Association between duration of oral contraceptive use and risk of hypertension: A meta-analysis

Association between the use of oral contraceptives and the occurrence of systemic hypertension: A systematic review with statistical comparison between randomized clinical trial interventions

Introduction

In the WHO eligibility criteria, there is agreement that hypertensive women taking Oral Contraceptive Hormonal Combined (OCHC) may be at increased risk of cardiovascular disease. The risk-to-benefit ratio hinges on the severity of the condition. While a mild increase in blood pressure is a common occurrence in consumers of OCHC, the potential for developing high blood pressure exists during oral contraceptive use. Consequently, there is a possibility of increased cardiovascular risk, with limited available data on this issue.

Objective

To evaluate the potential effects of OCHC on blood pressure through a systematic review with statistical analysis of existing randomized controlled trials.

Method

This systematic review with statistical comparison adheres to the recommendations outlined in the PRISMA (Principal Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The analysis strategy involves comparing the mean difference in blood pressure change according to the type of treatment, in addition to the calculation of clinically relevant outcomes (CRO).

Results

Our findings suggest a clinically relevant outcome related to the increase in blood pressure in users of ethinyl estradiol combined with gestodene in a cyclic regimen over 6 months. Conversely, a decrease in blood pressure was observed among users of ethinyl estradiol combined with chlormadinone over 24 months of usage.

Conclusion

While our study found minor variations in blood pressure across varying forms of oral contraceptives, these differences are not significant enough to warrant specific clinical recommendations. However, the results suggest that individuals with hypertension should exercise caution with ethinyl estradiol, particularly when administered cyclically alongside gestodene, due to the potential risk of increased blood pressure. Additionally, the use of oral contraceptives containing ethinyl estradiol paired with chlormadinone acetate or ethinyl estradiol combined with drospirenone may be more suitable for individuals at a high risk of developing hypertension.

Oral contraceptives in adolescents: a retrospective population-based study on blood pressure and metabolic dysregulation

PURPOSE

This study aimed to explore the relationship between oral contraceptive use and blood pressure values and in a national cohort of women adolescents and to investigate the level of coexistence of the high blood pressure levels, dyslipidemia or insulin resistance.

METHODS

This is a retrospective cohort study that evaluated data form 14,299 adolescents aged 14 to 17 years. Crude and race-and age-adjusted analyses were performed using Poisson regression to estimate the prevalence ratios. Data clustering analysis was performed using machine learning approaches supported by an unsupervised neural network of self-organizing maps.

RESULTS

We found that 14.5% (n = 2076) of the women adolescents use oral contraceptives. Moreover, an increased prevalence of high blood pressure, dyslipidemia, and insulin resistance (all P < 0.001) was observed among adolescents who use oral contraceptives as compared to those who do not. Our analysis also showed that 2.3% of adolescents using oral contraceptives had both high blood pressure levels and dyslipidemia, whereas 3.2% had high blood pressure levels combined with insulin resistance (all P < 0.001). The algorithmic investigative approach demonstrated that total cholesterol, LDLc, HDLc, insulin, and HOMA-IR were the most predicted variables to assist classificatory association in the context of oral contraceptive use among women adolescents with high blood pressure.

CONCLUSIONS

These findings suggest that oral contraceptives were associated with an increased prevalence of high blood pressure, dyslipidemia, and insulin resistance among women adolescents. Although the indication of this therapy is adequate to avoid unintended pregnancies, their use must be based on rigorous individual evaluation and under constant control of the cardiometabolic risk factors.

The role of sex hormones, oral contraceptive use, and its parameters on visuospatial abilities, verbal fluency, and verbal memory

Sex hormones can cross the blood-brain barrier and access brain regions underlying higher-order cognition. Containing synthetic sex hormones, oral contraceptives (OC) have been found to modulate visuospatial and verbal abilities, though inconsistencies have been found in the literature. Among possible explanations, certain OC use parameters (progestin androgenicity, synthetic hormone levels, duration of use) have not received consistent consideration. Thus, the objectives were to (1) examine group differences between men, combined OC users, and naturally cycling women (NC women; not using OC) in visuospatial abilities, verbal fluency, and verbal memory and (2) investigate the contribution of endogenous and exogenous sex hormones on these effects. We also aimed to (3) identify OC use parameters relevant to cognitive outcomes. In total, 70 combined OC users, 53 early follicular (EF) women, 43 pre-ovulatory (PO) women, and 47 men underwent cognitive tests. Performance was compared based on hormonal milieus (OC, EF, PO, men) and OC users' contraceptive androgenicity (anti, low, high). Correlations between performance, hormone levels and OC use duration were also conducted. OC use dampened the sex difference that typically favors men in 3D visuospatial abilities, whereas its duration of use positively predicted verbal fluency. Androgenicity and hormone levels did not predict performance in any task. These results highlight the importance of considering OC use duration. Results also did not support a role for androgenicity in cognition. Importantly, combined OC use (including prolonged use) does not impair visuospatial, verbal, and memory functions in a healthy young sample.

The effects of oral contraceptives on resting autonomic function and the autonomic response to physiological stressors: a systematic review

PURPOSE

This systematic review aimed to summarize how oral contraceptives (OC) affect resting autonomic function and the autonomic response to a variety of physiological stressors.

METHODS

A search strategy was created to retrieve citations investigating physiological responses comparing OC users to non-users (NOC) in response to autonomic reflex activation.

RESULTS

A total of 6148 citations were identified across databases from inception to June 2, 2022, and 3870 citations were screened at the abstract level after deduplication. Then, 133 texts were assessed at full-text level, and only 40 studies met eligibility requirements. Included citations were grouped by the aspect of autonomic function assessed, including autonomic reflex (i.e., baroreflex, chemoreflex, mechanoreflex, metaboreflex, and venoarterial reflex), or indicators (i.e., heart rate variability, pulse wave velocity, and sympathetic electrodermal activity), and physiological stressors that may alter autonomic function (i.e., auditory, exercise, mental or orthostatic stress, altitude, cold pressor test, sweat test, and vasodilatory infusions).

CONCLUSION

OC influence the physiological responses to chemoreflex, mechanoreflex, and metaboreflex activation. In terms of autonomic indices and physiological stressors, there are more inconsistencies within the OC literature, which may be due to estrogen dosage within the OC formulation (i.e., heart rate variability) or the intensity of the stressor (exercise intensity/duration or orthostatic stress). Further research is required to elucidate the effects of OC on these aspects of autonomic function because of the relatively small amount of available research. Furthermore, researchers should more clearly define or stratify OC use by duration, dose, and/or hormone cycling to further elucidate the effects of OC.

Reproductive health factors in relation to risk of hypertension in postmenopausal women: Results from NHANES 2011-2014

Few studies have systematically assessed the relationship between multiple reproductive factors and hypertension, and these limited studies paid more attention to age at menarche and menopause, abortion, or the number of live births, and yielded controversial results. This study aimed to explore the relationship between reproductive health factors and hypertension from 5 aspects: history of menstruation, pregnancy, delivery, gynecological surgery, and reproductive-related medication use. We analyzed data from the National Health and Nutrition Examination Survey 2011 to 2014. Data on reproductive factors were collected using a questionnaire survey. The associations between multiple reproductive factors and the risk of hypertension were assessed using multivariable logistic regression models. There were significant inverse associations between age at menopause (odds ratio [OR] = 0.984, 95% confidence interval [CI]: 0.971-0.998, P = .0234 per 1-year increase), age at first live birth (OR = 0.970, 95% CI: 0.944-0.998, P = .0346 per 1-year increase), age at last live birth (OR = 0.982, 95% CI: 0.964-0.999, P = .0488 per 1-year increase), and the risk of hypertension. In contrast, a positive association was found between the risk of hypertension and a history of gestational diabetes (OR = 1.693, 95% CI: 1.042-2.751, P = .0333), hysterectomy (OR = 1.398, 95% CI: 1.139-1.717, P = .0014), ovariectomy (OR = 1.374, 95% CI: 1.074-1.758, P = .0115), and birth control pill use (OR = 1.293, 95% CI: 1.035-1.616, P = .0236). Age at menopause but not menarche, is inversely associated with hypertension. A history of gestational diabetes, hysterectomy, ovariectomy, or birth control pills was associated with a higher risk of hypertension.

Vascular function in hypertension: does gender dimension matter?

Blood pressure and vascular ageing trajectories differ between men and women. These differences develop due to sex-related factors, attributable to sex chromosomes or sex hormones, and due to gender-related factors, mainly related to different sociocultural behaviors. The present review summarizes the relevant facts regarding gender-related differences in vascular function in hypertension. Among sex-related factors, endogenous 17ß-estradiol plays a key role in protecting pre-menopausal women from vascular ageing. However, as vascular ageing (preceding and inducing hypertension) has a steeper increase in women than in men starting already from the third decade, it is likely that gender-related factors play a prominent role, especially in the young. Among gender-related factors, psychological stress (including that one related to gender-based violence and discrimination), depression, some psychological traits, but also low socioeconomic status, are more common in women than men, and their impact on vascular ageing is likely to be greater in women. Men, on the contrary, are more exposed to the vascular adverse consequences of alcohol consumption, as well as of social deprivation, while "toxic masculinity" traits may result in lower adherence to lifestyle and preventive strategies. Unhealthy diet habits are more prevalent in men and smoking is equally prevalent in the two sexes, but have a disproportional negative effect on women's vascular health. In conclusion, given the major and complex role of gender-related factors in driving vascular alterations and blood pressure patterns, gender dimension should be systematically integrated into future research on vascular function and hypertension and to tailor cardiovascular prevention strategies.

Opportunities and challenges: interleukin-22 comprehensively regulates polycystic ovary syndrome from metabolic and immune aspects

Polycystic ovary syndrome (PCOS) is known as a prevalent but complicated gynecologic disease throughout the reproductive period. Typically, it is characterized by phenotypic manifestations of hyperandrogenism, polycystic ovary morphology, and persistent anovulation. For now, the therapeutic modality of PCOS is still a formidable challenge. Metabolic aberrations and immune challenge of chronic low-grade inflammatory state are significant in PCOS individuals. Recently, interleukin-22 (IL-22) has been shown to be therapeutically effective in immunological dysfunction and metabolic diseases, which suggests a role in the treatment of PCOS. In this review, we outline the potential mechanisms and limitations of IL-22 therapy in PCOS-related metabolic disorders including its regulation of insulin resistance, gut barrier, systemic inflammation, and hepatic steatosis to generate insights into developing novel strategies in clinical practice.

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.

Estrogen and the Vascular Endothelium: The Unanswered Questions

Premenopausal women have a lower incidence of cardiovascular disease (CVD) compared with their age-matched male counterparts; however, this discrepancy is abolished following the transition to menopause or during low estrogen states. This, combined with a large amount of basic and preclinical data indicating that estrogen is vasculoprotective, supports the concept that hormone therapy could improve cardiovascular health. However, clinical outcomes in individuals undergoing estrogen treatment have been highly variable, challenging the current paradigm regarding the role of estrogen in the fight against heart disease. Increased risk for CVD correlates with long-term oral contraceptive use, hormone replacement therapy in older, postmenopausal cisgender females, and gender affirmation treatment for transgender females. Vascular endothelial dysfunction serves as a nidus for the development of many cardiovascular diseases and is highly predictive of future CVD risk. Despite preclinical studies indicating that estrogen promotes a quiescent, functional endothelium, it still remains unclear why these observations do not translate to improved CVD outcomes. The goal of this review is to explore our current understanding of the effect of estrogen on the vasculature, with a focus on endothelial health. Following a discussion regarding the influence of estrogen on large and small artery function, critical knowledge gaps are identified. Finally, novel mechanisms and hypotheses are presented that may explain the lack of cardiovascular benefit in unique patient populations.

Fasting blood glucose, blood pressure and body mass index among combined oral contraceptive users in Chencha town Southern Ethiopia, 2019

Background

The use of contraceptives has become prevalent among women in Ethiopia. Oral contraceptive use has been suggested to trigger changes in glucose metabolism, energy expenditure, blood pressure, and body weight, among various populations and ethnic groups.

Objective

To elucidate the pattern of fasting blood glucose, blood pressure, and body mass index among combined oral contraceptive pills users compared to controls.

Methods

An institution-based cross-sectional study design was employed. A total of 110 healthy women using combined oral contraceptive pills were recruited as cases. Another 110 healthy age and sex-matched women not using any hormonal contraceptives were recruited as controls. A study was conducted between October 2018 and January 2019. Data obtained was entered and analyzed using IBM SPSS version 23 software packages. One-way ANOVA was used to identify the variation of variables in relation to the duration of use of the drug. The P-value of < 0.05 at the 95% confidence level was statistically significant.

Results

Fasting blood glucose level among oral contraceptive users (88.55 ± 7.89 mg/dl) was higher than fasting blood glucose level among oral contraceptive non-users (86.00 ± 9.85 mg/dl) with a p-value of 0.025. The mean arterial pressure of oral contraceptive users (88.2 ± 8.48 mmHg) was relatively higher than their counterparts (86.0 ± 6.74 mmHg), with a p-value of 0.04. Comparatively the body weight and body mass index among oral contraceptive users were 2.5% and 3.9% higher than non-users with a p-value of 0.03 and 0.003, respectively(5). Utilization of oral contraceptive pills for prolonged period of time seemed to be a significant predictive factor for higher mean arterial pressure and body mass index with p < 0.001and p < 0.05 respectively.

Conclusions

Use of combined oral contraceptives was associated with higher fasting blood glucose (+2.9%), mean arterial pressure (+2.5%), and body mass index (3.9%) compared to controls.

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.

Renin-Angiotensin-Aldosterone System in Women Using Combined Oral Contraceptive: A Systematic Review

OBJECTIVE

 To describe the effects of combined oral contraceptives (COC) on the renin-angiotensin-aldosterone system (RAAS).

DATA SOURCES

 This is a systematic review according to the criteria of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), registered in PROSPERO under the ID: CRD42020200019. Searches were performed between August 2020 and December 2021, in the following databases: Medline via Pubmed, Cochrane Central Library, Scientific Electronic Library Online, and Latin American and Caribbean Literature in Health Sciences via Virtual Health Library. The effects of the combined oral contraceptive on plasma renin activity values, plasma renin values, angiotensinogen values- also known as plasma renin substrate- angiotensin, and/or aldosterone values.

STUDY SELECTION

 A total of 877 studies were selected and, of these, 10 articles met the eligibility criteria and were included in this review.

DATA COLLECTION

 Data were combined through qualitative synthesis and included in a spreadsheet previously prepared by the authors.

DATA SYNTHESIS

 The collected samples ranged from 18 to 137 participants, totaling 501 women aged between 18 and 49 years throughout all studies. The studies showed increased activity of plasma renin, plasma renin substrate, angiotensin II, and aldosterone in this population.

CONCLUSION

 The findings of this study suggest that the COC promotes greater activation of the RAAS. Supporting the idea that its use is related to an increased risk of cardiovascular events, including systemic arterial hypertension.

Effect of oral hormonal contraceptive pill use on the hemodynamic response to the cold pressor test

Acute increases in sympathetic nervous system activity (SNA) often elicit peripheral vasoconstriction and increases in blood pressure (BP). Given sympathetic support of BP is modulated by ovarian sex hormones (e.g., estradiol), we sought to examine the effect of menstrual cycle and oral hormonal contraceptive pill (OC) phase on the hemodynamic response to acute increases in SNA. We hypothesized sympathoexcitation via cold pressor test (CPT) would elicit greater peripheral vasoconstriction and increases BP in females with natural menstrual cycles (NC) compared with females taking OC. We further hypothesized that SNA-mediated vasoconstriction would be attenuated during the high estradiol (HE) phase versus the low estradiol (LE) phase of the menstrual/pill cycle. Female NC (n = 11, 25 ± 1 yr) and OC (n = 10, 24 ± 1 yr) participants were studied during the LE (early follicular, placebo pill) and HE (late follicular, active pill) phase of the menstrual/pill cycle. BP (finger photoplethysmography), heart rate (HR, ECG), and forearm blood flow (FBF, venous occlusion plethysmography) were measured during a 5-min baseline and a 2-min CPT. CPT elicited an increase in BP in both groups (time, P < 0.01). During CPT, OC participants exhibited greater and sustained increases in HR compared with NC participants (group × time, P < 0.01). Higher HRs were met with increases in FBF in OC participants during the CPT, which was not observed in NC participants (group × time, P < 0.01). OC participants exhibit greater increases in HR, and paradoxical vasodilation during acute sympathetic activation compared with NC participants. Group differences are unaffected by menstrual/pill phase.NEW & NOTEWORTHY Acute increases in sympathetic nervous system activity often elicit peripheral vasoconstriction and increases in blood pressure (BP). Given sympathetic support of BP is modulated by ovarian sex hormones (e.g., estradiol), we sought to examine the effect of menstrual cycle and oral hormonal contraceptive pill (OC) phase on the hemodynamic response to acute increases in sympathetic nervous system activity via the cold pressor test. We show OC participants exhibit paradoxical vasodilation during acute sympathetic activation compared with participants with natural menstrual cycles; notably, group differences were unaffected by menstrual/pill phase.

Spironolactone Versus Oral Contraceptive Pills in the Treatment of Adolescent Polycystic Ovarian Syndrome: A Systematic Review

Polycystic ovarian syndrome (PCOS) is a multi-system endocrinopathy that affects women of reproductive age. Due to features that coincide with puberty, it frequently remains undiagnosed in adolescent females. The lack of evidence on management alternatives has resulted in significant variation in practice. This systematic review evaluated the therapeutic advantages and adverse effects of a regularly used therapy option, combined oral contraceptive pills (COC/OCP) with spironolactone (SP), a newer alternative that may be used alone or in conjunction with other drugs to treat adolescent PCOS. A literature search was conducted using PubMed, PubMed Central, Scopus, and Google Scholar. It was restricted to studies published in English between 2021 and 2011 that discussed the management of adolescent PCOS with COC, SP, or both. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Two reviewers independently examined the content of the included studies using appropriate quality assessment tools. Four meta-analyses, four randomized controlled trials (RCTs), and one traditional review were found to be eligible. After extensive analysis, we concluded that SP, alone or in combination, is far safer than COC. However, COC treats more PCOS-associated symptoms than SP, including acne and menstrual irregularities, while also providing contraceptive benefits. However, SP monotherapy is cardioprotective and therapeutic when combined with other drugs. Long-term COC use has been linked to an increased risk of venous thromboembolism, hypertension, dyslipidemia, low-density lipoprotein (LDL) elevation, dysglycemia, and cancer in women.

Association between past oral contraceptive use and the prevalence of hypertension in postmenopausal women: the fifth (2010-2012) Korea National Health and Nutrition Examination Survey (KNHANES V)

BACKGROUND

There is little evidence as to whether the use of oral contraceptives(OC) during the fertile years affects the development of postmenopausal hypertension. This study aimed to evaluate the association between past use of OC and development of hypertension in postmenopausal women.

METHODS

This was a cross-sectional study conducted using data from the Fifth Korea National Health and Nutrition Examination Survey of postmenopausal women. Subjects were classified into three groups based on past OC use duration: nonusers, short-term users(0-30 months), and long-term users(≥ 30 months). We evaluated the development of hypertension in women after menopause. A multivariable logistic regression model was used to identify the association between the use of OC during the fertile years and the prevalence of hypertension after menopause following adjustment for potential confounding factors.

RESULTS

Of the 3,386 postmenopausal women, 2,713 were nonusers of OC, 489 were short-term users, and 184 were long-term users. Women who had used OC for 30 months or more had a significantly greater prevalence of hypertension after menopause than those who had never taken OC. The association between taking OC for 30 months or more during the fertile years and the prevalence of hypertension after menopause was significant following adjustment for potential confounding factors (adjusted OR:1.75; 95%CI:1.12-2.74).

CONCLUSION

This study identified an association between past OC use and an increased prevalence of hypertension in postmenopausal women. Our results suggest that long-term use of OC during the fertile years can be an important risk factor for subsequent hypertension after menopause.

Association of Hormonal Contraceptive Use With Adverse Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials and Cohort Studies

IMPORTANCE

Meta-analyses have reported conflicting data on the safety of hormonal contraception, but the quality of evidence for the associations between hormonal contraceptive use and adverse health outcomes has not been quantified in aggregate.

OBJECTIVE

To grade the evidence from meta-analyses of randomized clinical trials (RCTs) and cohort studies that assessed the associations between hormonal contraceptive use and adverse health outcomes among women.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Database of Systematic Reviews were searched from database inception to August 2020. Search terms included hormonal contraception, contraceptive agents, progesterone, desogestrel, norethindrone, megestrol, algestone, norprogesterones, and levonorgestrel combined with terms such as systematic review or meta-analysis.

EVIDENCE REVIEW

The methodological quality of each meta-analysis was graded using the Assessment of Multiple Systematic Reviews, version 2, which rated quality as critically low, low, moderate, or high. The Grading of Recommendation, Assessment, Development and Evaluations approach was used to assess the certainty of evidence in meta-analyses of RCTs, with evidence graded as very low, low, moderate, or high. Evidence of associations from meta-analyses of cohort studies was ranked according to established criteria as nonsignificant, weak, suggestive, highly suggestive, or convincing.

RESULTS

A total of 2996 records were screened; of those, 310 full-text articles were assessed for eligibility, and 58 articles (13 meta-analyses of RCTs and 45 meta-analyses of cohort studies) were selected for evidence synthesis. Sixty associations were described in meta-analyses of RCTs, and 96 associations were described in meta-analyses of cohort studies. Among meta-analyses of RCTs, 14 of the 60 associations were nominally statistically significant (P ≤ .05); no associations between hormonal contraceptive use and adverse outcomes were supported by high-quality evidence. The association between the use of a levonorgestrel-releasing intrauterine system and reductions in endometrial polyps associated with tamoxifen use (odds ratio [OR], 0.22; 95% CI, 0.13-0.38) was graded as having high-quality evidence, and this evidence ranking was retained in the subgroup analysis. Among meta-analyses of cohort studies, 40 of the 96 associations were nominally statistically significant; however, no associations between hormonal contraceptive use and adverse outcomes were supported by convincing evidence in the primary and subgroup analyses. The risk of venous thromboembolism among those using vs not using oral contraception (OR, 2.42; 95% CI, 1.76-3.32) was initially supported by highly suggestive evidence, but this evidence was downgraded to weak in the sensitivity analysis.

CONCLUSIONS AND RELEVANCE

The results of this umbrella review supported preexisting understandings of the risks and benefits associated with hormonal contraceptive use. Overall, the associations between hormonal contraceptive use and cardiovascular risk, cancer risk, and other major adverse health outcomes were not supported by high-quality evidence.

ERICA: cardiovascular risks associated with oral contraceptive use among Brazilian adolescents

OBJECTIVE

To investigate the association between oral contraceptive use and cardiovascular risks, including metabolic syndrome and their components in Brazilian adolescents.

METHOD

This study used data from the Study of Cardiovascular Risks in Adolescents (Estudo de Riscos Cardiovasculares em Adolescentes - ERICA), a nationwide, cross-sectional, school-based study with individuals aged 12-17 years. Sociodemographic variables and OC use were assessed by a self-administered questionnaire. International Diabetes Federation criteria were used to define metabolic syndrome. Descriptive statistics were reported as prevalence and their respective confidence interval of 95% of oral contraceptives according to variables. Logistic regression was performed. Crude and adjusted odds ratios were calculated.

RESULTS

This subsample was composed of 22,682 female adolescents, of which 12.65% reported using oral contraceptives and their use was associated with hypertension and hypertriglyceridemia. These associations remained statistically significant after adjusting for age, school region, race, and tobacco use with an increase of 2.68 (1.66 - 4.32) and 3.45 (2.56 - 4.65) times, respectively.

CONCLUSION

The present study was the first to examine the association between the use of oral contraceptives and cardiovascular risk factors among the largest number of female Brazilian adolescents. This method was significantly associated with hypertension, hypertriglyceridemia. Teenagers using oral contraceptives should be monitored for side effects, including blood pressure measurements and advised to avoid smoking.

The use of oral contraceptive is inversely associated with the risk of type 2 diabetes mellitus among middle-aged women

OBJECTIVE

To assess the cross-sectional association between oral contraceptive (OC) use and type 2 diabetes mellitus (T2DM) risk among US women.

METHODS

The data was obtained from the National Health and Nutrition Examination Survey (NHANES 2007-2018). OC use was assessed by questionnaires and the diagnosis of T2DM was confirmed by the glycosylated hemoglobin, fasting blood glucose, and self-report. Binary logistic regression models and the restricted cubic spline model were adopted to evaluate whether OC use was associated with T2DM.

RESULTS

Compared with non-users, the odds ratio (OR) with 95% confidence interval (CI) of T2DM risk for the OC users was 0.71 (0.57-0.89) in unadjusted Model. The association remained significant in fully adjusted models, and the OR with 95%CI was 0.78 (0.62-0.99). In the stratified analyses, there was an inverse association of OC use with T2DM risk when women were overweight. Dose-response analysis also revealed an inversely nonlinear relationship between the duration of OC use and T2DM (p-value for linearity = .589).

CONCLUSIONS

Our findings suggested that OC use may be inversely associated with T2DM risk.

Demographic, socioeconomic, and biological correlates of hypertension in an adult population: evidence from the Bangladesh demographic and health survey 2017-18

Background

Bangladesh is well advanced in the epidemiologic transition from communicable to noncommunicable diseases, which now account for two out of three deaths annually. This paper examines the latest nationally representative hypertension prevalence estimates, awareness, treatment, and control—to identify their association with potential correlates.

Methods

The analyses are based on the recent Bangladesh Demographic and Health Survey 2017–18 data. Univariate analyses and bivariate analyses between the outcome variables and individual covariates were carried out. Then chi-square tests were done to see the proportional differences between them. To examine the demographic, socioeconomic and biological factors affecting hypertension, awareness, treatment and control, we used multivariate logistic regression models.

Results

We found that prevalence of hypertension for females and males together aged 35 or more has risen by half between 2011 (25.7%) to 2017 (39.4%). With the broader age range used in 2017, the prevalence is now 27.5% in the population aged 18 years or more. The factors associated with hypertension included older age, being female, urban residence, higher wealth status, minimal education, higher body mass index and high blood glucose level. Following multivariate analyses, many of these characteristics were no longer significant, leaving only age, being female, nutritional status and elevated blood glucose level as important determinants. Over half (58%) of females and males who were found to be hypertensive were not aware they had the condition. Only one in eight (13%) had the condition under control.

Conclusion

In the coming years, a rising trend in hypertension in Bangladeshi adults is expected due to demographic transition towards older age groups and increase in overweight and obesity among the population of Bangladesh. With more women being hypertensive than men, a targeted approach catering to high risk groups should be thoroughly implemented following the Multisectoral NCD Action Plan 2018–2025. Acting in close collaboration with other ministries/relevant sectors to bring an enabling environment for the citizens to adopt healthy lifestyle choices is a prerequisite for adequate prevention. While screening the adult population is essential, the public sector cannot possibly manage the ever-expanding numbers of hypertensives. The private sector and NGOs need to be drawn into the program to assist.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11234-5.

Oral contraceptives and hypertension in women: results of the enrolment phase of Tabari Cohort Study

BACKGROUND

The association between oral contraceptives (OCP) and hypertension has been reported in the literature with controversial results. According to the growing use of OCPs among women in Iran, this study aims to investigate the association between the duration of the OCP consumption and risk of hypertension among Iranian women.

METHODS

In the current study, the data collected during the enrolment phase of the Tabari cohort were analyzed. Of 6106 women recruited in the cohort, 133 pregnant women were excluded. Epidemiological variables were collected using pre-designed questionnaires as well as the health insurance evidences. In addition, blood pressure and anthropometric factors were measured based on the standard guidelines. Chi square and partial correlation tests as well as logistic regression models were applied for data analysis.

RESULTS

Frequency of oral contraceptive use among 35-70 year-old women in Tabari cohort study (TCS) was 42.2% (2520/5973). Hypertension was observed among 25% (1793/5973) of them. The adjusted odds ratio for OCP use was 1.23 (95% confidence interval: 1.08, 1.40, p = 0.002). The corresponding odds ratios for 61-120 months and more than 120 months OCP use were 1.39 (1.12,1.73) and 1.47 (1.16,1.87) respectively.

CONCLUSIONS

Oral contraceptives especially in long term use can be associated with hypertension.

Combined Oral Contraceptive Pill-Induced Hypertension and Hypertensive Disorders of Pregnancy: Shared Mechanisms and Clinical Similarities

PURPOSE OF REVIEW

Oral contraceptive pill-induced hypertension (OCPIH) and hypertensive disorders in pregnancy (HDP) share common risk factors and pathophysiological mechanisms, yet the bidirectional relationship between these two conditions is not well-established. We review and describe OCPIH and HDP to better understand how hormonal and metabolic imbalances affect hypertension.

RECENT FINDINGS

Oral contraceptive pills continue to be a popular method of contraception, with an incidence of OCPIH ranging from 1-8.5% among OCP users. HDP have an incidence of 5-10% of all pregnancies in the USA and have been shown to be a powerful predictor of lifetime adverse cardiovascular outcomes, including future hypertension. OCPIH and HDP share common risk factors such as age, BMI, past personal and family history of hypertension, as well as pathogenic mechanisms, including alterations in hormonal metabolism and the renin angiotensin aldosterone system; imbalance of vasodilator-vasoconstrictor compounds; and changes in the cardiovascular system. Future research should address additional potential mechanisms that underlie hypertension in these two conditions where endocrine changes, either physiological (pregnancy) or iatrogenic (use of OCP), play a role. This may lead to novel, targeted treatment options to improve hypertension management and overall cardiovascular risk profile management in this subset of young female patients.

The risk factors of gestational hypertension in patients with polycystic ovary syndrome: a retrospective analysis

BACKGROUND

The hypertensive disorders complicating pregnancy (HDCP) is common in patients with polycystic ovary syndrome (PCOS), yet the potential influencing factors remained unclear. We aimed to assess the independent risk factors of HDCP in patients with PCOS, to provide clinical evidences for the management of PCOS.

METHODS

Pregnant PCOS patients treated in our hospital from June 1, 2018 to November 30, 2020 were approached. The personal and clinical characteristics of patients with and without gestational hypertension were evaluated. Logistic regressions were conducted to identify the independent risk factors of HDCP, Receiver operating characteristics (ROC)curve analysis was conducted to evaluate the predicting value.

RESULTS

A total of 188 PCOS patients were included, the incidence of HDCP in patients with PCOS was 27.66 %. There were significant differences in the age, BMI, family history of hypertension, the history of adverse pregnancy, history of contraceptive pills use and family history of HDCP between HDCP group and no-HDCP group (all p < 0.05), and there were no significant differences in the family history of diabetes, multiple pregnancy and long-term smoking history between HDCP group and no-HDCP group (all p > 0.05). Age ≥ 27y(OR2.048, 95 %CI1.121 ~ 3.208), BMI ≥ 24 kg/m2(OR1.463, 95 %CI1.069 ~ 2.011), family history of hypertension(OR2.129, 95 %CI1.093 ~ 3.042), the history of adverse pregnancy(OR2.435, 95 %CI1.264 ~ 4.085), history of contraceptive pills use(OR3.806, 95 %CI1.184 ~ 6.102), family history of HDCP(OR1.934, 95 %CI1.016 ~ 2.774) were the independent risk factors of HDCP in patients with PCOS (all p < 0.05). ROC curve analyses indicated that those factors had good predictive value on HDCP in PCOS patients.

CONCLUSIONS

The incidence of HDCP in PCOS patients is relatively high. In clinical practice, medical workers should carry out early prevention and intervention measures for these risk factors to reduce the incidence of HDCP.

Association between oral contraceptive use and incident heart failure

Aims

Oral contraceptives (OCs) are widely used in women of reproductive age, but their influences on heart failure (HF) development have yet to be reported. This study was performed to assess HF risk associated with OC use.

Methods and results

We studied women participating in the Multi‐Ethnic Study of Atherosclerosis with available data on OC use. Inverse probability of treatment weighting analyses were used to reduce baseline imbalances. Cox proportional hazards models were applied to evaluate the associations of OC use and HF risk. The primary analysis comprised a total of 3594 participants [average age 62.10 (10.24) years]. During an average follow‐up of 12.45 (3.75) years, 138 incident HF occurred. In unadjusted Cox model, OC use was associated with a decreased risk of HF [hazard ratio (HR) = 0.45, 95% confidence interval (CI) 0.31–0.64, P < 0.001]. However, in multivariable‐adjusted and inverse probability of treatment weighting models, the results were attenuated and became non‐significant (HR = 0.96, 95% CI 0.63–1.48, P = 0.86 and HR = 0.79, 95% CI 0.45–1.40, P = 0.43, respectively). Duration of OC use was not related to increased risks of HF. When stratifying HF into subtypes, similar associations were observed. In multivariable–adjusted regression models, OC use was positively associated with left ventricular end‐diastolic mass [coefficient (β) = 3.04, P = 0.006] and stroke volume (β = 1.76, P = 0.01 for the left ventricle; β = 2.17, P = 0.005 for the right ventricle) but had no impact on left ventricular ejection fraction (β = 0.09, P = 0.75) and right ventricular ejection fraction (β = 0.33, P = 0.25).

Conclusions

Oral contraceptive use in women of reproductive age does not portend increased risk of HF. However, whether the formulations or dosages differently impact this association should be further investigated.

Arterial Stiffness and Hemodynamics in Young Women: The Effects of Oral Contraceptive Intake and Physical Habits

Oral contraceptive (OC) intake seems to be associated with increased central hemodynamics and arterial stiffness. Conversely, physical activity (PA) is known to induce benefits on vascular structure and function, suggesting that the negative effects of the OC pill could be counterbalanced by regular PA. The aim of this cross-sectional study was to determine (1) whether OC intake in young women is associated with higher values of hemodynamic parameters and arterial stiffness and (2) whether these negative effects could be counterbalanced by regular physical activity. Forty-nine young healthy women (21.9 years ± 2.1) were recruited and divided into 4 groups, depending on their hormonal status (OC users: OC+ or non-OC users: OC−) and their physical habits (active/inactive). Assessments of central hemodynamics (central blood pressure, Aix75) and pulse wave velocity (PWV) were performed using applanation tonometry. cBP was higher in OC+ vs. OC−, while PWV was similar between these two groups. No interaction between physical activity and hormonal status was observed for any of these variables. Nevertheless, PWV was lower in young active women compared with age-matched inactive women, suggesting that the positive effect of regular physical exercise on the cardiovascular system is already visible in the first years of women’s adulthood, whatever the hormonal status.

Postmenopausal hormone therapy for cardiovascular health: the evolving data

Postmenopausal (PM) hormone therapy (HT) was extremely popular for years as a treatment for many conditions, including cardiovascular (CV) disease (CVD) prevention. The adverse results from the Women's Health Initiative (WHI) ended the widespread prescriptive use of HT for nearly 20 years. The WHI findings have been broadly and unfairly applied to all hormone formulations, including modern treatments using human-identical hormones. Although CV health is indisputably linked to oestrogen status, HT involving any combination of hormones currently is not recommended for primary or secondary prevention of CVD. In the wake of more positive results from recent studies and re-evaluation of the WHI, HT has re-emerged as an issue for specialists in CVD to discuss with their patients. Rigorous scientific analysis is needed to explain the paradox of cardioprotection conferred by endogenous ovarian hormones with apparent cardiotoxicity inflicted by HT. This review will cover the origins of HT, hormone terminology and function, and key studies that contribute to our current understanding. Based on evolving evidence, if HT is to be used, we propose it be initiated immediately after cessation of ovarian hormone production and dosed as transdermal oestradiol combined with cyclic dosing of human-identical progesterone (P4).

Hypertension in a patient with medullary sponge kidney: A case report

RATIONALE

Medullary sponge kidney (MSK) is a congenital renal disorder characterized by recurrent nephrolithiasis or nephrocalcinosis. Recently, it has been found that MSK can be also combined with other diseases, such as primary aldosteronism and Beckwith-Wiedemann, but whether it is associated with secondary hypertension remains unknown.

PATIENT CONCERNS

A 22-year-old hypertensive female presented to our hospital characterized by hypokalemia and hypertension.

DIAGNOSIS

The laboratory examination showed secondary aldosteronism. And the common causes for secondary aldosteronism include renal artery stenosis, glomerulonephritis, lupus nephropathy, and diabetic nephropathy, all of which were excluded except MSK.

INTERVENTIONS

She was treated with angiotensin-converting enzyme inhibitors.

OUTCOMES

Her blood pressure, serum potassium, and plasma renin levels were reversed after treatment with angiotensin-converting enzyme inhibitors.

LESSONS

We presumed that MSK may be associated with secondary hypertension, and the mechanism may be the activation of the renin-angiotensin-aldosterone system.

[Myocardial Infarction in Women of Reproductive age: Risk Factors, Clinical Picture, Prognosis]

Aim        To study risk factors (RF) and clinical and anamnestic features of the course and prediction in women with a preserved menstrual cycle and postmenopausal women after ST segment elevation (STEMI) and non-ST elevation myocardial infarction (NSTEMI).Material and methods        This study included 121 women aged 32 to 55 years diagnosed with MI. The patients were divided into two groups, group 1 (study group) consisting of 60 women with preserved menstrual function (1А, STEMI; n=38; age, 48.3±5.7 years and 1B, NSTEMI; n=22; age. 49.0±4.8 years), and group 2 (control) consisting of 61 postmenopausal women (2А, STEMI; n=43; age, 49.05±4.9 years; 2B, NSTEMI; n=18; age, 49.9±3.5 years). Beside the analysis of RF and clinical features, a prediction was produced for each subgroup at one year after discharge from the hospital based on the following indexes: hospitalization for unstable angina, non-fatal MI, revascularization, cardiovascular (CV) death, and major adverse cardiac events (MACE), which included all these outcomes.Results   In all subgroups, the most frequent RFs were arterial hypertension (AH), overweight and obesity, family history, smoking, and type 2 diabetes mellitus (DM2). Among patients with STEMI, smoking was significantly more frequently observed in the group with preserved menstrual function. Oral contraceptives were used by 3 and 6 women of reproductive age in the STEMI and NSTEMI subgroups, respectively. Incidence of STEMI as the onset of ischemic heart disease (IHD, 46.7%) was higher than in subgroup 2A (27.9 %; р=0.003). Early postinfarction angina was a more frequent complication of MI in subgroup 1A than in 2A (р=0.02).Conclusion            The incidence rate of RFs, including AH, overweight and obesity, dyslipidemia, family history, and DM2, was similar in both STEMI and NSTEMI groups. Incidence rate of smoking was statistically significantly higher in subgroup 1A. One-year prediction for women with STEMI and NSTEMI was comparable irrespective of the presence or absence of the menstrual function.

Hypertension and Reproduction

PURPOSE OF REVIEW

Many aspects of reproduction have been associated with increased blood pressure and impaired glucose metabolism that reveals a subsequent increased risk of cardiovascular disease. The aim of this review is to assess reproductive life factors associated with an increased risk of hypertension and cardiovascular disease, e.g., early life programming, sexual, and reproductive health in men and women.

RECENT FINDINGS

Impaired fetal growth, with low birth weight adjusted for gestational age, has been found associated with hypertension in adulthood. Erectile dysfunction, currently considered an early diagnostic marker of cardiovascular disease preceding the manifestation of coronary artery disease by several years, frequently coexisting with hypertension, could also be exacerbated by some antihypertensive drugs. Male hypogonadism or subfertility are associated with increased cardiovascular risk. Hypertensive disorders in pregnancy including preeclampsia represent a major cause of maternal, fetal and neonatal morbidity, and mortality. The risk of developing preeclampsia can be substantially reduced in women at its high or moderate risk with a low dose of acetylsalicylic acid initiated from 12 weeks of gestation. An increased risk of hypertension in women following invasive-assisted reproductive technologies has been newly observed. Blood pressure elevation has been noticed following contraceptive pill use, around the menopause and in postmenopausal age. Furthermore, drug treatment of hypertension has to be considered as a factor with a potential impact on reproduction (e.g., due to teratogenic drug effects). In summary, a deeper understanding of reproductive life effects on hypertension and metabolic abnormalities may improve prediction of future cardiovascular disease.

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.

Oral Contraceptive Use and Increased Risk of Stroke: A Dose-Response Meta-Analysis of Observational Studies

Background: Oral contraceptive (OCP) use might increase the risk of stroke in women. We examined a possible dose–response relation between OCP use and the risk of stroke in young and middle-aged women.

Methods: A retrieval of PubMed and EMBASE databases was performed. We selected observational studies that reported odds ratios (ORs) with 95% confidence intervals (CIs) for the risk of stroke in OCP users. A two-stage dose–response analysis was conducted using the random-effects model and the restricted spline model.

Results: A total of 6 cohort studies and 12 case–control studies were included, which involved 2,143,174 participants and 11,661 cases of stroke including ischemic stroke (IS), hemorrhagic stroke (HS), and stroke of unknown origin. The pooled ORs of total stroke were 1.19 (95% CI, 1.16–1.23) for every 10-μg increment in estrogen dosage, 1.20 (95% CI, 1.05–1.37) for every 5-years increment in duration of OCP use, and 0.82 (95% CI, 0.68–0.98) for every 5-years increment in duration of OCP cessation. The ORs of IS were 1.20 (95% CI, 1.17–1.22) in estrogen dosage, 1.24 (95% CI, 1.04–1.49) in duration of OCP use, and 0.78 (95% CI, 0.67–0.92) in duration of OCP cessation. The ORs of HS were 1.10 (95% CI, 1.04–1.16) in estrogen dosage, 1.13 (95% CI, 0.93–1.36) in duration of OCPs, and 0.71 (95% CI, 0.55–0.92) in duration of OCP cessation. The pooled ORs of total stroke from prospective studies (1.12; 95% CI, 1.01–1.24) were lower than those from retrospective studies (1.30; 95% CI, 1.01–1.67).

Conclusions: The higher estrogen dosage significantly increased the risks of total stroke, IS, and HS, respectively. The longer duration of OCP use significantly increased the risks of total stroke and IS, but its effects on HS risk were marginal. The longer duration of OCP cessation significantly decreased the risks of total stroke, IS, and HS, respectively. These findings affirm the contribution of estrogen dose and duration of OCP use to the increased risk of stroke, which may be critical for the instruction of OCP use and the prevention and management of cerebrovascular diseases.

Continuous Use of Combined Hormonal Contraceptive and the Effect on Blood Coagulation Factors in Female Capuchin Monkeys (Sapajus libidinosus)

This study aimed at evaluating the availability of the primate Sapajus libidinosus as an animal model for research assessing the physiological effects of the continuous use of combined hormonal contraceptives. In order to do this, six reproductively active female S. libidinosus from the Primate Research Center of the University of Brasília were selected to take part in this experiment. Every 21 days or so, each female received a single dose of combined hormonal contraceptive (algestone acetophenide and 17-enanthate estradiol) in a total of five doses throughout the experiment. The physiological parameters were accessed by means of 13 blood samples from each female, whereas three were gathered during the baseline and 10 samples were collected during the treatment phase. The results showed that the contraceptive use provoked changes in hematological coagulation factors such as an increase in the amount of platelets (p = 0.039) and a reduction in both prothrombin (p < 0.001) and thromboplastin coagulation time (p < 0.001). These results are similar to what has been observed in human patients; thus, it is concluded that S. libidinosus can be successfully used in studies about the physiological impact of hormonal contraceptives.

Consensus Statement on the Use of Oral Contraceptive Pills in Polycystic Ovarian Syndrome Women in India

OBJECTIVE

To provide consensus recommendations for health-care providers on the use of oral contraceptive pills (OCPs) in polycystic ovarian syndrome (PCOS) women in India.

PARTICIPANTS

Extensive deliberations, discussions, and brainstorming were done with different fraternities (specialists) being involved. These included endocrinologists, gynecologists, reproductive endocrinologists, dermatologists, public health experts, researchers, and a project manager with a team to develop the guideline.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 2003 to December 2017 using appropriate-controlled vocabulary (e.g., oral contraceptive pills, polycystic ovarian syndrome, long term outcomes, infertility). Clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies' publications and data were also reviewed to suggest the recommendations.

PROCESS

The working group for guideline committee included members from the PCOS Society (India), Indian Society for Assisted Reproduction, The Mumbai Obstetric and Gynecological Society, The Endocrine Society of India, Indian Association of Dermatologists, Venereologists and Leprologists, Cosmetic Dermatology Society (India), Academicians from Medical Colleges, National Institute for Research in Reproductive Health, and a Research Associate. The core team included five reproductive endocrinologists, five gynecologists, five dermatologists, three endocrinologists, two public health experts and one research associate.

CONCLUSIONS

This consensus statement provides the guidance/recommendations for Indian practitioners regarding the use of OCP in women with PCOS. PCOS is one of the common endocrinopathies encountered in gynecological/endocrine practice. The spectrum of this disorder may range from prepubertal girls with premature pubarche, young girls with hirsutism, acne and anovulatory cycles, married women with infertility, and elderly women. Although obesity is a common feature for most PCOS patients, 'lean PCOS' also exists. For several years, OCPs have played an important role in the symptom management of PCOS women. This is due to the fact that OCPs decrease the luteinizing hormone, reduce androgen production, and increase sex hormone-binding globulin, which binds androgens. Several new formulations of OCPs have been developed to decrease the side effects. This includes use of less androgenic progestins and lower doses of ethinyl estradiol. These consensus recommendations help the health provider to choose the right type of OCPs, which will alleviate the symptoms with least side effects. It also gives insight into the indications, contraindications, and concerns regarding its short, intermediate and long-term use.

Association between oral contraceptives and risk of hemorrhagic stroke: a meta-analysis of observational studies

OBJECTIVES

To estimate the risk of hemorrhagic stroke associated with current use of oral contraceptives (OCs), and to further depict how the risk was affected by study characteristics.

METHODS

We searched PubMed, Embase, and Cochrane Library for relevant articles published up to February 2017 that examined the association between OC use and risk of hemorrhagic stroke. Two investigators independently reviewed articles based on inclusion criteria. The Newcastle-Ottawa scale was employed to evaluate quality of studies. Random-effects meta-analysis model was used to generate summary risk estimates.

RESULTS

Fifteen independent studies (5 cohort studies and 10 case-control studies) with 4271 hemorrhagic stroke cases were included in this meta-analysis. The overall summary odds ratio (OR) for hemorrhagic stroke (HS) in relation to current OC use was 1.39 [95% confidence interval (CI), 1.05-1.83]. Subgroup analyses on hemorrhagic stroke types showed that OC use was associated with subarachnoid hemorrhage (SAH) (OR 1.68; 95% CI 1.21-2.12), but not with intracerebral hemorrhage (ICH) (OR 0.92; 95% CI 0.33-2.54). The risk of hemorrhagic stroke was increased slightly among current OC users with high-dose estrogen (OR 1.60; 95% CI 1.12-2.27). The risk of hemorrhagic stroke was further increased in OC users with additional risk factors including current smoking, hypertension, and history of migraine.

CONCLUSIONS

This meta-analysis of observational studies suggests that current use of OCs could contribute to a small increased risk of hemorrhagic stroke, and the increased risk is related to subarachnoid hemorrhage, but not intracerebral hemorrhage.