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[Hormonal contraception and vascular risk: CNGOF Contraception Guidelines]
G Plu-Bureau1, E Sabbagh2, J Hugon-Rodin1
1Unité de gynécologie endocrinienne, hôpital Port-Royal, 53, avenue de l'Observatoire, 75679 Paris 14, France; Université Paris Descartes, 75005 Paris, France; Inserm UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), 75000 Paris, France.
Insights
Combined hormonal contraceptives (CHCs) carry persistent vascular risks, with higher risks linked to formulations containing 50μg ethinyl estradiol (EE) and certain progestins. Progestin-only options generally offer a safer alternative for women with elevated vascular risk.
Area of Science:
- Reproductive Medicine
- Cardiovascular Health
- Pharmacology
Background:
- Combined hormonal contraceptives (CHCs) are associated with significant vascular risks, including venous thromboembolism and arterial ischemic events.
- Despite improvements in CHC formulations, persistent vascular risks remain a concern with current products.
- The vascular risk of CHCs is influenced by ethinyl estradiol (EE) content and specific progestins used.
Purpose of the Study:
- To evaluate the comparative vascular risks associated with different combined hormonal contraceptive formulations.
- To identify specific CHC components and patient factors that increase the risk of venous and arterial events.
- To provide guidance on contraceptive selection for women with varying vascular risk profiles.
Main Methods:
- Review of epidemiological studies assessing the association between CHC use and vascular events.
- Comparison of venous thromboembolism risk across different EE doses and progestin types (gestodene, desogestrel, drospirenone, cyproterone acetate, norgestimate, levonorgestrel).
- Evaluation of risks associated with non-oral CHC administration routes and progestin-only contraceptives.
Main Results:
- CHCs containing 50μg EE present a significantly higher vascular risk than those with lower EE doses.
- No significant difference in venous risk was observed between CHCs containing 20μg or 30μg EE.
- Gestodene, desogestrel, drospirenone, and cyproterone acetate-containing CHCs are linked to higher venous thrombosis risk compared to levonorgestrel-based options. Norgestimate-containing CHCs showed similar risk to levonorgestrel.
- Non-oral CHCs may carry a risk equivalent to gestodene or desogestrel-containing CHCs, though based on limited data.
- Progestin-only contraceptives, excluding medroxyprogesterone acetate, are not associated with increased arterial or venous vascular risk.
Conclusions:
- Vascular risk assessment, including family history, is crucial before prescribing CHCs.
- CHCs are contraindicated in women with thrombophilia, combined vascular risk factors, a strong family history of vascular events, or migraine with aura.
- Progestin-only contraceptives are a safer alternative for women with elevated vascular risk.
Abstract:
Venous thromboembolism and arterial ischemic events are the main deleterious diseases associated with the use of combined hormonal contraceptives (CHC). Even though their composition has been substantially improved, the vascular risk persists with the most recent CHCs use. If the vascular risk associated with CHCs containing 50μg EE is significantly higher than with those containing less than 50μg, there is no evidence that the CHCs containing either 30 or 20μg of EE induce different venous risks. CHC containing gestodene, desogestrel, drospirenone or cyproterone acetate are associated with a higher risk of venous thrombosis compared with levonorgestrel-containing CHCs. CHC containing norgestimate are associated with similar venous thrombosis risk than CHC containing levonorgestrel. Venous thrombosis risk of non-oral routes of administration of CHC appears to be equivalent to the risk of CHC containing gestodene or desogestrel, but this result is based on a small number of epidemiological studies. Before prescribing a CHC, it is important to determine all vascular risk factors. Family history of ischemic arterial event or venous thromboembolism disease should be routinely sought before any CHC prescription. All CHCs are contraindicated in women with biological thrombophilia, in women with combined vascular risk factors, in women with first-degree family history of arterial or venous event (under age 50) as well as in women suffering of migraine with aura. Progestin-only contraceptives are not associated with vascular risk (arterial or venous) outside of medroxyprogesterone acetate. In women with higher vascular risk, progestin-only contraceptives (administered by oral, sous-cutaneous or intra-uterine routes) can be prescribed.
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