Association between progestin-only contraceptive use and cardiometabolic outcomes: A systematic review and meta-analysis

Use of etonogestrel subcutaneous implant in Sardinia, Italy: women's compliance and satisfaction

PURPOSE OF THE ARTICLE

The main aim of the study was to analyze the population of women who used etonogestrel implant, the reason that led them to this type of contraception, and the degree of compliance with it. Materials and methods: We carried out a retrospective study on women who had etonogestrel subcutaneous implant placed (n°47) over a 6-year period (2015-2021). We submitted the women a series of questions by telephone questionnaire (range 10-72 months after placements, mean 40 months) that investigated the comorbidities and side effects related to etonogestrel implant.

MATERIALS AND METHODS

We carried out a retrospective study on women who had etonogestrel subcutaneous implant placed (n°47) over a 6-year period (2015-2021). We submitted the women a series of questions by telephone questionnaire (range 10-72 months after placements, mean 40 months) that investigated the comorbidities and side effects related to etonogestrel implant.

RESULTS

The average age of placement of etonogestrel implant was 33.8 ± 3.45 years. As regards level of education, 16/47 (34%) of the women had a university degree, 21/47 (44%) had a high school diploma and 10/47 (21%) had a secondary school diploma. The 12/47 (25%) of the women were, at the time of the counselling, unemployed and only 8% did not use in the past contraceptive methods other than etonogestrel implant. The 92% of women choose etonogestrel implant because it offered safe, comfortable and long-lasting contraception. Among the main side effects evaluated, we reported spotting in 24 out of 47 (51%), headache in 4 out of 47 (8.5%). The 85% of the women recommended etonogestrel implant to their friends as a contraceptive method, with an approval rating for the implant, expressed a rating from 1 to 10 with the mean that was 7.79, the median 8.

CONCLUSIONS

Our results are of interest because they derive from a region of Italy in which the Long acting reversible contraception (LARC) is strongly underused. Etonogestrel implant was a safe and effective, long-acting, reversible hormonal contraception (LARC) and majority of women recommended the etonogestrel implant to their friends as a contraceptive method.

Risk of Stroke in Women Using Levonorgestrel-Releasing Intrauterine Device for Contraception

BACKGROUND

The commonly used combined hormonal contraceptives with progestins and ethinylestradiol are associated with an increased risk of ischemic stroke (IS). Progestin-only preparations, including levonorgestrel-releasing intrauterine devices (LG-IUDs), are not associated with an increased risk, and in smaller studies, the risk is even reduced. The risk of intracerebral hemorrhage (ICH) has never been investigated. We studied the risk of IS and ICH in women using LG-IUDs compared with women not using hormonal contraceptives.

METHODS

In this Danish historical cohort study (2004-2021), we followed nonpregnant women (18-49 years) registering incident IS and ICH in relation to use of LG-IUDs/nonuse of hormonal contraceptives utilizing Danish high-quality registries with nationwide coverage. Poisson regression models adjusting for age, ethnicity, education, calendar year, and medication use for risk factors were applied.

RESULTS

A total of 1 681 611 nonpregnant women contributed 11 971 745 person-years (py) of observation. Mean age at inclusion was 30.0 years; mean length of follow-up was 7.1 years; 2916 women (24.4 per 100 000 py) had IS; 367 (3.1 per 100 000 py) had ICH. Of these, 364 784 were users of LG-IUD contributing 1 720 311 py to the investigation; mean age at start of usage was 34.6 years. Nonusers of hormonal contraceptives contributed 10 251 434 py; mean age at inclusion was 30.0 years. The incidence rate of IS/ICH among LG-IUD users was 19.2/3.0 and among nonusers, it was 25.2/3.1 per 100 000 py. After adjustment, incidence rate ratio for IS was 0.78 (CI, 0.70-0.88), and for ICH it was 0.94 (CI, 0.69-1.28).

CONCLUSIONS

The use of LG-IUD was associated with a 22% lower incidence rate of IS without raising the incidence rate of ICH. The finding raises the question of whether levonorgestrel, in addition to its contraceptive properties, could have the potential to prevent IS.

Disease severity drives risk of venous thrombotic events in women with sickle cell disease in a single-center retrospective study

Background

Estrogen-containing hormonal contraception (HC) is a well-established risk factor for venous thromboembolism (VTE). Women with sickle cell disease (SCD) also have an increased risk of VTE. However, it is unknown if exposure to HC exacerbates the risk of VTE in women with SCD.

Objectives

Assess the impact of HC on VTE risk in women with SCD and explore additional risk factors contributing to VTE development.

Methods

We analyzed a retrospective cohort of women of reproductive age (15-49 years) with SCD at the University of North Carolina from 2010 to 2022.

Results

We identified 370 women with SCD, and 93 (25.1%) had a history of VTE. Among 219 women exposed to HC, 38 of 184 (20.6%) had a VTE while actively using HC, whereas 20 of 151 (13.2%) women never exposed to HC had a VTE. Of the patients exposed to HC, 64 of 184 (34.7%) were on estrogen-containing HC, with 120 of 184 (65.3%) using progestin-only formulations. Cox regression analysis found that progestin-only formulations increased VTE risk (hazard ratio: 2.03; 95% CI: 1.107-3.726, P < .05). However, when accounting for disease severity, the association between progestin-only treatment and VTE risk was not significant. Indeed, a nuanced analysis revealed that both severe (odds ratio: 11.79; 95% CI: 5.14-27.06; P < .001) and moderate (odds ratio: 4.37; 95% CI: 1.77-10.76; P = .001) disease increased risk compared with mild disease. Neither genotype nor hydroxyurea use influenced VTE risk.

Conclusion

Overall, we found that increased thrombotic risk is more likely influenced by disease status than HC exposure and should play a role in shared decision-making with patients.

Exploring the potential for a set of UK hormone replacement therapy eligibility guidelines: A suggested proposal on the topic of venous thromboembolism

OBJECTIVE

To explore the feasibility for a set of hormone replacement therapy (HRT) eligibility guidelines that follow a similar structure and appearance to the UKMEC guidance for contraception. To enable non-specialists to feel confident in safely prescribing HRT and to aid selection of the most appropriate first line treatment.

METHODS

A literature review was undertaken with evidence summarised on the topic of venous thromboembolism (VTE) which is an area frequently considered a barrier to prescribing. Medical eligibility tables which separated HRT by type were then produced for a set of VTE-related topics.

RESULTS

The literature search confirmed the importance of distinguishing between different types and routes of administration when considering the suitability of HRT. Much of the evidence has been based on older synthetic types of HRT and whilst they still have a role in management, these medications carry different risks to the now more accepted use of body identical types. The search also highlighted the nuances involved, increasing the complexity of forming guidelines, with the need for consideration to be given to an individual's own perception of risks and benefits.

CONCLUSION

The demand for HRT has risen in recent years and there is a need for this to be managed effectively, particularly for patients in primary care. The production of this type of guidance will enable the non-specialist to feel confident in safe and evidence-based prescribing. The guidelines are also designed to demonstrate to prescribers which complex patients should be referred onto menopause specialists.

Contraceptives and Thrombosis: An Intertwined Revolutionary Road

The development of oral contraceptives (OCs) began in 1921 and continued in the following years until the first regulatory approval from the Food and Drug Administration was granted in 1960. However, it took several years to realize that OCs presented an important but not frequent risk of venous thrombosis. Several reports ignored this dangerous effect and only in 1967 the Medical Research Council clearly stated this as an important risk. Later, research led to the formulation of second-generation OCs containing progestins, which nevertheless presented an increased thrombotic risk. In early 1980s, OCs containing third-generation progestins were introduced into the market. Only in 1995, it became clear that these new compounds induced a higher thrombotic risk than that related to the second-generation progestins. It appeared clear that the modulating action of progestins was against the procoagulant activity of estrogens. Lastly, at the end of the 2000s, OCs containing natural estrogens and a fourth-generation progestin (dienogest) became available. The prothrombotic effect of those natural products was not different from that of preparations containing second-generation progestins. Moreover, research over the years has produced much data on risk factors associated with OCs use such as age, obesity, cigarette smoking, and thrombophilia. These findings allowed us to better assess the individual thrombotic risk (both arterial and thrombotic) of each woman before offering an OC. Furthermore, research has shown that in high-risk people the use of single progestin is not dangerous as far as thrombosis is concerned. In conclusion, the OCs road has been long and difficult but has led to a great and unthinkable scientific and social enrichment since the 1960s.

Hormones and thrombosis: the dark side of the moon

BACKGROUND

The main drawback of oral contraceptives (OC) and hormone replacement therapy (HRT) is an increased risk of venous and, to a lesser extent, arterial thrombosis.

MATERIALS AND METHODS

This narrative, case-based review describes the effect of available estrogens and progestogens on the hemostatic system and their potential impact on the risk of thrombosis. Clinical cases are used to illustrate different options for prescribing OC and HRT in the real-word. The aim is to offer discussion topics that could be helpful to guide the choice of different hormonal treatments over a woman's lifetime and in the presence of risk factors.

RESULTS

We describe physio-pathological changes occurring during the administration of hormonal therapies. Furthermore, we analyze the risk of venous and arterial thrombosis associated with different products, routes of administration and additional risk factors. New hormonal preparations, such as estradiol combined with dienogest, as well as non-oral hormonal therapies, are suggested to decrease thrombotic risk significantly.

DISCUSSION

The availability of many products and different routes of administration allow most women to safely use contraception, as well as HRT. We encourage careful counselling instead of inflexible or fearful behavior, as expanding options and choices will allow women to make the best decisions for their health.

Comparison of thromboembolism outcomes in patients with sickle cell disease prescribed hormonal contraception

Patients with sickle cell disease (SCD) are at a risk of thromboembolism (TE), and use of hormonal contraception can further increase that risk. This study aims to assess patterns of hormonal contraceptive use and compare risk of contraception-related TE between combined hormonal contraceptives (CHCs) and progestin-only contraceptives (POCs). Patients with SCD aged between 12 and 44 years with a new prescription of a hormonal contraceptive in the Centers for Medicare and Medicaid Services Medicaid Analytic eXtract database (2006-2018) were followed up to 1 year. We identified 7173 new users: 44.6% initiated CHC and 55.4% initiated POC. Combined oral contraceptive pills (OCPs; 36.5%) and progestin-only depot medroxyprogesterone acetate (33.9%) were the most frequently prescribed agents. A total of 1.8% of contraception users had a new diagnosis of TE within 1 year of the first identified contraception prescription. There were no significant differences in TE event rates between CHC and POC users (17.2 and 24.7 events per 1000 person-years, respectively). In patients prescribed OCP, there were no differences in TE event rates based on estrogen dose or progestin generation. Transdermal patch had a 2.4-fold increased risk of TE as compared with that of OCP. Although limited by the retrospective study design and use of administrative claims data, this study found no significant differences in TE rates between new users of CHC and POC in patients with SCD. Careful evaluation of underlying TE risk factors should be considered for each patient with SCD before initiation of hormonal contraception.

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.

Serum Progesterone is Negatively Associated with Hypertension and Blood Pressure Indicators Among Men and Postmenopausal Women

Sex hormones have been shown to be negatively associated with hypertension, but the relationship between serum progesterone levels and hypertension has not been adequately studied. Therefore, we aimed to evaluate the association between progesterone and hypertension among Chinese rural adults. A total of 6222 participants were recruited, which included 2577 men and 3645 women. The concentration of serum progesterone was detected by liquid chromatography-mass spectrometer system (LC-MS/MS). Logistic regression and linear regression were used to assess the associations between progesterone levels and hypertension and blood pressure related indicators, respectively. Constrained splines were used to fit the dose-response relationships of progesterone with hypertension and blood pressure related indicators. Moreover, the interactive effects of several lifestyle factors and progesterone were identified by a generalized linear model. After fully adjusting the variables, progesterone levels were inversely associated with hypertension in men [odds ratio (OR): 0.851, 95% confidence interval (CI): 0.752, 0.964]. Among men, a 2.738 ng/ml increase in progesterone was associated with a 0.557 mmHg decrease in diastolic blood pressure (DBP) (95% CI: -1.007, -0.107) and a 0.541 mmHg decrease in mean arterial pressure (MAP) (95% CI: -1.049, -0.034), respectively. Similar results were observed in postmenopausal women. Interactive effect analysis showed that only a significant interaction was observed between progesterone and educational attainment on hypertension in premenopausal women (p=0.024). Elevated levels of serum progesterone were associated with hypertension in men. Except for premenopausal women, a negative association of progesterone with blood pressure related indicators was observed.

Obesity and contraceptive use: impact on cardiovascular risk

Obesity and oestrogen containing contraceptive products are well-known independent cardiovascular risk factors. However, a significant number of obese women continue to receive prescriptions of hormonal products that contain oestrogens for their contraception. We have conducted a narrative review to discuss the latest evidence, ongoing research, and controversial issues on the synergistic effect of obesity and contraceptive use, in terms of cardiovascular risk. There is compelling evidence of an interplay between obesity and contraception in increasing cardiovascular risk. Women who present both obesity and use of combined oral contraceptives (COCs) have a greater risk (between 12 and 24 times) to develop venous thromboembolism than non-obese non-COC users. Data here discussed offer new insights to increase clinicians' awareness on the cardiovascular risk in the clinical management of obese women. The synergistic effect of obesity and COCs on deep venous thrombosis risk must be considered when prescribing hormonal contraception. Progestin-only products are a safer alternative to COCs in patients with overweight or obesity. Obese women taking contraceptives should be viewed as an 'at risk' population, and as such, they should receive advice to change their lifestyle, avoiding other cardiovascular risk factors, as a form of primary prevention. This indication should be extended to young women, as data show that COCs should be avoided in obese women of any age.

Association of Progestogens and Venous Thromboembolism Among Women of Reproductive Age

OBJECTIVE

To evaluate associations between use of seven progestogens and incident acute venous thromboembolism (VTE) among women of reproductive age.

METHODS

This nested matched case-control study identified women aged 15-49 years from January 1, 2010, through October 8, 2018, in the IBM MarketScan databases, a nationwide sample of private insurance claims in the United States. After exclusions, 21,405 women with incident acute VTE (case group), identified by diagnosis codes, were matched 1:5 by year of birth and index date through risk set sampling to 107,025 women without prior VTE (control group). From lowest to highest systemic dose based on a modified hierarchy, progestogens studied were levonorgestrel-releasing intrauterine device (LNG-IUD), oral norethindrone, etonogestrel implant, oral progesterone, oral medroxyprogesterone acetate, oral norethindrone acetate, and depot medroxyprogesterone acetate (DMPA). Conditional logistic regression models adjusted for 16 VTE risk factors were used to estimate odds ratios and 99% CIs for incident acute VTE associated with current progestogen use compared with nonuse. The primary analysis treated each progestogen as a binary exposure. Dose, which varied for oral formulations, and chronicity were explored separately. Significance was set at P <.01 to allow for multiple comparisons.

RESULTS

Current use of higher-dose progestogens was significantly associated with increased odds of VTE compared with nonuse (oral norethindrone acetate: adjusted odds ratio [aOR] 3.00, 99% CI 1.96-4.59; DMPA: aOR 2.37, 99% CI 1.95-2.88; and oral medroxyprogesterone acetate: aOR 1.98, 99% CI 1.41-2.80). Current use of other progestogens was not significantly different from nonuse (LNG-IUD, etonogestrel implant, and oral progesterone) or had reduced odds of VTE (oral norethindrone). Sensitivity analyses that assessed misclassification bias supported the primary findings.

CONCLUSION

Among reproductive-aged women using one of seven progestogens, only use of norethindrone acetate and medroxyprogesterone acetate-considered higher-dose progestogens-was significantly associated with increased odds of incident acute VTE. The roles of progestogen type, dose, and indication for use warrant further study.

Efficacy and Safety of Megestrol in the Hospitalized Older Person

Objectives To evaluate the efficacy and safety of megestrol for off-label use in older patients with weight loss. Design Retrospective, nonblinded cohort study. Setting Upstate University Hospital is a 420-bed facility and academic medical center with a level 1 trauma center. Upstate Community Hospital is a 314-bed acute care/hospital/ambulatory care center and long-term care hospital that also provides teaching services. Participants Patients 65 years of age and older without malignancy or acquired immunodeficiency syndrome who were initiated and continued megestrol therapy at the Upstate University hospitals for at least two weeks were included. Of the 1,290 patients initially screened, 16 patients on megestrol were evaluated. An age- and gender-matched control group of 16 patients was utilized for comparison of changes in weight and other variables. Interventions Patients in the megestrol group have received daily doses of megestrol between 160 mg to 800 mg for an average duration of 19 days. Patients in the control group had no history or current use of megestrol utilization. Main Outcome Measurements The primary outcome was an increase in weight. Secondary outcome measures included albumin and thromboembolic events. Changes in weight and albumin were also compared with the control group. Results At a mean duration of 19 days, there was no significant difference in weight gain (0.95 kg, OR = 1.33 [95% CI -1.615-3.527]). Albumin decreased by (0.4 g/dL OR = 0.916 [95% CI 0.12-0.78]) and none of the patients developed a thromboembolic event. Conclusion In older hospitalized patients, megestrol did not increase weight, and did not improve albumin. No thromboembolic events were observed, but this may be because of a limited duration of observation of therapy and the routine use of anticoagulation prophylaxis in the inpatient setting.

[Evolution of contraceptive practices in France: An overview from 2014 to 2019]

OBJECTIVES

To study the use of reimbursed contraceptive methods in France between 2014 and 2019, with an analysis of the profile of users by age group and an analysis by type of prescriber.

METHODS

We conducted a national descriptive study using data from the Assurance Maladie Open Data database on the use of contraceptive methods reimbursed in France from January 1, 2014, to December 31, 2019. We analyzed the number of users by year, by age group (<20years, 20-60years), and by prescriber (liberal general practitioner, liberal gynecologist, hospital practitioner, liberal midwife).

RESULTS

In 2019, 50.1% (5,345,122) of women of childbearing age used a reimbursed contraceptive method. Hormonal oral contraception was the leading contraceptive method used (42.3%), followed by the intrauterine device (6.2%) and the implant (1.6%). Use of combined estrogen-progestogen oral contraception had been declining since 2015 (-8.1 points), to the benefit of the micro progestin pill (+9.1 points) and the copper intrauterine device (+1.4 points). Among women under 20, the hormonal implant was the second most popular contraceptive method (1.2%), followed by the copper intrauterine device (0.8%) and the hormonal intrauterine system (0.2%). Among women over 20years of age of childbearing age, the copper IUD was the second most-reimbursed contraceptive method (2.4%), followed by the hormonal intrauterine system (1.6%) and the hormonal implant (1.2%). There are disparities in prescribing practices: in 2019, 51% of prescribers were general practitioners and 97% of them prescribed hormonal oral contraception.

CONCLUSION

The contraceptive supply in France is diversifying, although oral contraception remains predominant. Disparities exist between age groups of users and there is great heterogeneity in practices among contraceptive prescribers.

Hypertension and contraceptive use among women of child-bearing age in the United States from 2001 to 2018

BACKGROUND

Hypertension (HTN) in pregnancy is a leading cause of maternal mortality in the United States. Contraception is widely used, and estrogen-based combined hormonal forms are known to increase blood pressure (BP). With nearly half of pregnancies unplanned and many antihypertensive medications teratogenic, appropriate contraception is critical in child-bearing age women with HTN.

METHODS

Using the National Health and Nutrition Examination Surveys (NHANES) from 2001 to 2018, we evaluated contraception and antihypertensive medication use in women of child-bearing age (20-50 years). Women who had undergone sterilization or menopause were excluded. HTN was defined based on a self-reported provider diagnosis and BP ≥130/80 mm Hg or antihypertensive medication use. Contraception included non-barrier methods (pills/patch/ring, injections, long-acting reversible contraceptives) or consistent condom use. Multivariable logistic regression was used to model the odds of contraception use. Temporal trends in contraception use were reported.

RESULTS

Of the 8726 women, 12.4% had HTN with mean age (standard error) 36.0 (0.3) years. In women with HTN, 9.2% used non-barrier contraception and 10.4% used condoms only. Over half (52.7%) of women with HTN on antihypertensive medications were taking medications contraindicated in pregnancy, with no difference seen by contraceptive status. In logistic regression models, contraceptive use was lower in the older-aged women. In women with HTN on non-barrier contraception, combined hormonal contraceptive use declined, from 100% (2001-2006) to 81.4% (2013-2018, P < 0.001).

CONCLUSIONS

Many women with self-reported HTN are not using adequate contraception. Of the small proportion on non-barrier contraceptives, the majority are using estrogen-based, BP-raising methods.

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.

Obesity, Body Composition, and Sex Hormones: Implications for Cardiovascular Risk

Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex-based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1-45, 2022.

An oral combined contraceptive user with elevated D-dimer post COVID-19: a case report

BACKGROUND

This case discusses the challenges created by COVID-19 (coronavirus disease 2019) in the area of hormonal contraception, highlighting the contraception knowledge gap for women in their post COVID-19 period, especially if they had high D-dimer levels.

CASE PRESENTATION

This case involves a thirty-eight-year-old woman taking combined oral contraception (desogestrel/ethinyl oestradiol tablets) with a history of varicose veins. She recovered from a COVID-19 infection in November 2020. She presented to the emergency room with right lower-limb pain below the knee and progressive swelling for five days in February 2021. Physical examination of the lower limb showed mild swelling and tenderness of the right leg compared to the left leg. D-Dimer was elevated (1.06 mcg/mL FEU). COVID-19 screening was negative. A Doppler scan to exclude DVT was performed considering the clinical picture and high D-dimer level. There was no evidence of DVT in the right limb. She was reassured and discharged with instructions on when to visit the emergency room. The D-dimer had decreased to 0.53 mcg/mL FEU in March 2021. She booked an appointment with family medicine clinics because she was concerned about the continuation of combined oral contraception (desogestrel/ethinyl oestradiol tablets) with high D-dimer and risk of thrombosis. The follow-up D-dimer level in May 2021 was normal (0.4 mcg/mL FEU). The patient preferred to continue taking oral contraception.

CONCLUSION

An evidence-based consensus is needed to guide clinicians in providing contraception counselling for such patients.

Metabolic and laboratory effects of a progestin-only pill containing drospirenone 4 mg in comparison to desogestrel 75 µg: a double-blind, double-dummy, prospective, randomised study

Purpose: Steroid hormones in hormonal contraceptives influence a variety of metabolic parameters. Mainly, ethinyloestradiol (EE) in combined hormonal contraceptives (CHC) is a potent inducer of hepatic coagulation factors, has an impact on cholesterol and triglyceride levels and glucose tolerance. Progestins in CHC modify the oestrogen effects in different ways, depending on their pharmacologic properties. The metabolic impact of progestin-only contraceptives is generally considered low.Methods: The influence of novel drospirenone (DRSP)-only pill (4 mg DRSP in 24/4 intake) on a variety of lipid-, carbohydrate- and bone metabolic parameters and on haemostatic variables including clotting factors and D-Dimer level was evaluated in comparison to 0.075 mg desogestrel (DSG) during a multicentric, prospective, double-blind, double-dummy clinical trial with 1190 participants over nine treatment cycles.Results: For both DRSP and DSG, there was a decrease in cholesterol (total, HDL, and LDL) and triglyceride levels. No relevant influence on glucose, insulin, and c-peptide levels or bone remodelling markers were detected in both treatment groups. Considering the coagulatory parameters, there was no impact on hemostasis.Conclusions: The results confirm the beneficial properties of the drospirenone-only pill.EudraCT Number: 2011-002396-42.

Stroke in women: When gender matters

Stroke in women may be considered as a distinct entity due to numerous differences compared with men, including specific epidemiological, etiological, and outcome features along with unique pathophysiological mechanisms. Stroke is the second cause of death in women worldwide with sex-specific causes of stroke in youger women such as pregnancy, post-partum period, oral contraception and migraine. Substitutive hormone treatment in older women is no more recommended in regard of the increased thromboembolic risk it generates. Venous thrombolysis with rtPA and mechanical thrombectomy are now proven to be as efficacious in women as in men. After a stroke, women present poorer quality of life than men attributable to age, more severe stroke, pre-stroke dependency and depression. Recent data concerning the latest epidemiological surveys reveal a shift in trends with the rise of incidence of strokes in young women (≤55 years and 64 years) contrasting with the stability of incidence rates in older women. As science is unvealing sex-related differences in cardiovascular disorders, health policies need to be adapted accordingly to improve stroke prevention and pre-stroke health in women. In the meantime, therapeutical trials should include more women in order to be able to formulate adequate management.

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.

Which Hormones and Contraception for Women with APS? Exogenous Hormone Use in Women with APS

PURPOSE OF REVIEW

Use of exogenous estrogen carries significant risk for patients with prothrombotic disorders including those with antiphospholipid antibody (aPL) and antiphospholipid syndrome (APS). This review summarizes current knowledge of contraceptive and other hormone therapies for aPL-positive and APS women and highlights knowledge gaps to guide future research.

RECENT FINDINGS

Studies support very low risk for most progestin-only contraceptives in patients with increased thrombotic risk, but suggest increased VTE risk with depot-medroxyprogesterone acetate. Highest efficacy contraceptives are intrauterine devices and subdermal implants, and these are recommended for women with aPL/APS. Progestin-only pills are effective and low risk. Perimenopausal symptoms may be treated with nonhormone therapies in aPL/APS patients: vasomotor symptoms can improve with nonhormonal medications and cognitive behavioral therapy, and genitourinary symptoms often improve with intravaginal estrogen that has limited systemic absorption.

Minimizing Venous Thromboembolism in Feminizing Hormone Therapy: Applying Lessons From Cisgender Women and Previous Data

OBJECTIVE

To review he impact of estrogen-containing feminizing hormone regimens on transgender individuals' risk for VTE.

METHODS

We evaluated VTE risk by screening 1170 relevant studies published from 1994 to 2020, focusing on meta-analysis data.

RESULTS

The type of oral estrogen, route of administration, patient demographics, and comorbidities may affect the risk of VTE. Venous thrombosis is the most common vascular complication associated with HT.

CONCLUSION

Conjugated equine estrogens and 17-β estradiol appear to be safer than oral ethinyl estradiol. Transdermal estrogen formulations appear to be the least thrombogenic estrogens. Estrogens used concomitantly with progestins increase the risk of VTE compared to estrogens alone. To date, there are no data to demonstrate the benefit of holding HT prior to vaginoplasty or other gender affirming surgeries. For most young, healthy transgender women, there is little risk of VTE with HT, while older patients with risk factors should be discussed case by case.

Venous thromboembolism in the hormonal milieu

PURPOSE OF REVIEW

Hormonal therapy is administered for multiple indications including contraception, alleviation of menopausal symptoms, hypogonadism, and more recently, gender-affirming care. Data suggest varying degrees of increased risk for venous thromboembolism (VTE).

RECENT FINDINGS

While oral progestin only methods do not appear to increase the risk of VTE, an association was seen with injection progestin contraception. Combined oral contraception with low-dose ethinyl estradiol and most types of progestin increased the risk of VTE compared with levonorgestrel-containing oral therapies. While transdermal hormonal contraception has been previously associated with increased VTE, a recently approved levonorgestrel and ethinyl estradiol transdermal patch reported low rates (<0.2%) in a large single-arm open-label study. Women receiving postmenopausal HRT experienced an increased risk of VTE in a dose-dependent manner when using oral hormonal therapy while nonoral methods, such as topical estrogen, did not appear to increase the risk of VTE. Some studies suggest no increased risk of VTE with testosterone therapy, however, a recent case-crossover study suggested higher VTE risk in men on testosterone, particularly men less than age 65 without hypogonadism. Route of administration had no effect on VTE rates. The estimated incidence rate of VTE risk in transgender women receiving estrogen therapy is 2.3 per 1000 person years, but may be imprecise due to heterogeneity in studies included in published meta-analyses. Surgical risk estimates are primarily indirect data drawn from cisgender patients receiving hormone therapy in the perioperative setting.

SUMMARY

Hormonal therapy affects VTE risk to varying degrees dependent on specific type of hormone, formulation, and occasionally route of delivery.

C-Reactive Protein Mediates the Effect of Serum Progesterone on Obesity for Men and Postmenopausal Women in Henan Rural Cohort Study

Purpose

Studies of progesterone with obesity have been lacking, and no prior studies have investigated progesterone and C-reactive protein in rural natural populations. This study aimed to investigate the association of serum progesterone with obesity based on anthropometric parameters in Henan Rural Cohort, then further to explore the potential role of C-reactive protein in this association.

Patients and Methods

A total of 4687 participants (2474 men and 2213 postmenopausal women) from the Henan Rural Cohort study were included. Logistic regression analysis, linear regression analysis, and restricted cubic splines were performed to estimate the relationships between progesterone, C-reactive protein, obesity, and obesity-related parameters. Mediation analysis was carried out to assess the intermediary role of C-reactive protein played in the association between progesterone and obesity.

Results

After controlling for confounders, the odds ratios of obesity no matter how obesity was defined was associated with progesterone (P trend <0.05). Moreover, progesterone was related to obesity-related parameters. Also, C-reactive protein increased with the elevation of progesterone, and C-reactive protein was associated with obesity no matter how obesity was defined (P trend <0.001). Mediation analysis indicated that hsCRP had the mediating effects on the obesity, and the proportion of the effects were 15.35% and full mediating effect (defined by body mass index), 15.46% and 12.24% (defined by waist circumference), 19.14% and 12.12% (defined by waist-to-hip ratio), 23.81% and 15.09% (defined by waist-to-height ratio) for men and postmenopausal women, relatively.

Conclusion

In the Chinese rural men and postmenopausal women population, progesterone and C-reactive protein are related to obesity. We firstly found C-reactive protein partly mediates the effect of progesterone on obesity, indicating that systemic inflammation played a critical role in the association.

The Impact of Progestin-only Contraception on Adolescents with Macromastia

Progestin-only contraception has become increasingly popular among adolescents. However, patients, parents, and providers share concerns regarding the potential impact that progestin-only contraception may have on breast growth. We sought to explore the impact of progestin-only contraception on breast hypertrophy and symptomatology in adolescents with macromastia.

Drospirenone: a Latin American perspective for oestrogen-free oral contraception

AIM

Combined hormonal contraceptives, despite their high efficacy, are associated with an increased relative risk of cardiovascular events. The contraceptive mechanism of action of combined pills depends fundamentally on their progestin component.

METHODS

A narrative review was performed.

RESULTS

The drospirenone-only pill, including this synthetic progestogen with antimineralocorticoid and antiandrogenic activity, has high contraceptive efficacy that has been demonstrated with a 24-day schedule of 4-day administration of hormone-free pills. Due to its safety profile, the drospirenone-only pill is suitable even in high-risk populations, such as women with high blood pressure, thromboembolism, smoking or dyslipidemia.

CONCLUSION

Considering the increasing prevalence of these comorbidities in Latin America, the 4 mg drospirenone-only pill is suggested as one of the strategies of choice in the region for those women who choose oral contraceptives.

Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review

OBJECTIVE

To consolidate evidence from systematic reviews and meta-analyses investigating the association between reproductive factors in women of reproductive age and their subsequent risk of cardiovascular disease.

DESIGN

Umbrella review.

DATA SOURCES

Medline, Embase, and Cochrane databases for systematic reviews and meta-analyses from inception until 31 August 2019.

REVIEW METHODS

Two independent reviewers undertook screening, data extraction, and quality appraisal. The population was women of reproductive age. Exposures were fertility related factors and adverse pregnancy outcomes. Outcome was cardiovascular diseases in women, including ischaemic heart disease, heart failure, peripheral arterial disease, and stroke.

RESULTS

32 reviews were included, evaluating multiple risk factors over an average follow-up period of 7-10 years. All except three reviews were of moderate quality. A narrative evidence synthesis with forest plots and tabular presentations was performed. Associations for composite cardiovascular disease were: twofold for pre-eclampsia, stillbirth, and preterm birth; 1.5-1.9-fold for gestational hypertension, placental abruption, gestational diabetes, and premature ovarian insufficiency; and less than 1.5-fold for early menarche, polycystic ovary syndrome, ever parity, and early menopause. A longer length of breastfeeding was associated with a reduced risk of cardiovascular disease. The associations for ischaemic heart disease were twofold or greater for pre-eclampsia, recurrent pre-eclampsia, gestational diabetes, and preterm birth; 1.5-1.9-fold for current use of combined oral contraceptives (oestrogen and progesterone), recurrent miscarriage, premature ovarian insufficiency, and early menopause; and less than 1.5-fold for miscarriage, polycystic ovary syndrome, and menopausal symptoms. For stroke outcomes, the associations were twofold or more for current use of any oral contraceptive (combined oral contraceptives or progesterone only pill), pre-eclampsia, and recurrent pre-eclampsia; 1.5-1.9-fold for current use of combined oral contraceptives, gestational diabetes, and preterm birth; and less than 1.5-fold for polycystic ovary syndrome. The association for heart failure was fourfold for pre-eclampsia. No association was found between cardiovascular disease outcomes and current use of progesterone only contraceptives, use of non-oral hormonal contraceptive agents, or fertility treatment.

CONCLUSIONS

From menarche to menopause, reproductive factors were associated with cardiovascular disease in women. In this review, presenting absolute numbers on the scale of the problem was not feasible; however, if these associations are causal, they could account for a large proportion of unexplained risk of cardiovascular disease in women, and the risk might be modifiable. Identifying reproductive risk factors at an early stage in the life of women might facilitate the initiation of strategies to modify potential risks. Policy makers should consider incorporating reproductive risk factors as part of the assessment of cardiovascular risk in clinical guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120076.

Hormonal Contraceptives and the Risk of Venous Thrombosis

The risk of venous thrombosis (VT) varies according to the type of progestogen that is found in combined oral contraceptives (COCs). When combined with the estrogen component ethinylestradiol (EE), the androgenic progestogens are better able to counteract the EE-induced stimulation of liver proteins and hence are associated with a twofold decreased risk of VT compared with non- or antiandrogenic progestogens, which exert limited counteraction of EE. Because EE is responsible for the increased risk, novel estrogens such as estradiol were developed and seem to have a lower risk of VT than EE. Besides COCs, there are other methods of hormonal contraceptives, such as progestogen-only contraceptives, which do not increase VT risk, except for injectables. Other nonoral contraceptives are combined vaginal rings and patches. There is insufficient evidence regarding the risk of VT associated with these two methods compared with COCs. The increased risk associated with COCs is more pronounced in women with inherited thrombophilia. In these women, the progestogen levonorgestrel seems to be associated with the lowest risk of VT. Currently, there are no studies that have investigated the risk of VT in women who switch COCs. We hypothesize that switching COCs, even when switching from a high- to a low-risk COC, increases the risk of VT. Finally, risk prediction models in women who use COCs are lacking. Since there is a large number of VT cases associated with COC use, it is important to identify women at risk of VT and advise them on alternative contraception methods.

Best Practices for Counseling Adolescents about the Etonogestrel Implant

Among young persons, ease of use, high efficacy, and high acceptability makes the etonogestrel contraceptive implant an important choice for this age group. Adolescent-friendly, patient-centered counseling considers the patient's cognitive development, the influence of friends and family, as well as their own preferences and values. Age-appropriate language, graphics, and models are useful to explain contraceptive options and relevant side effects. Effectiveness, reversibility, safety, noncontraceptive benefits, and side effects are important attributes and should be discussed when teens are choosing a contraceptive method. In this review we describe suggested best practices for counseling adolescents about the etonogestrel implant so they can make informed, prudent decisions about using this contraceptive method.

Menopausal Hormone Therapy and Cardiovascular Risk: Where are we Now?

Transition to menopause is associated with an increase in cardiovascular disease (CVD) risk, mainly attributed to lipid and glucose metabolism dysregulation, as well as to body fat redistribution, leading to abdominal obesity. Indeed, epidemiological evidence suggests that both early menopause (EM, defined as age at menopause <45 years) and premature ovarian insufficiency (POI, defined as age at menopause <40 years) are associated with 1.5-2-fold increase in CVD risk. Menopausal hormone therapy (MHT) exerts a favorable effect on CVD risk factors (with subtle differences regarding oestrogen dose, route of administration, monotherapy or combination with progestogen and type of progestogen). Concerning CVD morbidity and mortality, most studies have shown a beneficial effect of MHT in women at early menopausal age (<10 years since the final menstrual period) or younger than 60 years. MHT is strongly recommended in women with EM and POI, as these women, if left untreated, are at risk of CVD, osteoporosis, dementia, depression and premature death. MHT has also a favorable benefit/ risk profile in perimenopausal and early postmenopausal women, provided that the patient is not at a high CVD risk (as assessed by 10-year calculation tools). Transdermal oestrogens have a lower risk of thrombosis compared with oral regimens. Concerning progestogens, natural progesterone and dydrogesterone have a neutral effect on CVD risk factors. In any case, the decision for MHT should be individualized, tailored according to the symptoms, patient preference and the risk of CVD, thrombotic episodes and breast cancer.

An Observational Study of Hypertension and Thromboembolism Among Transgender Patients Using Gender-Affirming Hormone Therapy

Purpose: Given evidence from cisgender patients that sex hormones can impact risk for some forms of cardiovascular disease (CVD), there are concerns regarding CVD among transgender patients using gender-affirming hormone therapy (HT). Methods: Using a retrospective cohort at a U.S. urban federally qualified health center (FQHC) focused on sexual and gender minority health, we examined associations between HT in transgender patients and two specific CVD outcomes, hypertension (HTN) and thromboembolism (TE). We assessed outcomes by ICD-10 codes in electronic medical records (EMR) of 4402 transgender patients. Hormone use was assessed both by blood concentrations and by prescriptions, from EMR. Results: Nineteen transwomen (TW) (0.8%) had a TE and 49 (2.1%) developed HTN; among transmen (TM), 27 (1.5%) developed HTN and there were no significant associations between hormones and HTN. Among transwomen, there was no association between TE and HT as assessed by blood concentrations. However, recent progestin prescriptions were associated with an increased odds of TE (adjusted odds ratio [aOR] 2.95 [95% confidence interval; CI 1.02-8.57]), with possibly differential effects for medroxyprogesterone acetate versus micronized progesterone. Higher total testosterone blood concentrations were associated with greater odds of HTN in TW (aOR 1.16 [95% CI 1.01-1.33]), after controlling for body mass index. Among TW, ever having a progestin prescription was protective for HTN (aOR 0.36 [95% CI 0.15-0.87]). Conclusion: We found no associations between HT and HTN among TM, More research is needed to examine the effect of recent progestin, specifically medroxyprogesterone acetate, on TE among transwomen. The protective association between progestins and HTN among TW is reassuring.

Progestogen-only pills: which progestogen would be ideal

Compared with nonuse, combined hormonal contraceptives containing estrogen and a progestogen are associated with a roughly 2- to 3-fold increased risk of venous and a 2-fold increased risk of arterial thromboembolism, including stroke and acute myocardial infarction. These events are, however, overall rare among women of reproductive age. Historically, progestin-only pills were not thought to be linked with any thromboembolic risk increase. Therefore, these preparations may be valuable options in women who are ineligible to take combined hormonal contraceptives. Until recently, only progestogens with partial androgenic activities were available. As demonstrated in animal studies, more modern progestogens such as drospirenone with its anti-mineralocorticoid effects may be associated with even more favorable aspects, which have to be clinically demonstrated, however, in future studies.

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

Although numerous studies have addressed the safety and effectiveness of hormonal contraceptive use in healthy women, data regarding women with underlying medical conditions or other special circumstances are limited. The U.S. Medical Eligibility Criteria (USMEC) for Contraceptive Use, 2016 (), which has been endorsed by the American College of Obstetricians and Gynecologists, is a published guideline based on the best available evidence and expert opinion to help health care providers better care for women with chronic medical problems who need contraception. The goal of this Practice Bulletin is to explain how to use the USMEC rating system in clinical practice and to specifically discuss the rationale behind the ratings for various medical conditions. Contraception for women with human immunodeficiency virus (HIV) (); the use of emergency contraception in women with medical coexisting medical conditions, including obesity, (); and the effect of depot medroxyprogesterone acetate (DMPA) on bone health () are addressed in other documents from the American College of Obstetricians and Gynecologists.

The hypertensive potential of estrogen: An untold story

Cardiovascular disease (CVD) is the major cause of morbidity and mortality worldwide. The implication of estrogen in this disease has been extensively studied. While the vast majority of published research argue for a cardioprotective role of estrogen in vascular inflammation such as in atherosclerosis, the role of estrogen in hypertension remains far from being resolved. The vasorelaxant effect of estrogen has already been well-established. However, emerging evidence supports a vasoconstrictive potential of this hormone. It has been proposed that the microenvironment dictates the effect of estrogen-induced type 1 nitric oxide synthase-1 (nNOS) on vasotone. Indeed, depending on nNOS product, nitric oxide or superoxide, estrogen can induce vasodilation or vasoconstriction, respectively. In this review, we discuss the evidence supporting the vasorelaxant effects of estrogen, and the molecular players involved. Furthermore, we shed light on recent reports revealing a vasoconstrictive role of estrogen, and speculate on the underlying signaling pathways. In addition, we identify certain factors that can account for the discrepant estrogenic effects. This review emphasizes a yin-yang role of estrogen in regulating blood pressure.

The case for extended thromboprophylaxis in medically hospitalised patients – not yet made

Background

The role of extended thromboprophylaxis is established for surgical patients, but not yet for hospitalised medical patients.

Design

This systematic review and meta-analysis sought to explore the role of extended thromboprophylaxis for medically ill hospitalised patients.

Methods

Medline, EMBASE and Cochrane Libraries were searched and five randomised controlled trials were identified, comprising 20,046 extended and 20,078 standard duration thromboprophylaxis patients.

Results

Allocation to extended treatment, compared with standard duration therapy, significantly reduced the risk of symptomatic deep vein thrombosis (relative risk (RR) 0.47, 95% confidence interval (CI) 0.29–0.78, P = 0.003) and non-fatal pulmonary embolism (RR 0.59, 95% CI 0.39–0.91, P = 0.02). The risk of venous thromboembolism-related death was comparable between the extended and standard duration treatment groups (RR 0.81, 95% CI 0.6–1.09, P = 0.16). Extended treatment also doubled the risk of major bleeding (RR 2.04, 95% CI 1.42–2.91, P &lt; 0.001), without significantly affecting the risk of intracranial bleeding or bleeding-associated death. The cost of preventing one symptomatic deep vein thrombosis and non-fatal pulmonary embolism was found to be £24,972 (€27,969) and £45,148 (€50,566), respectively, which outweigh the direct cost of managing established venous thromboembolism as previously reported.

Conclusions

Extended duration thromboprophylaxis caused a reduction in the risk of venous thromboembolic events, but also a numerically comparable increase in major bleeding. Further trials are required in high-risk subpopulations who may derive mortality benefits from treatment. Only then could a change in current policy and practice be supported.

Parity and risk of maternal cardiovascular disease: A dose-response meta-analysis of cohort studies

BACKGROUND

Parity has been reported to play an important role in the development of cardiovascular disease; however, the results are still controversial. We aimed to conduct a meta-analysis of cohort studies to assess quantitatively the association between parity and cardiovascular disease risk.

METHODS

PubMed and Web of Science databases were searched to 1 June 2018, supplemented by manual searches of the bibliographies of retrieved articles. And multivariate-adjusted relative risks were pooled by using random-effects models. Restricted cubic spline analysis with four knots was used to explore the relationship of parity and the risk of cardiovascular disease.

RESULTS

Ten cohort studies involving 150,512 incident cases of cardiovascular disease among 3,089,929 participants were included in the meta-analysis. A significant association between parity and cardiovascular disease risk was observed while comparing parity with nulliparity, with a summarised relative risk of 1.14 (95% confidence interval (CI) 1.09-1.18; I² = 62.0%, P = 0.002). In the dose-response analysis, we observed a potential non-linear J-shaped dose-response relationship between the number of parity and cardiovascular disease risk, the summary risk estimates for an increase of one live birth was 1.04 (95% CI 1.02-1.05), with significant heterogeneity ( I² = 89.6%). In addition, the similar J-shaped associations between parturition number and cardiovascular disease, ischaemic heart disease or stroke risk were also observed.

CONCLUSIONS

Our findings suggest that ever parity is related to cardiovascular disease risk and there is an association between the number of pregnancies and the risk of cardiovascular disease. Since the number of included studies was limited, further studies are warranted to confirm our findings.