Combined hormonal contraceptive use among women with known dyslipidemias: a systematic review of critical safety outcomes

Reproductive factors and cardiometabolic disease among middle-aged and older women: a nationwide study from CHARLS

Background

Cardiometabolic disease is skyrocketing to epidemic proportions due to the high prevalence of its components and the aging of the worldwide population. More efforts are needed to improve cardiometabolic health. The aim of this nationally representative study based on the China Health and Retirement Longitudinal Study (CHARLS, 2014-2018) was to examine the association between reproductive factors and cardiometabolic disease among Chinese women aged ≥45 years.

Methods

The CHARLS is an ongoing longitudinal study initiated in 2011, and the latest follow-up was completed in 2018. In total, 6,407 participants were analyzed. Effect-sizes are expressed as odds ratios (OR) and 95% confidence intervals (CI). Confounding was considered from statistical adjustment, subsidiary exploration, and unmeasured confounding assessment aspects.

Results

Of 6,407 accessible participants, 60.9% were recorded as having one or more of five predefined cardiovascular or metabolic disorders. Compared to those with two children, participants who had 0-1 child were found to have a lower risk of cardiometabolic disease (OR = 0.844, 95% CI: 0.714-0.998), and those who had ≥3 children had a greater risk (OR = 1.181, 95% CI: 1.027-1.357). Age at menarche of 16-18 years was a protective factor compared with ≤16 years of age (OR = 0.858, 95% CI: 0.749-0.982). In contrast, participants with a history of abortion were 1.212 times more likely to have cardiometabolic disorders (OR = 1.212, 95% CI: 1.006-1.465). The likelihood for the presence of unmeasured confounding was low, as reflected by E-values.

Conclusions

Our findings demonstrate that number of children, age at menarche, and history of abortion were associated with a significant risk of cardiometabolic disease among Chinese women aged ≥45 years.

Hormonal and natural contraceptives: a review on efficacy and risks of different methods for an informed choice

The debate about contraception has become increasingly important as more and more people seek safe and effective contraception. More than 1 billion women of reproductive age worldwide need a method of family planning, and wellbeing, socio-economic status, culture, religion and more influence the reasons why a woman may ask for contraception. Different contraceptive methods exist, ranging from 'natural methods' (fertility awareness-based methods - FABMs) to barrier methods and hormonal contraceptives (HCs). Each method works on a different principle, with different effectiveness.FABMs and HCs are usually pitted against each other, although it's difficult to really compare them. FABMs are a valid alternative for women who cannot or do not want to use hormone therapy, although they may have a high failure rate if not used appropriately and require specific training. HCs are commonly used to address various clinical situations, although concerns about their possible side effects are still widespread. However, many data show that the appropriate use of HC has a low rate of adverse events, mainly related to personal predisposition.The aim of this review is to summarize the information on the efficacy and safety of FABMs and HCs to help clinicians and women choose the best contraceptive method for their needs.

[Contraception in adolescents with obesity and diabetes mellitus]

Today most adolescents have their first sexual experience at the age of 15-19. However, only 44% of girls and young women (15-24 years old) report about contraception at that moment. A decision on pregnancy in adolescence is a difficult choice and any scenario may cause serious medical and social problems. Complications after an artificial abortion have a negative impact on a woman's fertility. Diabetes mellitus type 1 and arterial hypertension accompanied with obesity within the metabolic syndrome are defined by the World Health Organization (WHO) as diseases, which increase risk of an unplanned pregnancy. The article consoders problems of interaction of a doctor and a teenage girl with endocrinopathy, when discussing her sexual health, the analysis of the literature reflecting the influence of contraception on the course of the underlying pathology is presented. The authors formed a list of drugs acceptable for use in diabetes and obesity based on assessment of risks and preferences from the use of different methods of fertility control. The work contains information about the procedure of starting contraception, the rules of future dynamic monitoring of the patient.

Ischemic stroke on hormonal contraceptives: Characteristics, mechanisms and outcome

Introduction

Systemic contraceptives increase the risk of ischemic stroke but little is known about the characteristics, mechanisms and long-term outcome post stroke of patients on hormonal contraception. We sought to To assess characteristics and outcome of acute ischemic stroke (AIS) in young women using systemic hormonal contraceptives (SHC) and compare them to strokes in non-contraceptive users.

Patients and methods

Using the Acute STroke Registry and Analysis of Lausanne (ASTRAL), we analyzed demographics, risk factors, clinical, radiological and treatment data of consecutive female patients of <50 years between 2003 to 2015. We compared groups with and without SHC in a logistic regression analysis.

Results

Of the 179 female patients of <50 years during the observation period, 57 (39.6%) used SHC, 71.9% of whom, a combined oral contraceptive pill. On logistic regression contraceptive users were significantly younger but had comparable stroke severity. They had less migraine with aura and tobacco use, and more hyperlipidaemia. Also, contraceptive users had significantly less intra and extracranial stenosis and occlusion on arterial imaging, but more focal hypoperfusion on CT-perfusion. Undetermined mechanism of stroke was more frequent with SHC users, whereas rare mechanisms were more frequent in non-users. The contraceptive user group had a more favourable adjusted 12-month outcome with significantly fewer ischemic recurrences after stopping systemic contraception in all.

Conclusion

Contraceptive users with ischemic strokes are younger and have lesser tobacco use and migraine with aura and more hyperlipidemia. Their stroke mechanism is more often undetermined using a standardised work-up, and their adjusted long-term outcome is more favourable with less stroke recurrence.

Association between oral contraceptive use and incident heart failure

Aims

Oral contraceptives (OCs) are widely used in women of reproductive age, but their influences on heart failure (HF) development have yet to be reported. This study was performed to assess HF risk associated with OC use.

Methods and results

We studied women participating in the Multi‐Ethnic Study of Atherosclerosis with available data on OC use. Inverse probability of treatment weighting analyses were used to reduce baseline imbalances. Cox proportional hazards models were applied to evaluate the associations of OC use and HF risk. The primary analysis comprised a total of 3594 participants [average age 62.10 (10.24) years]. During an average follow‐up of 12.45 (3.75) years, 138 incident HF occurred. In unadjusted Cox model, OC use was associated with a decreased risk of HF [hazard ratio (HR) = 0.45, 95% confidence interval (CI) 0.31–0.64, P < 0.001]. However, in multivariable‐adjusted and inverse probability of treatment weighting models, the results were attenuated and became non‐significant (HR = 0.96, 95% CI 0.63–1.48, P = 0.86 and HR = 0.79, 95% CI 0.45–1.40, P = 0.43, respectively). Duration of OC use was not related to increased risks of HF. When stratifying HF into subtypes, similar associations were observed. In multivariable–adjusted regression models, OC use was positively associated with left ventricular end‐diastolic mass [coefficient (β) = 3.04, P = 0.006] and stroke volume (β = 1.76, P = 0.01 for the left ventricle; β = 2.17, P = 0.005 for the right ventricle) but had no impact on left ventricular ejection fraction (β = 0.09, P = 0.75) and right ventricular ejection fraction (β = 0.33, P = 0.25).

Conclusions

Oral contraceptive use in women of reproductive age does not portend increased risk of HF. However, whether the formulations or dosages differently impact this association should be further investigated.

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

OBJECTIVE

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

DESIGN

Umbrella review.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120076.

Development of an Integrated Platform Using Multidisciplinary Real-World Data to Facilitate Biomarker Discovery for Medical Products

Translational multidisciplinary research is important for the Center for Devices and Radiological Health's efforts for utilizing real‐world data (RWD) to enhance predictive evaluation of medical device performance in patient subpopulations. As part of our efforts for developing new RWD‐based evidentiary approaches, including in silico discovery of device‐related risk predictors and biomarkers, this study aims to characterize the sex/race‐related trends in hip replacement outcomes and identify corresponding candidate single nucleotide polymorphisms (SNPs). Adverse outcomes were assessed by deriving RWD from a retrospective analysis of hip replacement hospital discharge data from the National Inpatient Sample (NIS). Candidate SNPs were explored using pre‐existing data from the Personalized Medicine Research Project (PMRP). High‐Performance Integrated Virtual Environment was used for analyzing and visualizing putative associations between SNPs and adverse outcomes. Ingenuity Pathway Analysis (IPA) was used for exploring plausibility of the sex‐related candidate SNPs and characterizing gene networks associated with the variants of interest. The NIS‐based epidemiologic evidence showed that periprosthetic osteolysis (PO) was most prevalent among white men. The PMRP‐based genetic evidence associated the PO‐related male predominance with rs7121 (odds ratio = 4.89; 95% confidence interval = 1.41−17.05) and other candidate SNPs. SNP‐based IPA analysis of the expected gene expression alterations and corresponding signaling pathways suggested possible role of sex‐related metabolic factors in development of PO, which was substantiated by ad hoc epidemiologic analysis identifying the sex‐related differences in metabolic comorbidities in men vs. women with hip replacement‐related PO. Thus, our in silico study illustrates RWD‐based evidentiary approaches that may facilitate cost/time‐efficient discovery of biomarkers for informing use of medical products.

Associations of hormonal contraceptives and infertility medications on the risk of venous thromboembolism, ischemic stroke, and cardiovascular disease in women

The purpose of this study was to examine the relations of hormonal contraceptives and infertility drugs with the risk of venous thromboembolism (VTE), deep vein thrombosis (DVT), pulmonary embolism (PE), ischemic stroke, and cardiovascular disease. The Taiwan National Health Institute Research Database was searched for women who had taken hormonal contraceptives or infertility medications from 2000 to 2010. The two groups were age and index date matched with controls (1:4 ratios). Cox regression analysis was used to examine the risks of VTE, DTE, PE, ischemic stroke, and cardiovascular disease. A total of 32,067 women were included in the hormonal contraceptives group and 4710 in the infertility medications group (matched controls: 127,872 and 18,840, respectively). After adjustment for age, comorbidities, and other confounders, the contraceptives group had a higher risk of VTE (adjusted HR 1.14, 95% CI 1.004 to 1.30) and cardiovascular disease (adjusted HR 1.30, 95% CI 1.26 to 1.34), and lower risk of ischemic stroke (adjusted HR 0.90, 95% CI 0.86 to 0.95). The infertility medications group had a higher risk of VTE (adjusted HR 1.996, 95% CI 1.41 to 2.72) and DVT (adjusted HR 1.86, 95% CI 1.31 to 2.63), and lower risk of ischemic stroke (adjusted HR 0.82, 95% CI 0.68 to 0.99) and cardiovascular disease (adjusted HR 0.83, 95% CI 0.74 to 0.94). Hormonal contraceptives and infertility medications appear to lower the risk of ischemic stroke and increase the risk of VTE; however, their effect on the risk of other types of cardiovascular events varies.

Acute pancreatitis secondary to oral contraceptive-induced hypertriglyceridemia: a case report

Hypertriglyceridemia is the third most common cause of acute pancreatitis. Among the causes that lead to secondary hypertriglyceridemia, the use of contraceptive agents is the main reason to be assessed in young women. We report a case of a 31-year-old woman who had suffered two acute pancreatitis episodes secondary to hypertriglyceridemia. In the investigation, the previous medical team indicated a genetic screening before ruling out all secondary causes. LPL, apo CII and apo AV genes were negative for mutations. In the first appointment with us, the patient reported the use of a contraceptive agent for about 2 years. She was instructed to discontinue the drug. After one year of follow-up, her serum triglycerides are within the normal range and a copper intrauterine device was the method chosen by the patient for contraception.

Comprehensive review of cardiovascular toxicity of drugs and related agents

Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.

Hormonal contraception in women with polycystic ovary syndrome: choices, challenges, and noncontraceptive benefits

Polycystic ovary syndrome (PCOS) is an endocrine disorder among women of reproductive age characterized by chronic anovulation and polycystic ovary morphology and/or hyperandrogenism. Management of clinical manifestations of PCOS, such as menstrual irregularities and hyperandrogenism symptoms, includes lifestyle changes and combined hormonal contraceptives (CHCs). CHCs contain estrogen that exerts antiandrogenic properties by triggering the hepatic synthesis of sex hormone-binding globulin that reduces the free testosterone levels. Moreover, the progestogen present in CHCs and in progestogen-only contraceptives suppresses luteinizing hormone secretion. In addition, some types of progestogens directly antagonize the effects of androgens on their receptor and also reduce the activity of the 5α reductase enzyme. However, PCOS is related to clinical and metabolic comorbidities that may limit the prescription of CHCs. Clinicians should be aware of risk factors, such as age, smoking, obesity, diabetes, systemic arterial hypertension, dyslipidemia, and a personal or family history, of a venous thromboembolic event or thrombophilia. This article reports a narrative review of the available evidence of the safety of hormonal contraceptives in women with PCOS. Considerations are made for the possible impact of hormonal contraceptives on endocrine, metabolic, and cardiovascular health.

Vascular Disease in Young Indians (20-40 years): Role of Ischemic Heart Disease

Coronary Artery Disease (CAD) occurs at a younger age in Indians with over 50% of Cardiovascular Disease (CVD) mortality occurring in individuals aged less than 50 years. Although several risk factors have been suggested; smoking, dyslipidemia and hypertension are major risk factors in the young. In this review, we have pooled the current evidence on Ischemic Heart Disease (IHD) in young (20-40 years) and provided an opinion for the effective management of IHD in young Indians.

Parity and serum lipid levels: a cross-sectional study in chinese female adults

Reproductive factors have been shown to correlate with lipid metabolism. The aim of this study was to investigate the relationship between parity and serum lipid levels in community-based Chinese female adults. A total of 4,217 female participants were enrolled. Parity was recorded according to questionnaire and serum lipid profile, including triglycerides (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), and high density lipoprotein cholesterol (HDL-C), was measured. Logistic regression models were used to analyze the association of parity to serum lipid levels, while adjusting for demographics and metabolic risk factors. Parity in this population ranged from 0 to 7. After adjusting for potential confounders, it indicated that females with more than 2 parities appeared to be less likely to suffer from abnormal serum TC level compared with nulliparae (parity = 2, odds ratio (OR) = 0.457, 95% confidence interval (CI) = 0.284–0.736; parity ≥ 3, OR = 0.363, 95% CI = 0.202–0.653). These findings suggested that parity could correlate with lipid metabolism in Chinese women. Individuals with higher parity appeared to have a lower total cholesterol in blood.

Do women aged over 40 need different counseling on combined hormonal contraception?

There is still a risk of pregnancy during the menopause transition, for most women after the age of 40, as occasional, spontaneous ovulation can occur. Women in this age group may therefore consider using contraception and want appropriate counseling. Aging is accompanied by changes that can increase the risks associated with the use of combined hormonal contraceptives (CHCs), but we do not have sufficient evidence to determine whether age alone increases the risks of using CHCs or whether there are additional risks if CHC use begins at an earlier age. Another issue is whether we can differentiate between initiator versus continuation influences on risk. The objective of this article is to review the risks associated with CHC to determine whether there is a need for more appropriate contraceptive counseling for women aged over 40.