1
|
Abouharb ALZ, Mehta S, Rathnayake H, Pandit H. Withholding of Hormone Replacement Therapy Prior to Total Joint Arthroplasty Surgery to Reduce the Risk of Postoperative Thromboembolic Events: Is It Justified?-A Systematic Review of Clinical Practice Guidelines. J Arthroplasty 2024; 39:541-548.e24. [PMID: 37634878 DOI: 10.1016/j.arth.2023.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Hormone replacement therapy (HRT), menopausal hormone therapy (MHT), and estrogen-containing medications are frequently withheld before elective lower limb arthroplasty, based on a perceived risk of venous thromboembolism (VTE). However, evidence linking HRT, MHT, and an increased VTE risk is equivocal. This systematic review evaluated the concordance of international clinical practice guidelines (CPGs) on the withholding of HRT or MHT. METHODS The PubMed, Google Scholar, Cochrane, and Ovid databases were searched for CPGs for the preoperative, perioperative, and postoperative management of patients on HRT and MHT undergoing elective lower limb arthroplasty. This was supplemented by an internet search. There were 7 international CPGs in English, from Europe and North America, published between January 2000 and February 2023 reviewed against the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE-II) criteria, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. RESULTS The guidelines reviewed revealed a mixed picture on HRT or MHT withdrawal and use in arthroplasty, with some featuring detailed advice on the preoperative and postoperative management of HRT or MHT (Scottish Intercollegiate Guidelines Network), while others featured no guidance (American College of Chest Physicians). The evidence referenced in these guidelines highlighted studies showing HRT or MHT to play a limited role in increasing VTE risk, with most studies from the 1990s and 2000s. CONCLUSIONS Based on current evidence, non-estrogen-containing transdermal HRT or MHT should not be withheld in patients undergoing elective joint arthroplasty, though further evidence is required to justify withholding estrogen-containing forms.
Collapse
Affiliation(s)
- Alexander L Z Abouharb
- Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, West Yorkshire, United Kingdom; Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Sachit Mehta
- Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Hasithe Rathnayake
- Imperial College London, Faculty of Medicine, St Mary's Hospital, London, United Kingdom
| | - Hemant Pandit
- Leeds Teaching Hospitals NHS Trust, St. James's University Hospital, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom
| |
Collapse
|
2
|
Zotz RB, Hart C, Beyer-Westendorf J, Rott H, Linnemann B. Blutgerinnung und hormonelle Kontrazeptiva. GYNAKOLOGISCHE ENDOKRINOLOGIE 2022. [DOI: 10.1007/s10304-022-00472-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
3
|
Al Kindi R, Al Salmani A, Al Hadhrami R, Al Sumri S, Al Sumri H. Perspective Chapter: Modern Birth Control Methods. Stud Fam Plann 2022. [DOI: 10.5772/intechopen.103858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This chapter focuses on various modern birth control methods, including combined oral contraceptives, progestogen-only pills, progestogen-only injectables, progestogen-only implants, intrauterine devices, barrier contraceptives, and emergency contraceptive pills. Each contraceptive method is covered in detail, including mechanism of action, effectiveness, health benefits, advantages, disadvantages, risks, and side-effects.
Collapse
|
4
|
Special Considerations for Women of Reproductive Age on Anticoagulation. J Gen Intern Med 2022; 37:2803-2810. [PMID: 35641728 PMCID: PMC9411301 DOI: 10.1007/s11606-022-07528-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/29/2022] [Indexed: 01/07/2023]
Abstract
Anticoagulation poses unique challenges for women of reproductive age. Clinicians prescribing anticoagulants must counsel patients on issues ranging from menstruation and the possibility of developing a hemorrhagic ovarian cyst to teratogenic risks and safety with breastfeeding. Abnormal uterine bleeding affects up to 70% of young women who are treated with anticoagulation. As such, thoughtful clinical guidance is required to avoid having young women who are troubled by their menses, dose reduce, or prematurely discontinue their anticoagulation, leaving them at increased risk of recurrent thrombosis. Informed by a review of the medical literature, we present current recommendations for assisting patients requiring anticoagulation with menstrual management, prevention of hemorrhagic ovarian cysts, and avoiding unintended pregnancy. The subdermal implant may be considered a first-line option for those requiring anticoagulation, given its superior contraceptive effectiveness and ability to reliably reduce risk of hemorrhagic ovarian cysts. All progestin-only formulations-such as the subdermal implant, intrauterine device, injection, or pills-are generally preferred over combined hormonal pills, patch, or ring. Tranexamic acid, and in rare cases endometrial ablation, may also be useful in managing menorrhagia and dysmenorrhea. During pregnancy, enoxaparin remains the preferred anticoagulant and warfarin is contraindicated. Breastfeeding women may use warfarin, but direct oral anticoagulants are not recommended given their limited safety data. This practical guide for clinicians is designed to inform discussions of risks and benefits of anticoagulation therapy for women of reproductive age.
Collapse
|
5
|
Lete I. Evolución del estrógeno en la anticoncepción hormonal combinada: del etinilestradiol al estetrol pasando por el estradiol. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2022. [DOI: 10.1016/j.gine.2022.100755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
Brabaharan S, Veettil SK, Kaiser JE, Raja Rao VR, Wattanayingcharoenchai R, Maharajan M, Insin P, Talungchit P, Anothaisintawee T, Thakkinstian A, Chaiyakunapruk N. Association of Hormonal Contraceptive Use With Adverse Health Outcomes: An Umbrella Review of Meta-analyses of Randomized Clinical Trials and Cohort Studies. JAMA Netw Open 2022; 5:e2143730. [PMID: 35029663 PMCID: PMC8760614 DOI: 10.1001/jamanetworkopen.2021.43730] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Sharmila Brabaharan
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia
| | - Sajesh K. Veettil
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City
| | - Jennifer E. Kaiser
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City
| | | | - Rujira Wattanayingcharoenchai
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Marikannan Maharajan
- Department of Pharmacy Practice, School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
| | - Putsarat Insin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Rajavithi Hospital, Bangkok, Thailand
| | - Pattarawalai Talungchit
- Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thunyarat Anothaisintawee
- Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City
- School of Pharmacy, University of Wisconsin–Madison, Madison
| |
Collapse
|
7
|
Kaplan S, Bertoia ML, Wang FT, Zhou L, Lass A, Evans A, Dhanda S, Roy D, Seeger JD. Long-term safety of extended levonorgestrel-containing oral contraceptives in the United States. Contraception 2021; 105:26-32. [PMID: 34599911 DOI: 10.1016/j.contraception.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To compare the safety profile of Seasonique, a 91-day levonorgestrel-containing combined oral contraceptive (COCLNG), to 28-day COCLNG regarding the risk of venous thromboembolism (VTE) and arterial thromboembolism (ATE). STUDY DESIGN A new user cohort study was conducted in a US health care database from 2006 to 2017. Each 91-day COCLNG treatment episode in females was matched to up to four 28-day COCLNG treatment episodes by propensity score. We identified VTE cases in either (1) an inpatient setting with ICD-9 and ICD-10 diagnosis codes of PE and/or DVT in the primary position, or (2) an outpatient setting with ICD-9 or ICD-10 diagnosis codes of DVT in conjunction with an anticoagulant medication dispensing or alteplase (thrombolytic) during the 30-day period following the date of DVT diagnosis. VTE was validated using medical records. We assessed the study endpoints in the two cohorts using incidence rates and Cox proportional hazards models adjusted for potential confounders. RESULTS Of the 25,593 treatment episodes in 91-day COCLNG and 76,586 treatment episodes in 28-day COCLNG, 35 and 68 patients had VTEs, respectively, corresponding to a hazard ratio (HR) of 1.40 (95% confidence interval [CI], 0.90-2.19). The VTE algorithm had a positive predictive value of 76.4% (95% CI, 66.2%-84.8%). ATEs were recorded in 13 and 28 episodes, respectively, with a corresponding HR of 1.21 (95% CI, 0.58-2.53). CONCLUSIONS These results do not indicate a significant difference between 91-day COCLNG and 28-day COCLNG in terms of VTE or ATE risk. IMPLICATIONS Compared to use of 28-day COCLNG, use of 91-day extended COCLNG was not associated with a significant difference in risk of venous and arterial thromboembolism.
Collapse
Affiliation(s)
- Sigal Kaplan
- Global Pharmacovigilance, Teva Pharmaceutical Industries Ltd, Netanya, Israel.
| | | | | | - Li Zhou
- Epidemiology, Optum, Boston, MA, USA
| | | | - Alison Evans
- Drug Safety Research Unit, Southampton, UK; School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Sandeep Dhanda
- Drug Safety Research Unit, Southampton, UK; School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Debabrata Roy
- Drug Safety Research Unit, Southampton, UK; School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | | |
Collapse
|
8
|
Papadakis E, Sarigianni M, Tziomalos K, Mavromatidis G, Panidis D. Oral contraceptives increase platelet microparticle levels in normal-weight women with polycystic ovary syndrome. Hormones (Athens) 2020; 19:565-571. [PMID: 32078734 DOI: 10.1007/s42000-020-00182-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/10/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Platelet microparticles (PMPs), which are microvesicles shed from platelets, participate in inflammation, vascular homeostasis, and thrombosis. PMPs are increased in obese women with polycystic ovary syndrome (PCOS). Agents that modulate hormonal aspects of PCOS could affect the levels of PMPs. The aim of the present study was to evaluate the effects of oral contraceptives (OCPs), antiandrogen, and metformin use for 6 and 12 months on PMPs in normal-weight women with PCOS. METHODS Forty-five women with PCOS and 13 healthy women were recruited. Biochemical, hormonal, and clinical parameters were recorded. Women with PCOS received treatment with OCPs, OCPs+antiandrogens, or metformin, depending on their main complaint or clinical/biochemical findings. PMPs were measured at baseline and after 6 and 12 months. RESULTS At baseline, patients with PCOS had higher levels of PMPs than controls (p = 0.017), which increased after 6-month treatment with OCPs (p = 0.006). Subsequently, they decreased after 12-month treatment (p = 0.046). Metformin had no effect on PMP levels. CONCLUSION In conclusion, PMP levels are increased in PCOS and further increase with OCP use. This effect could possibly contribute to the increased risk of venous thromboembolism associated with OCP use. However, further studies are needed to elucidate the exact role of PMPs in PCOS.
Collapse
Affiliation(s)
- Efstathios Papadakis
- Second Department of Obstetrics and Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Maria Sarigianni
- Second Medical Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Tziomalos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
| | - Georgios Mavromatidis
- Second Department of Obstetrics and Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Panidis
- Second Department of Obstetrics and Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
9
|
Rodrigues MF, Pereira I, Morais RL, Lobón GS, Gil EDS, Vaz BG. A New Strategy for the Analysis of Steroid Hormones in Industrial Wastewaters by Paper Spray Ionization Mass Spectrometry. JOURNAL OF THE AMERICAN SOCIETY FOR MASS SPECTROMETRY 2020; 31:2250-2257. [PMID: 32930580 DOI: 10.1021/jasms.0c00145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A new approach using paper spray ionization mass spectrometry (PSI-MS) for the analysis of steroid hormones in wastewater samples has been demonstrated. Triangular papers containing paraffin barriers as microfluidic channels were used to direct the sample solution to the paper tip, preventing the sample from spreading over the corners of the paper. The method was used to analyze the hormones levonorgestrel and algestone acetophenide in industrial wastewaters. Analytical curves presented a correlation coefficient (R2) above 0.99. Limits of quantification were below 2.3 ppm and limits of detection below 0.7 ppm. Values of precision (coefficient of variation) and accuracy (relative error) were less than 15% for all analyses. Recovery results ranged from 82% to 102%. Levonorgestrel was also analyzed by high-performance liquid chromatography coupled to mass spectrometry in order to compare the analytical performance with PSI-MS. No statistically significant differences were found between both methods. This study demonstrates the usefulness of PSI-MS for rapid analysis of hormones in industrial wastewater samples and also indicates its potential to be employed as a simple and reliable analytical method in environmental sciences.
Collapse
Affiliation(s)
| | - Igor Pereira
- Chemistry Institute, Federal University of Goiás, Goiânia 74690900, Brazil
| | - Ruiter Lima Morais
- Faculty of Pharmacy, Federal University of Goiás, Goiânia 74690900, Brazil
| | - Gérman Sanz Lobón
- Chemistry Institute, Federal University of Goiás, Goiânia 74690900, Brazil
| | - Eric de Souza Gil
- Faculty of Pharmacy, Federal University of Goiás, Goiânia 74690900, Brazil
| | - Boniek Gontijo Vaz
- Chemistry Institute, Federal University of Goiás, Goiânia 74690900, Brazil
| |
Collapse
|
10
|
Ramírez I, De la Viuda E, Baquedano L, Coronado P, Llaneza P, Mendoza N, Otero B, Sánchez S, Cancelo MJ, Páramo JA, Cano A. Managing thromboembolic risk with menopausal hormone therapy and hormonal contraception in the COVID-19 pandemic: Recommendations from the Spanish Menopause Society, Sociedad Española de Ginecología y Obstetricia and Sociedad Española de Trombosis y Hemostasia. Maturitas 2020; 137:57-62. [PMID: 32498938 PMCID: PMC7200366 DOI: 10.1016/j.maturitas.2020.04.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 01/17/2023]
Abstract
COVID-19 is associated with a systemic inflammatory response with activation of coagulation in symptomatic patients. The possibility of coagulopathies in peri- and postmenopausal women taking estrogen therapies makes it necessary to consider antithrombotic strategies, such as the use of low molecular weight heparins (LMWH) at specific prophylactic or treatment doses for each individual case, depending on the risk factors that each woman presents. For such reasons, a panel of experts from various Spanish scientific societies has met to develop usage recommendations for managing menopausal women taking menopausal hormone therapy (MHT) or combined hormonal contraception (CHC) during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Isabel Ramírez
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain.
| | - Esther De la Viuda
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | - Laura Baquedano
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | - Pluvio Coronado
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | - Plácido Llaneza
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | - Nicolás Mendoza
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | - Borja Otero
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | - Sonia Sánchez
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | - Mª Jesús Cancelo
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| | | | - Antonio Cano
- Spanish Menopause Society (Asociación Española para el Estudio de la Menopausia - AEEM), Spain; Sociedad Española de Ginecología y Obstetricia (SEGO), Spain.
| |
Collapse
|
11
|
Sutherland CS, Ademi Z, Michaud J, Schur N, Lingg M, Bhadhuri A, Pache TD, Bitzer J, Suchon P, Albert V, Hersberger KE, Tanackovic G, Schwenkglenks M. Economic evaluation of a novel genetic screening test for risk of venous thromboembolism compared with standard of care in women considering combined hormonal contraception in Switzerland. BMJ Open 2019; 9:e031325. [PMID: 31699733 PMCID: PMC6858234 DOI: 10.1136/bmjopen-2019-031325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM The aim of this study was to assess the cost effectiveness of the Pill Protect (PP) genetic screening test for venous thromboembolism (VTE) risk compared with standard of care (SoC), for women considering combined hormonal contraceptives (CHCs) in Switzerland. METHODS A two-part microsimulation model was developed to estimate VTE events, costs and quality-adjusted life years (QALYs) associated with the PP and SoC strategies. In the first portion of the model, a cohort of 1 million Swiss first-time seekers of a CHC were simulated. It was determined whether each women would receive a CHC or non-CHC by using prescribing patterns elicited from a modified Delphi study. These results formed the basis of the SoC strategy. For the PP strategy, a PP test was included and the results considered in addition to SoC practice. Each woman then entered a Markov model that captured morbidity and mortality over a lifetime. The risk of having a VTE was derived from the risk algorithm that underpins the PP test. The remaining model inputs relating to population characteristics, costs, health resource use, mortality and utilities were derived from published studies or national sources. The model was validated and calibrated to align with population-based studies. Extensive uncertainty analyses were conducted. RESULTS From a Swiss health system perspective, the PP strategy in comparison with the SoC strategy generated an additional CHF 231, and gained 0.003 QALYs per woman, leading to an incremental cost-effectiveness ratio of CHF 76 610 per QALY gained. Assuming a threshold of CHF 100 000 per QALY gained, the PP strategy is likely to be cost effective. Our results were generally robust to variations in the parameter values. CONCLUSIONS The PP test may be cost effective in Switzerland for screening women seeking CHCs for their risk of VTE based on the current evidence.
Collapse
Affiliation(s)
- C Simone Sutherland
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Zanfina Ademi
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Nadine Schur
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Myriam Lingg
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Arjun Bhadhuri
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | | | - Johannes Bitzer
- Department of Obstetrics and Gynecology, University Hospital Basel, Basel, Switzerland
| | - Pierre Suchon
- Laboratory of Haematology, La Timone Hospital, Marseille, France
- C2VN, Aix Marseille Universite, INSERM, INRA, Marseille, France
| | - Valerie Albert
- Pharmaceutical Care Research Group (PCRG), University of Basel, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group (PCRG), University of Basel, Basel, Switzerland
| | | | | |
Collapse
|
12
|
FSRH Guideline (January 2019) Combined Hormonal Contraception (Revision due by January 2024). BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:1-93. [PMID: 30665985 DOI: 10.1136/bmjsrh-2018-chc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
|
13
|
Beyer-Westendorf J, Bauersachs R, Hach-Wunderle V, Zotz RB, Rott H. Sex hormones and venous thromboembolism - from contraception to hormone replacement therapy. VASA 2018; 47:441-450. [PMID: 30008249 DOI: 10.1024/0301-1526/a000726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The use of sex hormones such as combined oral contraceptives (COC) or hormone replacement therapy (HRT) increases the risk for venous thromboembolism (VTE) considerably, especially in patients with an increased intrinsic risk for thromboembolic complications. Despite public and media attention and increasing scientific evidence, prescription patterns seem to be hard to change. It is well recognized that the patient's baseline risk is the most relevant factor in the absolute risk for developing VTE. The relative risk increase associated with sex hormones, depends on the type and dosage of hormones, the route of application (oral, vaginal, transdermal), and for COC, on the specific combination of oestrogen and gestagen components. Consequently, a careful decision for or against any specific type of hormone treatment needs to be based on an assessment of the patient's risk profile (disposition) as well as on the treatment-associated risks and benefits (exposition). This review discusses the most common sex hormone treatments in contraception and HRT, the relevance for VTE risk patients, and strategies to counsel patients with regard to hormone use according to their risk profiles. Keywords: Oral contraceptives, hormonal contraception, hormone replacement therapy, venous thromboembolism.
Collapse
Affiliation(s)
- Jan Beyer-Westendorf
- 1 Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany.,2 Kings Thrombosis Service, Department of Hematology, Kings College London, UK
| | | | | | - Rainer B Zotz
- 5 Institute for Laboratory Medicine, Blood Coagulation and Transfusion Medicine (LBT), Düsseldorf, Germany.,6 Department of Haemostasis, Haemotherapy and Transfusion Medicine, Heinrich Heine University Medical Centre, Düsseldorf, Germany
| | | |
Collapse
|
14
|
García-Franco AL, Baeyens Fernández JA, Bailón Muñoz E, Iglesias Piñeiro MJ, Cura González ID, Del Moral AO, Landa Goñi J, Alonso Coello P, Arribas Mir L. Actividades preventivas en la mujer. Actualización PAPPS 2018. Aten Primaria 2018; 50 Suppl 1:125-146. [PMID: 29866353 PMCID: PMC6836928 DOI: 10.1016/s0212-6567(18)30366-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
| | | | - Emilia Bailón Muñoz
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Universitario de Albaycín, Granada
| | | | - Isabel Del Cura González
- Especialista en Medicina Familiar y Comunitaria, Unidad de Investigación, Gerencia Asistencial de Atención Primaria, Madrid
| | | | - Jacinta Landa Goñi
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Emisora, Pozuelo de Alarcón, Madrid
| | - Pablo Alonso Coello
- Especialista en Medicina Familiar y Comunitaria, Centro Cochrane Iberoamericano (CIBERESP-IIB Sant Pau), Barcelona
| | - Lorenzo Arribas Mir
- Especialista en Medicina Familiar y Comunitaria, Centro de Salud Universitario La Chana, Granada
| |
Collapse
|
15
|
Oedingen C, Scholz S, Razum O. Systematic review and meta-analysis of the association of combined oral contraceptives on the risk of venous thromboembolism: The role of the progestogen type and estrogen dose. Thromb Res 2018; 165:68-78. [DOI: 10.1016/j.thromres.2018.03.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
|
16
|
Dragoman MV, Tepper NK, Fu R, Curtis KM, Chou R, Gaffield ME. A systematic review and meta-analysis of venous thrombosis risk among users of combined oral contraception. Int J Gynaecol Obstet 2018; 141:287-294. [PMID: 29388678 PMCID: PMC5969307 DOI: 10.1002/ijgo.12455] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/06/2017] [Accepted: 01/29/2018] [Indexed: 12/11/2022]
Abstract
Background Combined oral contraceptives (COCs) containing various progestogens could be associated with differential risks for venous thromboembolism (VTE). Objective To evaluate the comparative risks of VTE associated with the use of low‐dose (less than 50 μg ethinyl estradiol) COCs containing different progestogens. Search strategy PubMed and the Cochrane Library were searched from database inception through September 15, 2016, by combining search terms for oral contraception and venous thrombosis. Selection criteria Studies reporting VTE risk estimates among healthy users of progestogen‐containing low‐dose COCs were included. Data collection and analysis A random‐effects model was used to generate pooled adjusted risk ratios and 95% confidence intervals; subgroup and sensitivity analyses assessed the impact of monophasic‐COC use and study‐level characteristics. Main results There were 22 articles included in the analysis. The use of COCs containing cyproterone acetate, desogestrel, drospirenone, or gestodene was associated with a significantly increased risk of VTE compared with the use of levonorgestrel‐containing COCs (pooled risk ratios 1.5–2.0). The analysis restricted to monophasic COC formulations with 30 μg of ethinyl estradiol yielded similar findings. After adjustment for study characteristics, the risk estimates were slightly attenuated. Conclusions Compared with the use of levonorgestrel‐containing COCs, the use of COCs containing other progestogens could be associated with a small increase in risk for VTE. Combined oral contraceptives containing certain progestogens could be associated with a small increase in risk for venous thromboembolism compared with those containing levonorgestrel.
Collapse
Affiliation(s)
- Monica V Dragoman
- Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Naomi K Tepper
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Rongwei Fu
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
| | - Kathryn M Curtis
- Division of Reproductive Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Roger Chou
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR, USA
| | - Mary E Gaffield
- Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| |
Collapse
|
17
|
Larivée N, Suissa S, Khosrow-Khavar F, Tagalakis V, Filion KB. Drospirenone-containing oral contraceptive pills and the risk of venous thromboembolism: a systematic review of observational studies. BJOG 2017; 124:1490-1499. [DOI: 10.1111/1471-0528.14623] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2017] [Indexed: 01/11/2023]
Affiliation(s)
- N Larivée
- Center for Clinical Epidemiology; Lady Davis Institute; Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology, Biostatistics and Occupational Health; McGill University; Montreal QC Canada
| | - S Suissa
- Center for Clinical Epidemiology; Lady Davis Institute; Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology, Biostatistics and Occupational Health; McGill University; Montreal QC Canada
- Department of Medicine, McGill University; McGill University; Montreal QC Canada
| | - F Khosrow-Khavar
- Center for Clinical Epidemiology; Lady Davis Institute; Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology, Biostatistics and Occupational Health; McGill University; Montreal QC Canada
| | - V Tagalakis
- Center for Clinical Epidemiology; Lady Davis Institute; Jewish General Hospital; Montreal QC Canada
- Division of General Internal Medicine; Jewish General Hospital; Montreal QC Canada
| | - KB Filion
- Center for Clinical Epidemiology; Lady Davis Institute; Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology, Biostatistics and Occupational Health; McGill University; Montreal QC Canada
- Department of Medicine, McGill University; McGill University; Montreal QC Canada
| |
Collapse
|
18
|
Affiliation(s)
- Angelo Cagnacci
- Department of Gynaecology and Obstetrics, University of Udine, Udine, Italy
| |
Collapse
|
19
|
Tepper NK, Dragoman MV, Gaffield ME, Curtis KM. Nonoral combined hormonal contraceptives and thromboembolism: a systematic review. Contraception 2017; 95:130-139. [PMID: 27771476 PMCID: PMC11025291 DOI: 10.1016/j.contraception.2016.10.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/13/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Combined hormonal contraceptives (CHCs), containing estrogen and progestin, are associated with an increased risk of venous thromboembolism (VTE) and arterial thromboembolism (ATE) compared with nonuse. Few studies have examined whether nonoral formulations (including the combined hormonal patch, combined vaginal ring and combined injectable contraceptives) increase the risk of thrombosis compared with combined oral contraceptives (COCs). OBJECTIVES The objectives were to examine the risk of VTE and ATE among women using nonoral CHCs compared to women using COCs. METHODS We searched the PubMed database for all English language articles published from database inception through May 2016. We included primary research studies that examined women using the patch, ring or combined injectables compared with women using levonorgestrel-containing or norgestimate-containing COCs. Outcomes of interest included VTE (deep venous thrombosis or pulmonary embolism) or ATE (acute myocardial infarction or ischemic stroke). We assessed the quality of each individual piece of evidence using the system developed by the United States Preventive Services Task Force. RESULTS Eight studies were identified that met inclusion criteria. Of seven analyses from six studies examining VTE among patch users compared with levonorgestrel- or norgestimate-containing COC users, two found a statistically significantly elevated risk among patch users (risk estimates 2.2-2.3), one found an elevated risk that did not meet statistical significance (risk estimate 2.0), and four found no increased risk. Of three studies examining VTE among ring users compared with levonorgestrel COC users, one found a statistically significantly elevated risk among patch users (risk estimate 1.9) and two did not. Two studies did not find an increased risk for ATE among women using the patch compared with norgestimate COCs. We did not identify any studies examining combined injectable contraceptives. CONCLUSION Limited Level II-2 good to fair evidence demonstrated conflicting results on whether women using the patch or the ring have a higher risk of VTE than women using COCs. Evidence did not demonstrate an increased risk of ATE among women using the patch. Overall, any potential elevated risk likely represents a small number of events on a population level. Additional studies with standard methodology are needed to further clarify any associations and better understand mechanisms of hormone-induced thrombosis among users of nonoral combined hormonal contraception.
Collapse
Affiliation(s)
- Naomi K Tepper
- Division of Reproductive Health, US Centers for Disease Control and Prevention, 4770 Buford Hwy, MS F-74, Atlanta, GA 30341.
| | - Monica V Dragoman
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Mary E Gaffield
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Kathryn M Curtis
- Division of Reproductive Health, US Centers for Disease Control and Prevention, 4770 Buford Hwy, MS F-74, Atlanta, GA 30341
| |
Collapse
|
20
|
Combined hormonal contraception and the risk of venous thromboembolism: a guideline. Fertil Steril 2016; 107:43-51. [PMID: 27793376 DOI: 10.1016/j.fertnstert.2016.09.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 11/18/2022]
Abstract
While venous thromboembolism (VTE) is rare in young women of reproductive age, combined oral contraceptives increase the risk of VTE. In the patient in whom combined hormonal contraception is appropriate, it is reasonable to use any currently available preparation.
Collapse
|
21
|
Stanczyk FZ, Mathews BW, Cortessis VK. Does the type of progestin influence the production of clotting factors? Contraception 2016; 95:113-116. [PMID: 27421764 DOI: 10.1016/j.contraception.2016.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/06/2016] [Accepted: 07/10/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Frank Z Stanczyk
- Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA; Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
| | - Brett W Mathews
- Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Victoria K Cortessis
- Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA; Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA
| |
Collapse
|
22
|
Cotton CC, Baird D, Sandler RS, Long MD. Hormonal Contraception Use is Common Among Patients with Inflammatory Bowel Diseases and an Elevated Risk of Deep Vein Thrombosis. Inflamm Bowel Dis 2016; 22:1631-8. [PMID: 27306071 PMCID: PMC5064836 DOI: 10.1097/mib.0000000000000800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Persons with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism. We sought to examine whether the self-report of hormonal contraception (HC), as a proxy for exposure to estrogen-based contraception, was less common for women with multiple risk factors for venous thromboembolism. METHODS We examined the prevalence of personal use of hormonal birth control in a large internet-based cohort of patients with IBD. To determine whether HC was less common among patients with IBD with increased risk of thrombosis, we estimated unadjusted and adjusted prevalence ratios (PRs) for the use of HC. RESULTS Thousand four hundred ninety-nine female survey respondents answered optional fertility questions and were included in the analysis. The prevalence of HC was 33.7% (95% CI, 30.6%-36.9%) among women with Crohn's disease and was 32.6% (95% CI, 28.6%-36.8%) for women with ulcerative colitis. Women with one risk factor for thrombosis were not significantly less likely to receive HC (PR = 0.91, 95% CI: 0.76-1.08; adjusted PR = 0.94, 95% CI: 0.80-1.11) compared with women without risk factors nor were women with 2 or more risk factors (PR = 1.10, 95% CI 0.56-1.28; adjusted PR = 1.10, 95% CI: 0.83-1.45). The use of an intrauterine device was also similar between women with and without risk factors for venous thromboembolism. CONCLUSIONS The prevalence of HC use in women with multiple risk factors was similar to that in women without risk factors, which represents an opportunity for prevention. Gastroenterologists should ask patients with IBD using HC about risk factors for thromboembolic disease to identify patients who may benefit from alternative contraception.
Collapse
Affiliation(s)
- Cary C. Cotton
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, USA; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA
| | - Donna Baird
- NIH, Epidemiology Branch, National Institute of Environmental Health Sciences, NC, USA
| | - Robert S. Sandler
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, USA; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA
| | - Millie D. Long
- University of North Carolina at Chapel Hill, Department of Medicine, Division of Gastroenterology and Hepatology, USA; Center for Gastrointestinal Biology and Disease, Chapel Hill, NC, USA
| |
Collapse
|
23
|
Efficacy and safety of a 21/7-active combined oral contraceptive with continuous low-dose ethinyl estradiol. Contraception 2015; 93:249-56. [PMID: 26499407 DOI: 10.1016/j.contraception.2015.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Substituting low-dose ethinyl estradiol (EE) for the hormone-free interval in combined oral contraceptives (COCs) may enhance ovarian suppression and improve tolerability. This noncomparative phase 3 study evaluated the efficacy and safety of a 21/7-active COC regimen including 21days of desogestrel (DSG)/EE followed by 7days of EE. STUDY DESIGN This multicenter, open-label, phase 3, single-arm study enrolled sexually active women aged 18-40years at risk for pregnancy. Women received up to 1year, or 13 consecutive 28-day cycles, of DSG 150mcg/EE 20mcg for 21days and EE 10mcg alone for 7days. Participants kept diaries to record compliance, bleeding/spotting and other contraceptive use. Efficacy was measured using the Pearl Index (PI) and life-table approach. Safety and tolerability were assessed primarily through reported adverse events (AEs). RESULTS A total of 2858 women enrolled and 1680 completed the study. Forty-six pregnancies in 2401 women aged 18-35years occurred after COC initiation and up to 7days after last DSG/EE or EE-only tablet was taken. When cycles in which another contraceptive method was used were excluded, the PI was 2.68 [95% confidence interval (CI), 1.96-3.57]. The cumulative pregnancy rate after 1year of treatment was 2.47% (95% CI, 1.85-3.29) for all users aged 18-35years. When only cycles during which women considered compliant were included, the PI was 2.00 (95% CI, 1.39-2.80). AEs were similar to those seen with other oral contraceptives. CONCLUSIONS This 21/7-active DSG/EE COC with 7days of low-dose EE was efficacious and well tolerated for pregnancy prevention. IMPLICATIONS STATEMENT This phase 3 open-label study demonstrated that a 21/7-active COC regimen including 21days of DSG 150mcg/EE 20mcg and 7days of EE 10mcg was efficacious and well tolerated for pregnancy prevention.
Collapse
|
24
|
Luque-Ramírez M, Escobar-Morreale HF. Targets to treat androgen excess in polycystic ovary syndrome. Expert Opin Ther Targets 2015; 19:1545-60. [DOI: 10.1517/14728222.2015.1075511] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
|
25
|
Abstract
Polycystic ovary syndrome (PCOS) is a common reproductive and metabolic disorder. Patients with PCOS present with clinical signs of androgen excess (ie, hirsutism and acne), menstrual irregularities, and infertility. Combined oral contraceptive (OC) pills are the first-line medical therapy for the long-term management of PCOS. Containing a combination of estrogen and progestin, OCs restore regular menses, improve androgen excess, and provide effective contraception and protection from endometrial cancer. The benefits of hormonal contraception outweigh the risks in the vast majority of women with PCOS. However, concerns have been raised about potential adverse cardiovascular and metabolic effects of OCs. Currently available evidence indicates an increased relative risk of venous thrombosis associated with OCs varying among different formulations. Arterial thrombosis risk attributable to OCs does not appear to be significantly increased in young nonsmoking women. OC use might be associated with increased risk of diabetes in morbidly obese women with PCOS with severe insulin resistance. A tailored clinical approach to oral contraception in women with PCOS requires individualized risk stratification and management by determination of each PCOS patient's personal cardiometabolic risk profile at baseline and during follow-up. Before prescribing an OC, clinicians should document individual risk factors including age, smoking, obesity, any degree of glucose intolerance including prediabetes and diabetes, hypertension, dyslipidemia, thrombophilia, and personal or family history of a venous thromboembolic event.
Collapse
Affiliation(s)
- Bulent O Yildiz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hacettepe University School of Medicine, 06100 Ankara, Turkey
| |
Collapse
|
26
|
Hugon-Rodin J, Gompel A, Plu-Bureau G. Epidemiology of hormonal contraceptives-related venous thromboembolism. Eur J Endocrinol 2014; 171:R221-30. [PMID: 25012200 DOI: 10.1530/eje-14-0527] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
For many years, it has been well documented that combined hormonal contraceptives increase the risk of venous thromboembolism (VTE). The third-generation pill use (desogestrel or gestodene (GSD)) is associated with an increased VTE risk as compared with second-generation (levonorgestrel) pill use. Other progestins such as drospirenone or cyproterone acetate combined with ethinyl-estradiol (EE) have been investigated. Most studies have reported a significant increased VTE risk among users of these combined oral contraceptives (COCs) when compared with users of second-generation pills. Non-oral combined hormonal contraception, such as the transdermal patch and the vaginal ring, is also available. Current data support that these routes of administration are more thrombogenic than second-generation pills. These results are consistent with the biological evidence of coagulation activation. Overall, the estrogenic potency of each hormonal contraceptive depending on both EE doses and progestin molecule explains the level of thrombotic risk. Some studies have shown a similar increased VTE risk among users of COCs containing norgestimate (NGM) as compared with users of second-generation pill. However, for this combination, biological data, based on quantitative assessment of sex hormone-binding globulin or haemostasis parameters, are not in agreement with these epidemiological results. Similarly, the VTE risk associated with low doses of EE and GSD is not biologically plausible. In conclusion, newer generation formulations of hormonal contraceptives as well as non-oral hormonal contraceptives seem to be more thrombogenic than second-generation hormonal contraceptives. Further studies are needed to conclude on the combinations containing NGM or low doses of EE associated with GSD.
Collapse
Affiliation(s)
- Justine Hugon-Rodin
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
| | - Anne Gompel
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
| | - Geneviève Plu-Bureau
- Department of Gynecology and EndocrinologyHôpitaux Universitaires Paris Centre, Paris-Descartes University, Paris, France
| |
Collapse
|
27
|
Association of Venous Thromboembolism With Hormonal Contraception and Thrombophilic Genotypes. Obstet Gynecol 2014; 124:600-609. [DOI: 10.1097/aog.0000000000000411] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
28
|
Nappi RE, Paoletti AM, Volpe A, Chiovato L, Howard B, Weiss H, Ricciotti N. Multinational, multicentre, randomised, open-label study evaluating the impact of a 91-day extended regimen combined oral contraceptive, compared with two 28-day traditional combined oral contraceptives, on haemostatic parameters in healthy women. EUR J CONTRACEP REPR 2014; 19:285-94. [PMID: 24923685 PMCID: PMC4134112 DOI: 10.3109/13625187.2014.918596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To evaluate the impact of a 91-day extended regimen combined oral contraceptive (150 μg levonorgestrel [LNG]/30 μg ethinylestradiol [EE] for 84 days, followed by 10 μg EE for seven days [Treatment 1]) compared with two traditional 21/7 regimens (21 days 150 μg LNG/30 μg EE [Treatment 2] or 150 μg desogestrel [DSG]/30 μg EE [Treatment 3], both with seven days' hormone free), on several coagulation factors and thrombin formation markers. METHODS Randomised, open-label, parallel-group comparative study involving healthy women (18-40 years). The primary endpoint was change from baseline in prothrombin fragment 1 + 2 (F1 + 2) levels over six months. RESULTS A total of 187 subjects were included in the primary analysis. In all groups, mean F1 + 2 values were elevated after six months of treatment. Changes were comparable between Treatments 1 and 2 (least squares mean change: 170 pmol/L and 158 pmol/L, respectively) but noticeably larger after Treatment 3 (least squares mean change: 592 pmol/L). The haemostatic effects of Treatment 1 were comparable to those of Treatment 2 and noninferior to those of Treatment 3 (lower limit of 95% confidence interval [- 18.3 pmol/L] > - 130 pmol/L). CONCLUSIONS The LNG/EE regimens had similar effects on F1 + 2. Noninferiority was demonstrated between extended regimen LNG/EE and DSG/EE.
Collapse
Affiliation(s)
- Rossella E. Nappi
- *Research Center for Reproductive Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Anna Maria Paoletti
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
| | | | - Luca Chiovato
- Department of Internal Medicine and Endocrinology, IRCCS Maugeri Foundation, University of Pavia, Italy
| | | | - Herman Weiss
- ˆTeva Global Medical Affairs, Petach Tikva, Israel
| | - Nancy Ricciotti
- Teva Branded Pharmaceutical Products, R&D, Inc., Frazer, PA, USA
| |
Collapse
|
29
|
Abstract
BACKGROUND Hirsutism has a relatively high prevalence among women. Depending upon societal and ethnic norms, it can cause significant psychosocial distress. Importantly, hirsutism may be associated with underlying disorders and co-morbidities. Hirsutism should not simply be looked upon as an issue of cosmesis. Patients require appropriate evaluation so that underlying etiologies and associated sequelae are recognized and managed. Treatment of hirsutism often requires a multidisciplinary approach, and a variety of physical or pharmacologic modalities can be employed. Efficacy of these therapies is varied and depends, among other things, upon patient factors including the underlying etiology, hormonal drive, and local tissue sensitivity to androgens. OBJECTIVE The objective of this paper is to review and summarize current evidence evaluating the efficacy of various treatment modalities for hirsutism in premenopausal women. METHODS Online databases were searched to identify all relevant prior systematic reviews and meta-analyses as well as recently published (2012-present) randomized controlled trials (RCTs) on hirsutism treatment. RESULTS Four recently published RCTs met criteria for inclusion in our review. In addition, one meta-analysis and one systematic review/treatment guideline were identified in the recent literature. Physical modalities and oral contraceptive pills (OCPs) remain first-line treatments. Evidence supports the use of electrolysis for permanent hair removal in localized areas and lasers (particularly alexandrite and diode lasers) for permanent hair reduction. Topical eflornithine can be used as monotherapy for mild hirsutism and as an adjunct therapy with lasers or pharmacotherapy in more severe cases. Combined OCPs as a class are superior to placebo; however, antiandrogenic and low-dose neutral OCPs may be slightly more efficacious in improving hirsutism compared with other types of OCPs. Antiandrogens are indicated for moderate to severe hirsutism, with spironolactone being the first-line antiandrogen and finasteride and cyproterone acetate being second-line antiandrogens. Due to its risk for hepatotoxicity, flutamide is not considered a first-line therapy. If used, the lowest effective dose should be administered with careful monitoring of liver enzymes. Monotherapy with an insulin sensitizer does not significantly improve hirsutism. While insulin sensitizers improve important metabolic and endocrine aberrations in polycystic ovary syndrome, they are not recommended when hirsutism is the sole indication for use. Lifestyle modification counseling is recommended. Gonadotropin-releasing hormone analogs and glucocorticoids are only recommended in specific circumstances. Additional therapies without sufficient supportive evidence of efficacy are ovarian surgery, statins (HMG-CoA reductase inhibitors), and vitamin D supplementation. LIMITATIONS In general, most therapies garner recommendations that are weak (where the estimates of benefits versus risks of therapy are either closely balanced or uncertain) and are based on low- to moderate-quality evidence. CONCLUSIONS Risks and benefits of treatment must be carefully considered and discussed with the patient. Expectations for efficacy should be appropriately set. A minimum of 6 months is required to see benefit from pharmacotherapy and lifelong treatment is often necessary for sustained benefit.
Collapse
|
30
|
2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2014; 31:1281-357. [PMID: 23817082 DOI: 10.1097/01.hjh.0000431740.32696.cc] [Citation(s) in RCA: 3284] [Impact Index Per Article: 328.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
31
|
|
32
|
Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F, Redon J, Dominiczak A, Narkiewicz K, Nilsson PM, Burnier M, Viigimaa M, Ambrosioni E, Caufield M, Coca A, Olsen MH, Schmieder RE, Tsioufis C, van de Borne P, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Clement DL, Coca A, Gillebert TC, Tendera M, Rosei EA, Ambrosioni E, Anker SD, Bauersachs J, Hitij JB, Caulfield M, De Buyzere M, De Geest S, Derumeaux GA, Erdine S, Farsang C, Funck-Brentano C, Gerc V, Germano G, Gielen S, Haller H, Hoes AW, Jordan J, Kahan T, Komajda M, Lovic D, Mahrholdt H, Olsen MH, Ostergren J, Parati G, Perk J, Polonia J, Popescu BA, Reiner Z, Rydén L, Sirenko Y, Stanton A, Struijker-Boudier H, Tsioufis C, van de Borne P, Vlachopoulos C, Volpe M, Wood DA. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34:2159-219. [PMID: 23771844 DOI: 10.1093/eurheartj/eht151] [Citation(s) in RCA: 3168] [Impact Index Per Article: 288.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Giuseppe Mancia
- Centro di Fisiologia Clinica e Ipertensione, Università Milano-Bicocca, Milano, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Chabbert-Buffet N, Guigues B, Trillot N, Biron C, Morange P, Pernod G, Scheffler M, Brugere S, Hedon B. [DVT and combined oral contraceptives: update of the pluridisciplinary CNGOF-FNCGM-GEHT-SFMV group]. J Gynecol Obstet Hum Reprod 2013; 42:309-315. [PMID: 23642503 DOI: 10.1016/j.jgyn.2013.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 03/25/2013] [Accepted: 03/26/2013] [Indexed: 06/02/2023]
Abstract
Thrombotic risk among combined oral contraceptives (COC) users has recently been debated following a court action initiated by a patient. Recent epidemiological data, as well as accumulating biological data underlying these data, have led French Health authorities to modify COC prescription and reimbursement modalities. A short synthesis is proposed by a multidisciplinary group of experts from four French societies (CGOF, FNCGM, GHT, and SFMV).
Collapse
Affiliation(s)
- N Chabbert-Buffet
- Collège national des gynécologues-obstétriciens français (CNGOF), 91, boulevard de Sébastopol, 75002 Paris, France.
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Bitzer J, Amy JJ, Beerthuizen R, Birkhäuser M, Bombas T, Creinin M, Darney PD, Vicente LF, Gemzell-Danielsson K, Imthurn B, Jensen JT, Kaunitz AM, Kubba A, Lech MM, Mansour D, Merki G, Rabe T, Sedlecki K, Serfaty D, Seydoux J, Shulman LP, Sitruk-Ware R, Skouby SO, Szarewski A, Trussell J, Westhoff C. Statement on combined hormonal contraceptives containing third- or fourth-generation progestogens or cyproterone acetate, and the associated risk of thromboembolism. EUR J CONTRACEP REPR 2013; 18:143-7. [PMID: 23578274 DOI: 10.3109/13625187.2013.792637] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Johannes Bitzer
- Department of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Bitzer J, Amy JJ, Beerthuizen R, Birkhäuser M, Bombas T, Creinin M, Darney PD, Vicente LF, Gemzell-Danielsson K, Imthurn B, Jensen JT, Kaunitz AM, Kubba A, Lech MM, Mansour D, Merki G, Rabe T, Sedlecki K, Serfaty D, Seydoux J, Shulman LP, Sitruk-Ware R, Skouby SO, Szarewski A, Trussell J, Westhoff C. Statement on combined hormonal contraceptives containing third- or fourth-generation progestogens or cyproterone acetate, and the associated risk of thromboembolism. ACTA ACUST UNITED AC 2013; 39:156-9. [PMID: 23585363 DOI: 10.1136/jfprhc-2013-100624] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Johannes Bitzer
- Department of Obstetrics and Gynaecology, University Hospital, Basel, Switzerland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Rosa MI, Madeira K, Medeiros LR. Can a meta-analysis that included articles with high heterogeneity appropriately evaluate the risk of venous thromboembolism in users of combined hormonal contraceptives containing drospirenone or desogestrel? EUR J CONTRACEP REPR 2013; 18:137-9. [DOI: 10.3109/13625187.2013.764406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
37
|
Martínez F, Latorre K, Ramírez I, Pérez-Campos E, Lete I. Can a meta-analysis that included articles with high heterogeneity appropriately evaluate the risk of venous thromboembolism in users of combined hormonal contraceptives containing drospirenone or desogestrel? A reply to Rosa et al. EUR J CONTRACEP REPR 2013; 18:139-42. [DOI: 10.3109/13625187.2013.780593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
38
|
Wu CQ, Grandi SM, Filion KB, Abenhaim HA, Joseph L, Eisenberg MJ. Drospirenone-containing oral contraceptive pills and the risk of venous and arterial thrombosis: a systematic review. BJOG 2013; 120:801-10. [DOI: 10.1111/1471-0528.12210] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2013] [Indexed: 11/27/2022]
Affiliation(s)
| | - SM Grandi
- Center for Clinical Epidemiology; Lady Davis Institute for Medical Research; Jewish General Hospital; Montreal; QC; Canada
| | | | | | | | | |
Collapse
|
39
|
Chabbert-Buffet N, Amy JJ. The combination of ethinylestradiol/cyproterone acetate is temporarily withdrawn from the market in France. Is the measure justified? EUR J CONTRACEP REPR 2013; 18:75-8. [DOI: 10.3109/13625187.2013.780203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
40
|
Plu-Bureau G, Maitrot-Mantelet L, Hugon-Rodin J, Canonico M. Hormonal contraceptives and venous thromboembolism: an epidemiological update. Best Pract Res Clin Endocrinol Metab 2013; 27:25-34. [PMID: 23384743 DOI: 10.1016/j.beem.2012.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Since the early 1960s, it has been well documented that combined hormonal contraceptives increase the risk of cardiovascular disease. Newer generation of oral formulations, as well as non-oral contraceptives (transdermal and vaginal), have been recently studied for thrombotic risk. This review provides a summary of the association between hormonal contraceptives and venous thromboembolism with emphasis on new formulations of hormonal contraceptives as well as route of administration. A systematic search of Medline database was done for all relevant articles which included women having used third generation pills, and the development of new progestins. Eligible articles published in English and reporting the risk of venous thromboembolism (VTE) (pulmonary embolism or deep venous thrombosis) among users of hormonal contraceptives were reviewed. A quantitative assessment was made from included studies. Current use of drospirenone or cyproterone oral combined contraceptives increased the risk of VTE compared with second generation pills (pooled OR: 1.7; 95% confidence interval [95% CI]: 1.4-2.2 and OR: 1.8; 95% CI: 1.4-2.3, respectively). In the context of contraceptive use, non-oral route of ethinyl-estradiol administration seems to be more thrombogenic than oral route. In contrast, low doses of both oral progestin contraceptives and intrauterine levonorgestrel could be safe with respect to VTE risk. In conclusion, newer generation formulations of hormonal contraceptives, as well as the non-oral hormonal contraceptive, seem to be more thrombogenic than second generation hormonal contraceptives.
Collapse
Affiliation(s)
- Genevieve Plu-Bureau
- Department of Gynecology and Endocrinology, Hôpital Universitaires Paris Centre, Paris-Descartes University, Paris, France.
| | | | | | | |
Collapse
|