Cerebral venous sinus thrombosis in users of four hormonal contraceptives: levonorgestrel-containing oral contraceptives, norgestimate-containing oral contraceptives, desogestrel-containing oral contraceptives and the contraceptive patch

U.S. Medical Eligibility Criteria for Contraceptive Use, 2024

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Pulse wave velocity, augmentation index, and carotid intima-media thickness are each associated with different inflammatory protein signatures in young healthy adults: The lifestyle, biomarkers and atherosclerosis study

BACKGROUND AND AIMS

We aimed to identify plasma protein biomarkers related to inflammation that correlated with physiological measurements of vascular function and structure in healthy individuals.

METHODS

We used the OLINK proteomics panel, which measures 92 inflammatory proteins, in 834 young, healthy non-smokers (ages 18-26). Principal component analysis (PCA) was employed to identify patterns of proteins. The following measurements were used: pulse-wave velocity (PWV), carotid intima-media thickness (cIMT) and augmentation index (AIX). Established cardiovascular risk factors were included in multivariable models.

RESULTS

PCA showed four principal components (PC 1, PC 2, PC 3, PC 4). PC 3, comprising proteins related to hemostasis, was significantly and inversely correlated with PWV. Among the proteins with the highest factor loadings on PC 3, uPA was negatively correlated with PWV in multivariable regression models. AIX was significantly correlated with PC 2, comprising inflammatory cytokines. Among the proteins with the highest factor loadings on PC 2, interleukin-6 was significantly correlated with AIX in the multivariable model. cIMT was significantly correlated with PC 4, comprising proteins related to chemotaxis. Among the proteins with the highest factor loadings on PC 4, fractalkine was significantly correlated with cIMT in the multivariable model.

CONCLUSIONS

In young, healthy individuals, OLINK inflammatory proteins correlated with measures of vascular status. Each of the three measures PWV, AIX, and cIMT, which target different parts of the vasculature, correlated with its own specific protein signature, indicating that different subsets of inflammatory mediators affect different parts of the vasculature and are detectable already in young healthy adults.

Thromboembolic disease in females and males aged 10 to 39 years in Germany

BACKGROUND

We analysed differences in hospitalization rates for venous diseases such as pulmonary embolism (PE), deep vein thrombosis (DVT), sinus vein thrombosis (SVT), portal vein thrombosis (PVT), and Budd-Chiari syndrome (BCS) as well as for arterial diseases such as myocardial infarction (MI) and embolic stroke (ES) in females and males aged 10 to 39 years.

PATIENTS AND METHODS

Detailed lists of hospitalizations with the principal and additional diagnoses for PE (ICD-code I26.0 + I26.9), DVT (I80.0-I80.9), SVT (I67.6), PVT (I81), BCS (I82.0), MI (I21.0-I21.9), and ES (I63.1 + I63.4) in males and females aged 10 to 39 years in the years 2006 to 2015 were provided by the Federal Statistical Office in Germany.

RESULTS

Considering the 10-year period there were more female than male cases hospitalized with the principal diagnoses for PE, DVT, SVT, and BCS. Looking at the principal diagnosis of the year 2015, one can see a steep increase in numbers of hospitalization for PE, DVT, and SVT in females ranging from the ages 12 to 13 and 14 to 15 years compared to males. The curves of PE and DVT meet again in the age group between 32 and 33 years, but not for SVT. The greatest differences are seen at the end of the second and at the beginning of the third decade of life. In contrast, MI was more frequent in young males beginning at the age of 18 to 19 years. The number of female and male cases with ES and PVT were almost similar in the different age groups.

CONCLUSIONS

The presented data show higher hospitalization rates for females in the age group 10 to 39 years for different venous thrombosis but not for MI and ES.

[Clinical presentations, diagnosis and treatment of cerebral vein and sinus thrombosis]

The problem of thrombosis of cerebral veins and venous sinuses is insufficiently studied. The real incidence of cerebral venous thrombosis remains incompletely defined. The article presents results of clinical research on cerebral vein and sinus thrombosis, which served as a ground for an analysis of causes and development of the disease. In 20-35% of patients with cerebral venous thrombosis, this disease remains idiopathic after extensive investigation. Particular attention is given to risk factors, clinical presentations, early diagnosis, treatment, prognosis of cerebral vein and sinus thrombosis.

Nonoral combined hormonal contraceptives and thromboembolism: a systematic review

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.

Combined hormonal contraception and the risk of venous thromboembolism: a guideline

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.

The Importance of Early Recognition of Cerebral Venous Sinus Thrombosis: A Case Report

A 33-year-old lady presented to the emergency department (ED) of Kuala Lumpur Hospital with subacute onset of headaches, irritability, and vomiting. Neurological examination revealed a restless agitated patient, poor responses to verbal commands with a Glasgow Coma Scale of 14/15, photophobia, blurred nasal margins with generalised weakness, hyperreflexia, and downgoing plantars. Computed tomography (CT) of the brain showed evidence of biparietal infarction with an empty delta sign. Urgent magnetic resonance imaging and venography (MRI/MRV) of the brain in the ED showed evidence of thrombosis of the superior sagittal sinus extending to the torcular herophili, straight sinus, transverse sinuses, sigmoid sinuses, and proximal internal jugular veins. The precipitating factor for the thrombosis was possibly oral contraceptive pill usage, which she had been taking for a month. She was treated aggressively with anticoagulation. The patient subsequently improved symptomatically and achieved full neurological recovery. In this patient, early recognition of the clinical symptoms and a CT scan with confirmation by MRI/MRV of the brain enabled the prompt diagnosis and treatment of cerebral venous sinus thrombosis with a good clinical outcome.

Hormonal contraceptives and cerebral venous thrombosis risk: a systematic review and meta-analysis

Objectives: Use of oral contraceptive pills (OCP) increases the risk of cerebral venous sinus thrombosis (CVST). Whether this risk varies by type, duration, and other forms of hormonal contraceptives is largely unknown. This systematic review and meta-analysis update the current state of knowledge.

Methods: We performed a search to identify all published studies on the association between hormonal contraceptive use and risk of CVST in women aged 15–50 years.

Results: Of 861 studies reviewed, 11 were included. The pooled odds of developing CVST in women aged 15–50 years taking OCPs was 7.59 times higher compared to women not taking OCPs (OR = 7.59, 95% CI 3.82–15.09). Data are insufficient to make conclusions about duration of use and other forms of hormonal contraceptives.

Conclusion: Oral contraceptive pills use increases the risk of developing CVST in women of reproductive age. Future studies are required to determine if duration and type of hormonal contraceptives modify this risk.

The combined vaginal contraceptive ring, nuvaring, and cerebral venous sinus thrombosis: a case report and review of the literature

BACKGROUND

Combined oral contraceptives are known to confer a risk of venous thromboembolism, including cerebral venous sinus thrombosis (CVST), to otherwise healthy women. NuvaRing (Organon USA, Inc., Roseland, NJ) is a contraceptive vaginal ring that delivers 120 μg of etonogestrel and 15 μg of ethinyl estradiol per day. Its use has been associated with rare venous thromboembolic events, but few cases of CVST associated with NuvaRing have been reported.

OBJECTIVE

To describe a case that illustrates the increased risk of CVST associated with use of NuvaRing. We describe the case of a NuvaRing user who presented to our emergency department with a headache, who was diagnosed with CVST.

CONCLUSION

Evidence suggests that NuvaRing has at least as much prothrombotic potential as combined oral contraceptives. Thus, emergency physicians should suspect serious venous thromboembolic events, including CVST, deep venous thrombosis, and pulmonary embolism, in NuvaRing users in the proper clinical setting.

Risk of non-fatal venous thromboembolism in women using oral contraceptives containing drospirenone compared with women using oral contraceptives containing levonorgestrel: case-control study using United States claims data

OBJECTIVE

To compare the risk of non-fatal venous thromboembolism in women receiving oral contraceptives containing drospirenone with that in women receiving oral contraceptives containing levonorgestrel.

DESIGN

Nested case-control and cohort study.

SETTING

The study was based on information from PharMetrics, a United States based company that collects information on claims paid by managed care plans.

PARTICIPANTS

The study encompassed all women aged 15 to 44 years who received an oral contraceptive containing either drospirenone or levonorgestrel after 1 January 2002. Cases were women with current use of a study oral contraceptive and a diagnosis of venous thromboembolism in the absence of identifiable clinical risk factors (idiopathic venous thromboembolism). Up to four controls were matched to each case by age and calendar time.

MAIN OUTCOME MEASURES

Odds ratios comparing the risk of non-fatal venous thromboembolism in users of the two contraceptives; incidence rates and rate ratios of non-fatal venous thromboembolism for users of each of the study contraceptives.

RESULTS

186 newly diagnosed, idiopathic cases of venous thromboembolism were identified in the study population and matched with 681 controls. In the case-control analysis, the conditional odds ratio for venous thromboembolism comparing use of oral contraceptives containing drospirenone with use of those containing levonorgestrel was 2.3 (95% confidence interval 1.6 to 3.2). The incidence rates for venous thromboembolism in the study population were 30.8 (95% confidence interval 25.6 to 36.8) per 100,000 woman years among users of oral contraceptives containing drospirenone and 12.5 (9.61 to 15.9) per 100,000 woman years among users of oral contraceptives containing levonorgestrel. The age adjusted incidence rate ratio for venous thromboembolism for current use of oral contraceptives containing drospirenone compared with those containing levonorgestrel was 2.8 (2.1 to 3.8).

CONCLUSIONS

The risk of non-fatal venous thromboembolism among users of oral contraceptives containing drospirenone seems to be around twice that of users of oral contraceptives containing levonorgestrel, after the effects of potential confounders and prescribing biases have been taken into account.

Cerebral venous sinus thrombosis in a woman using the etonogestrel-ethinyl estradiol vaginal contraceptive ring: a case report

BACKGROUND

The vaginal contraceptive ring is a hormonal contraceptive that releases etonogestrel and ethinyl estradiol. Cerebral venous sinus thrombosis (CVST) is a rare but serious complication of hormonal contraceptive use.

CASE

We present a case of CVST in a 33-year-old nulligravid woman who was using a vaginal contraceptive ring. At the time of presentation, she had been using the ring for 18 months, having previously used oral contraceptives for 13 years. She had no additional risk factors for thrombosis apart from cigarette smoking. Despite vigorous management, the patient died from the effects of the CVST.

CONCLUSION

The serious adverse effects of the vaginal contraceptive ring are not well known, although deep vein thrombosis, pulmonary embolism, and aortic thrombosis in association with use of the ring have been reported to Health Canada. Continuing post-market surveillance of thrombotic risk in users of the vaginal contraceptive ring is critical.

Cerebral venous sinus thrombosis: review of the demographics, pathophysiology, current diagnosis, and treatment

Cerebral venous sinus thrombosis (CVST) is a rare clinicopathological entity. The incidence of CVST in children and neonates has been reported to be as high as 7 cases per million people, whereas in adults the incidence is 3-4 cases per million. The predisposing factors to this condition are mainly genetic and acquired prothrombotic states and infection. The clinical picture of CVST is nonspecific, highly variable, and can mimic several other clinical conditions. Diagnosis of CVST is established with the implementation of neuroimaging studies, especially MR imaging and venography. Identification and elimination of the underlying cause, anticoagulation, proper management of intracranial hypertension, and anticonvulsant prophylaxis constitute cornerstones of CVST treatment. Newer treatment strategies such as endovascular thrombolysis and decompressive craniectomy have been recently used in the treatment of patients with CVST with variable success rates. Further clinical research must be performed to delineate the exact role of these newer treatments in the management of severe cases of CVST. The recent advances in the diagnosis and treatment of patients with CVST have significantly lowered the associated mortality and morbidity and have improved the outcome of these patients.

Safety, efficacy and patient acceptability of the combined estrogen and progestin transdermal contraceptive patch: a review

The worldwide introduction of the first, unique patch for hormonal contraception (ethinyl estradiol/norelgestromin, EE/NGMN patch) was widely recognized as a significant event in the development of drug delivery systems. This innovation offers a number of advantages over the oral route, and extensive clinical trials have proved its safety, efficacy, effectiveness, and tolerability. The weekly administration and ease of use/simplicity of the EE/NGMN patch contribute to its acceptability, and help to resolve the two main problems of non-adherence, namely early discontinuation and inconsistent use. The patch offers additional benefits to adolescents (improvement of dysmenorrhea and acne), adults (improvement in emotional and physical well-being, premenstrual syndrome, and menstrual irregularities), and perimenopausal women (correction of hormonal imbalance, modulation of premenopausal symptoms), thus providing high satisfaction rates (in nearly 90% of users). Since its introduction, the transdermal contraceptive patch has proved to be a useful choice for women who seek a convenient formulation which is easy to use, with additional, non-contraceptive tailored benefits for all the ages.

Sex hormones and thrombosis

There is compelling evidence that use of oral formulations of female hormone replacement and of the combined oral contraceptive induces a prothrombotic state. This translates to an increased thrombotic risk. Within the individual, the absolute risk is determined by the interaction between that induced by hormone use and heritable and acquired risk factors for thrombosis. Knowledge of the accumulating epidemiologic and clinical trial-derived data on this topic is essential for the delivery of evidence-based counseling in the clinical environment and is the subject of this review.

The Contraceptive Patch in Relation to Ischemic Stroke and Acute Myocardial Infarction

STUDY OBJECTIVE

To compare rates of stroke and acute myocardial infarction in users of the Ortho EVRA contraceptive patch with these rates in users of norgestimate-containing oral contraceptives (OCs) with 35 microg of ethinyl estradiol.

DESIGN

Retrospective, population-based, epidemiologic study.

DATA SOURCE

PharMetrics database.

SUBJECTS

Females aged 15-45 years in the PharMetrics database who had filled at least one prescription for the Ortho EVRA contraceptive patch or a norgestimate OC between April 1, 2002, and March 31, 2005.

MEASUREMENTS AND MAIN RESULTS

Incidence rates and 95% confidence intervals (CI) were estimated for the outcomes of ischemic stroke and acute myocardial infarction by exposure. Crude incidence rates of ischemic stroke among users of the patch and users of norgestimate OCs were 13.6/100,000 woman-years (95% CI 5.9-26.8) and 11.3/100,000 woman-years (95% CI 5.4-20.8), respectively. The crude incidence rate of acute myocardial infarction was 1.7/100,000 woman-years (95% CI 0.04-9.5) in current patch users and 7.9/100,000 woman-years (95% CI 3.2-16.3) in current users of norgestimate OCs. Incidence rate ratios (IRRs) were estimated for the outcomes by comparing data for users of the patch and users of a norgestimate OC. The IRR for stroke was 1.2 (95% CI 0.41-3.4) and for acute myocardial infarction was 0.2 (95% CI 0.004-1.7).

CONCLUSION

Ischemic stroke and acute myocardial infarction are rare among young women who use hormonal contraceptives, and the current data provide no suggestion of an increased risk of either ischemic stroke or acute myocardial infarction in users of the Ortho EVRA contraceptive patch compared with users of norgestimate OCs.