Oral contraception and thrombophilia

U.S. Selected Practice Recommendations for Contraceptive Use, 2024

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Neurological and Neurosurgical Emergencies in Patients with Hematological Disorders

PURPOSE OF REVIEW

Hematologic diseases are blood disorders which can affect different organs, including the central and peripheral nervous systems. Some of them are associated with increased risk of permanent disability and death. This review highlights a selected group of primary and acquired hematologic disorders that can present as neurologic or neurosurgical emergencies.

RECENT FINDINGS

There is an increasing recognition of the broad neurologic presentations of hematologic disorders. Diagnostic criteria continue to be revised as we learn more about these diseases. Treatment options are varied depending on the hematologic syndrome. Clinical judgment is important on a case by case basis given the complexity of these patients. Early recognition of neurologic manifestations of hematologic disorders is important as emergent treatment may be warranted. Clinical signs, appropriate laboratory testing and progression of disease must be taken into consideration to make a timely and definitive diagnosis which will aid in guiding treatment.

Provider and Patient Attitudes Regarding Sexual Health in Young Women With Cystic Fibrosis

OBJECTIVE

To explore the attitudes, preferences, and experiences of patients with cystic fibrosis (CF) and CF providers toward sexual and reproductive health (SRH) care for young women with CF.

METHODS

Young women with CF aged 18 to 30 years from a US CF care center and pediatric and adult CF program directors from a national sample participated in qualitative interviews investigating their experiences regarding SRH care and their attitudes and preferences toward SRH care provision in the CF setting. Interviews were audio-recorded, transcribed, and coded by using a thematic analysis approach.

RESULTS

Twenty-two patient participants and 16 CF program directors were interviewed. Themes shared by both groups included the importance of SRH discussion in the CF care setting, patient and provider discomfort as a barrier to SRH care, and the need for SRH educational resources and provider training to improve SRH care. Providers highlighted the lack of standardization around SRH care in the current CF care model. Patients desired SRH educational resources coupled with early SRH discussions initiated by their CF provider.

CONCLUSIONS

Both CF providers and patients agree that the CF provider has a fundamental role in providing CF-specific SRH care. Educational resources coupled with individualized SRH discussions may facilitate improved SRH care for young women with CF. Investigation into the implementation of SRH education and services into pediatric-onset chronic disease care models is needed.

Isolated cortical vein thrombosis: case series

OBJECT

Isolated cortical vein thrombosis (ICVT) accounts for less than 1% of all cerebral infarctions. ICVT may cause irreversible parenchymal damage, rendering early and accurate diagnosis critical. This case series and literature review presents the clinical and radiological findings in 7 patients with ICVT, and highlights risk factors and imaging modalities that may be most beneficial in rendering an accurate and timely diagnosis.

METHODS

Patients with CT and MRI findings consistent with ICVT examined between January 2011 and June 2014 were included in this retrospective review.

RESULTS

Seven patients (5 females, 2 males), ranging in age from 11 months to 34 years, met the inclusion criteria. The most common clinical presentations were headaches (n = 4) and seizures (n = 3). The most common comorbidities noted in these patients were hypercoagulable states (n = 4) and intracranial hypotension (n = 3). Five patients had intraparenchymal involvement. CT suggested the correct diagnosis in 4 patients, and MRI confirmed the diagnosis in all 7 patients. All patients who received anticoagulation therapy (n = 5) experienced complete resolution of their symptoms.

CONCLUSIONS

The majority of these patients were adult females, consistent with published data. Seizures and headaches were the most common presenting symptoms. Hypercoagulable state and intracranial hypotension, both known risk factors for thrombosis, were the most commonly noted ICVT risk factors. Intraparenchymal involvement was prevalent in nearly all ICVT cases and presented as vasogenic edema, early intraparenchymal hemorrhage, or hemorrhagic venous infarction. Susceptibility-weighted imaging was the most sensitive imaging technique in diagnosing ICVT.

The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease

Trying to conceive and being pregnant is an emotional period for those involved. In the majority of patients suffering from inflammatory bowel disease, maintenance therapy is required during pregnancy to control the disease, and disease control might necessitate introduction of new drugs during a vulnerable period. In this updated consensus on the reproduction and pregnancy in inflammatory bowel disease reproductive issues including fertility, the safety of drugs during pregnancy and lactation are discussed.

Stroke in Young Women

In women ages 15-45 years, an additional set of risk factors are important in the pathogenesis of ischemic stroke. Some of these pertain strictly to women, and relate to exogenous hormones and pregnancy. Various other conditions are more common in women, which include migraine with aura, selected vascular disorders and autoimmune conditions. These differences do have implications for management in both the primary and secondary prevention of stroke in this age group.

Women Stroke Association Statement on Stroke

We describe the current and future objectives of the Women Stroke Association, a nonprofit multidisciplinary organization promoting research awareness on medical, psychological, and social issues concerning women affected by cerebrocardiovascular disease. In this paper, we deal with only cerebrovascular disease, whereas cardiovascular disorders will be addressed in a future paper. Gender differences in the clinical presentation of cerebrovascular diseases have been repeatedly suggested, and some treatment options may not be as effective and safe in men and women. For many years, women have either been underrepresented or excluded from randomized clinical trials, and the majority of therapeutic research has been carried on predominantly male populations. Furthermore, gender differences have been shown to contribute to different responses to cerebrovascular drugs in women when compared with men, regarding pharmacokinetics, pharmacodynamics, and physiology. In this statement, we discuss main research fields relevant to Women Stroke Association's mission and commitment, highlighting opportunities and critical from the women's health perspective. Future directions and goals of the Women Stroke Association arise from these considerations and represent the association's commitment to combating stroke.

Contraception-related venous thromboembolism in a pediatric institution

STUDY OBJECTIVE

To define the thrombotic risk factors of young women presenting to a children's hospital with hormonal contraception-related venous thromboembolism (VTE). We hypothesized that the majority of patients would have additional risk factors for VTE.

DESIGN

Clinical and laboratory data obtained retrospectively from electronic medical records concerning history of presentation, body mass index (BMI), medical and family history, medication profile, and relevant laboratory studies.

SETTING

Nationwide Children's Hospital in Columbus, Ohio, November 2008-May 2012.

PARTICIPANTS

Twenty-six female patients, age 12-21 years, admitted for hormonal contraception-related VTE.

RESULTS

Fifty-seven VTE cases were reviewed, and 26 were identified as contraception-related VTE. 96% of patients had at least 1 additional risk factor for VTE, and 42% of patients had 2 or more additional risk factors. 50% patients had a BMI ≥ 25 kg/m(2). 35% of patients had a positive family history of VTE in a first or second-degree relative. 27% of patients were subsequently diagnosed with an inherited thrombophilia, 5 of whom had a positive family history.

CONCLUSION

In a small population of adolescents presenting to a children's hospital with contraception-related VTE, the majority of patients had multiple risk factors for VTE. Obesity was the most common additional risk factor (50%) identified in our study population. More research is needed regarding the impact of obesity on contraception-related VTE in young women, and whether the presence of obesity should influence thrombophilia screening practices prior to prescribing contraception.

Oral contraceptive causing renal artery thrombosis

A young female presented with acute left lower quadrant pain followed by nausea and vomiting. She was found to have haematuria and elevated serum creatine. CT scan revealed a wedge-shaped hypodensity along with an intraluminal filling defect on the left kidney. Renal artery duplex showed no evidence for stenosis and MRI was negative for any atherosclerotic disease. Technetium scan confirmed the diagnosis of left renal infarct. Following day the patient became febrile and was noted to have leucocytosis and elevated serum lactate dehydrogenase. She was started on enoxaparin and low-dose aspirin. Blood cultures were negative. The oral contraceptive was stopped. Fever and leucocytosis resolved in the following 3 days. Extensive thrombophilic work-up was negative. No recurrence of thrombosis was found during a 6-month follow-up period. To the best of our knowledge, this is the first report of renal artery thrombosis leading to acute renal infarction associated with oral contraceptive use.

Estrogen and thrombosis: controversies and common sense

Soon after the introduction of hormonal oral contraceptive agents reports of thrombotic complications appeared. In the past several decades, large epidemiological studies helped defined these risks for both arterial and venous complications. Clinicians can assess a patient's risk of thrombosis by both composition of the agent and patients' personal risk factors. For women with bleeding disorders these prothrombotic changes can help decrease bleeding complications. There is now also abundant data on future management of patients with estrogen related thrombosis.

Thrombophilia screening--at the right time, for the right patient, with a good reason

Thrombophilia can be identified in about half of all patients presenting with venous thromboembolism (VTE). Thrombophilia screening for various indications has increased tremendously, but whether the results of such tests help in the clinical management of patients is uncertain. Here, current recommendations for thrombophilia screening in selected groups of patients, and considerations whether other high-risk subjects should be tested are reviewed. The methods for determination of the most common thrombophilic defects (antithrombin, protein C, protein S deficiencies, Factor V Leiden and prothrombin G20210A) associated with strong to moderate risk of VTE are described, indicating the timing and location of thrombophilia screening. Circumstances when a positive result of thrombophilia screening helps clinicians decide if adjustments of the anticoagulant regime are needed are discussed. Finally, psychological, social and ethical dilemmas associated with thrombophilia screening are indicated.

Thrombophilic conditions in the adolescent: the gynecologic impact

As Virchow's triad suggests, a fine balance exists between the vascular wall, intravascular contents, and dynamic blood flow, such that a shift in this balance predisposes to thrombosis. Although thromboembolic events (TEs) are relatively infrequent in adolescents, the morbidity and mortality associated with TEs can be significant. Over the past 15 years, TEs and inherited and acquired thrombophilic conditions underlying them have become increasingly recognized in teens at risk, with combined hormonal contraception constituting one of the most significant of these risk factors. Therefore, managing gynecologic problems in teens who have thrombophilic conditions can be challenging. It is important to have a clear understanding about safe options available to help address adolescent gynecologic concerns in this setting and to manage situations collaboratively with a hematologist.

Venous thromboembolism in young female while on oral contraceptives: high frequency of inherited thrombophilia and analysis of thrombotic events in 400 czech women

Oral contraceptive use is a common risk factor for venous thromboembolism in women of reproductive age. The presence of inherited thrombophilia further increases this risk.

METHODS

We analyzed a large group of 400 Czech women with venous thromboembolism in association with oral contraceptive with regard to duration of use at the time of manifestation of venous thromboembolism, the frequency of inherited and acquired thrombophilia, the frequency of eliciting risk factor for thrombosis including immobilization, surgery, administration of plaster cast, long travel, and so on, and the type of thrombosis. The mean age of the women was 26 years, and the average duration of use was 45 months at the onset of thrombosis.

RESULTS

Venous thrombosis solely due to the pill occurred in 57% of the women, and in the other 43%, an additional transient eliciting factor was recognized. Among the clinical manifestation, distal thrombosis prevailed (N = 231, 58%) followed by proximal deep vein thrombosis (N = 65, 16%), pulmonary embolism (N = 21, 5%), and thrombosis in unusual sites (N = 20, 5%). Inherited or acquired thrombophilia was diagnosed in 195 (49%) women: factor V Leiden mutation in 35%, congenital deficiency of antithrombin in 1.8%, protein C in 0.8%, protein S in 1%, F IIG20210A in 5%, and antiphospholipid syndrome (APS) in 5.3%. Among the most common risk factors were immobilization of lower limb, minor and major surgery, and trauma.

CONCLUSION

The results confirm that venous thromboembolism is a multifactorial disease in which thrombophilia screening is needed in young symptomatic women on the pill with thrombosis. The results also emphasize the value of proper thromboprophylaxis in women while on oral contraceptive in situations of increased risk for venous thromboembolism.