop hypertension at later ages than men, new data shows women's BP starts to increase as early as the third decade. Understanding how age and sex both contribute to hypertension in elderly women is crucial to identify optimal blood pressure and treatment targets. Effective screening, monitoring, and treatment of hypertension throughout a women's lifespan are necessary to reduce CVD risk. We highlight several gaps in the literature pertaining to understanding sex-specific hypertension mechanisms.

A Pharmacoepidemiologic Approach to Evaluate Real-world Effectiveness of Hormonal Contraceptives in the Presence of Drug-drug Interactions

Accurate estimation of conception is critical in the assessment of the effects of drugs used during pregnancy or to prevent pregnancy. In a novel application, we studied the effectiveness of oral contraceptives (OCs), where misclassification of conception relative to OC exposure may obscure effect estimates.

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman’s risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

An Update on Contraception in Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a common endocrine disorder in reproductive-aged women, characterized by hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology. Combined oral contraceptives (COCs), along with lifestyle modifications, represent the first-line medical treatment for the long-term management of PCOS. Containing low doses of estrogen and different types of progestin, COCs restore menstrual cyclicity, improve hyperandrogenism, and provide additional benefits such as reducing the risk of endometrial cancer. However, potential cardiometabolic risk associated with these agents has been a concern. COCs increase the risk of venous thromboembolism (VTE), related both to the dose of estrogen and the type of progestin involved. Arterial thrombotic events related to COC use occur much less frequently, and usually not a concern for young patients. All patients diagnosed with PCOS should be carefully evaluated for cardiometabolic risk factors at baseline, before initiating a COC. Age, smoking, obesity, glucose intolerance or diabetes, hypertension, dyslipidemia, thrombophilia, and family history of VTE should be recorded. Patients should be re-assessed at consecutive visits, more closely if any baseline cardiometabolic risk factor is present. Individual risk assessment is the key in order to avoid unfavorable outcomes related to COC use in women with PCOS.

Twelve-month Continuation of the Etonogestrel Implant in Adolescents With Polycystic Ovary Syndrome

STUDY OBJECTIVE

To identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Demographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at <12 months), and groups were compared.

RESULTS

A total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m²). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P < .001) were more likely to discontinue.

CONCLUSIONS

The ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.

Migraine diagnosis and treatment: A knowledge and needs assessment of women's healthcare providers

BACKGROUND

Studies suggest that migraine is often underdiagnosed and inadequately treated in the primary care setting, despite many patients relying on their primary care provider (PCP) to manage their migraine. Many women consider their women's healthcare provider to be their PCP, yet very little is known about migraine knowledge and practice patterns in the women's healthcare setting.

OBJECTIVE

The objective of this study was to assess women's healthcare providers' knowledge and needs regarding migraine diagnosis and treatment.

METHODS

The comprehensive survey assessing migraine knowledge originally developed for PCPs was used in this study, with the addition of a section regarding the use of hormonal medications in patients impacted by migraine. Surveys were distributed online, and primarily descriptive analyses were performed.

RESULTS

The online survey was completed by 115 women's healthcare providers (response rate 28.6%; 115/402), who estimated that they serve as PCPs for approximately one-third of their patients. Results suggest that women's healthcare providers generally recognize the prevalence of migraine, but experience some knowledge gaps regarding migraine management. Despite 82.6% (95/115) of survey respondents feeling very comfortable or somewhat comfortable with diagnosing migraine, only 57.9% (66/114) reported routinely asking patients about headaches during annual visits. Very few were familiar with the American Academy of Neurology guidelines on preventative treatment (6.3%; 7/111) and the Choosing Wisely Campaign recommendations on migraine treatment (17.3%; 19/110), and many prescribed medications known to contribute to medication overuse headache. In addition, only 24.3% (28/115) would order imaging for a new type of headache, 35.7% (41/115) for worsening headache, and 47.8% (55/115) for headache with neurologic symptoms; respondents cited greater tendency with sending patients to an emergency department for the same symptoms. Respondents had limited knowledge of evidence-based, non-pharmacological treatments for migraine (i.e., biofeedback or cognitive behavioral therapy), with nearly none placing referrals for these services. Most providers were comfortable prescribing hormonal contraception (mainly progesterone only) to women with migraine without aura (80.9%; 89/110) and with aura (72.5%; 79/109), and followed American College of Obstetricians and Gynecologists (ACOG) guidelines to limit combination hormonal contraception for patients with aura. When queried, 6.3% or less (5/79) of providers would prescribe estrogen-containing contraception for women with migraine with aura. Only 37.3% (41/110) of respondents reported having headache/migraine education. Providers indicated interest in education pertaining to migraine prevention and treatment (96.3%; 105/109), migraine-associated disability (74.3%; 81/109), and diagnostic testing (59.6%; 65/109).

CONCLUSION

Women's healthcare providers appear to have several knowledge gaps regarding the management of migraine in their patients. These providers would likely benefit from access to a headache-specific educational curriculum to improve provider performance and patient outcomes.

Contraception for the Cardiac Patient: a Cardiologist’s Primer

Purpose of review

Cardiovascular disease (CVD) is the number one cause of maternal mortality in the USA. There are many cardiac conditions which pose significant risk to maternal health, and these women should be offered options to avoid unwanted pregnancies. Individualized contraceptive counseling focusing on woman’s desire for future pregnancy, comorbid conditions, and desire for hormone or non-hormonal (contraceptive) options is paramount to avoid adverse or unwanted side effects. The purpose of this review is to give general guidance on prescribing both hormonal and non-hormonal contraceptives for providers caring for women with heart disease.

Recent findings

Specific recommendation for the use of either non-hormonal or hormonal contraception requires knowledge of the types of contraceptive options available, cost, failure rates, and contraindications to use. Newer progestin-only options have become available and should be considered first-line therapy for women with cardiovascular disease.

Summary

The physiologic burden of pregnancy on the cardiovascular system can cause significant maternal morbidity and mortality for women with underlying CVD. These women should be offered safe and effective options for birth control, and both cardiology and obstetrical providers alike should possess fundamental knowledge of appropriate options.