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Jacqueline CONARD, Paris, France
*Abstract presented at the 64th Meeting of the French Society of Angiology, Paris, France, 27-28 January, 2012
Although the contraceptive pill is taken by millions of women daily, cases of venous thrombosis or venous thromboembolism are rare. Yet, such cases are severe and may result in the patient’s death. Therefore, it is important to detect patients at risk of venous problems and choose the most appropriate contraceptive pill.
The risk factors for venous thromboembolism (VTE) are now well-known. They include age, obesity, cancer, surgery, immobilization in plaster casts, long-haul flights, long-haul car or bus trips, pregnancy, in vitro fertilization, and hormonal treatments (contraceptive pill, hormonal replacement therapy in menopause, and treatment of breast cancer). Personal history of VTE and/or established biological thrombophilia (congenital deficiency in antithrombin, protein C, protein S, factor V Leiden, mutation in the prothrombin 20210A gene, and the presence of circulating antiphospholipid antibodies) also increase the risk of venous thrombosis.
Oral estroprogestative contraceptive pills may increase the risk of venous thrombosis (VT) by 4 to 6 times, in particular during the first year of administration. Factors associated with VT include the dose of ethinyl-estradiol (EE) and the type of combined progestogen drug, as the risk is higher with the third generation of progestogen drugs compared with those of the second generation. Some combined contraceptives containing EE and progestogens such as cyproterone acetate and possibly drospirenone lead to a higher risk of VT. The use of EE-based contraceptives whether as a patch or as a vaginal ring is also associated with a significant increase in the risk of VTE. However, the absolute risk of VT related to contraceptive use is low when there is no other associated risk factor, especially before the age of 40.
In the absence of risk factors for VT, the first prescribed contraceptive is usually a pill containing a low dose of EE associated with a second generation progestogen compound (levonorgestrel). Prescription is then further adapted according to the tolerability of the pill.
In women older than 40 years, the benefits of the combined (EE-progestogen) pill should be assessed according to the other associated risk factors.
In women with a personal history of VTE and/or thrombophilia, the estroprogestative contraceptive pill is contraindicated whatever the administration mode (oral, patch, or vaginal ring), the EE dose, or the type of progestogen. Since there is a lack of data on estradiol-based contraception, none of the oral contraceptive pills containing estradiol (not EE) are recommended in this type of patient. Only progestogen contraceptives in the form of oral pills, subcutaneous implants, or intra-uterine devices are advisable for patients at high risk of VT.
In patients with a family history of severe VT without thrombophilia in a first-line relative (in particular, hormone-related VTE in the mother or sister), prescription of a contraceptive should be carefully considered and the combined estroprogestative contraceptive pill is not recommended.
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