Risks of thromboembolism associated with hormonal contraceptives related to body mass index and aging in Japanese women

Evaluating the Efficacy and Safety of 48-Week Low-Dose Dienogest Administration in Patients With Dysmenorrhea Caused by Endometriosis: Protocol for a Randomized, Open-Label, Parallel-Group Trial

BACKGROUND

The treatment of endometriosis includes analgesics, hormone therapy, and surgery. Even after surgical removal of endometriotic lesions, the risk of recurrence remains high once the normal menstrual cycle resumes. Therefore, long-term hormone therapy is essential to prevent recurrence. Among hormonal treatments, low-dose estrogen progestin preparations are not recommended for patients older than 40 years due to the increased risk of thrombotic side effects. In contrast, dienogest does not carry a thrombotic risk, making it a suitable option for older patients. Although dienogest requires long-term administration until menopause in patients with endometriosis, data on its long-term efficacy and potential adverse effects remain limited. In particular, comparative studies assessing the safety and effectiveness of long-term use of dienogest at different doses (1 mg/day vs 2 mg/day) have not been conducted, highlighting the need for further investigation.

OBJECTIVE

The purpose of this study is to investigate the efficacy and the incidence of adverse events of dienogest 1 mg/day after 48 weeks in patients with dysmenorrhea due to endometriosis, compared with dienogest 2 mg/day.

METHODS

This randomized, open-label, parallel-group, dose-comparison, multicenter trial follows the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) 2013 guidelines and is conducted at 6 centers in Japan. Participants are randomly assigned in a 1:1 ratio to receive either dienogest 1 mg/day or 2 mg/day. The drug is administered for 48 weeks, and its therapeutic effects and side effects are evaluated. Hospital visits include the use of questionnaires, vital sign measurements, imaging studies (magnetic resonance imaging and ultrasound), blood tests, and bone density assessments. The primary endpoint is the change in the pain visual analog scale (VAS) score from baseline to 48 weeks. The VAS is a 10 cm horizontal scale where 0 cm represents no pain and 10 cm represents the maximum imaginable pain; participants indicate their pain level on the scale, and the change is analyzed over time. The target sample size is 88, determined with a noninferiority margin based on existing literature. The protocol was approved by the Nagoya City University Hospital Clinical Research Review Board. Findings will be presented at academic conferences and published in peer-reviewed journals.

RESULTS

Currently, data collection is ongoing. The first participant was enrolled in August 2021. As of March 22, 2025, a total of 88 participants had been enrolled in this clinical trial.

CONCLUSIONS

This is the first trial to compare efficacy and safety between 1 mg/day and 2 mg/day of long-term dienogest use in patients with dysmenorrhea caused by endometriosis. Combining diagnostic imaging with patient questionnaires and blood tests allows the determination of efficacy against endometriosis itself.

TRIAL REGISTRATION

Japan Registry of Clinical Trials jRCTs041210016; https://jrct.mhlw.go.jp/en-latest-detail/jRCTs041210016.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66246.

Impact of Estetrol Combined with Drospirenone on Blood Coagulation and Fibrinolysis in Patients with Endometriosis: A Multicenter, Randomized, Open-Label, Active-Controlled, Parallel-Group Study

Venous thromboembolism is a serious safety concern in women using combined oral contraceptives; ethinyl estradiol (EE) is widely used as an estrogen. Estetrol (E4) is a native estrogen with selective tissue activity and exclusively produced by the fetal liver. This study used a multicenter, randomized, open-label, active-controlled, parallel-group design to evaluate the effects of E4 combined with drospirenone (DRSP) on coagulation and fibrinolysis in Japanese patients with endometriosis. Participants were randomized to receive either E4 15 mg/DRSP 3 mg or EE 20 µg/DRSP 3 mg for 12 weeks. E4/DRSP and EE/DRSP were administered orally once a day in a cyclic regimen, ie, 24-day active use followed by a 4-day hormone-free period, and a flexible extended regimen, respectively, and blood coagulation and fibrinolysis markers were measured. The effect on coagulation and fibrinolysis was considerably less in the E4/DRSP group than in the EE/DRSP group. Major anticoagulant proteins, protein S (free, total) and tissue factor pathway inhibitor (free), were reduced following EE/DRSP treatment. Consequently, thrombin generation determined by the activated protein C sensitivity ratio was increased by approximately 4-fold in the EE/DRSP group than in the E4/DRSP group. Eventually, the fibrinolysis cascade was triggered to compensate for disturbed coagulation, and D-dimer levels were 4.7-fold higher in the EE/DRSP group than in the E4/DRSP group. This study demonstrated that the effect of E4/DRSP on the blood coagulation and fibrinolysis cascades was significantly less than that of EE/DRSP in participants with endometriosis, a disease of women of advanced and reproductive age (jRCT2080225090, https://jrct.niph.go.jp/en-latest-detail/jRCT2080225090).

Contraception and Cardiovascular Effects: What Should the Cardiologist Know?

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death in women. This review highlights contraceptive options and their effects on the cardiovascular system (CVS). It provides guidance to cardiologists to make informed decisions regarding the safety of contraceptive use and cardiovascular risk stratification in the care of women of childbearing age.

RECENT FINDINGS

Approximately 44% of American women live with some type of CVD. Many women use hormonal contraception during their lifetime. It is imperative that cardiologists have a robust understanding of the forms of contraception in current use and their cardiovascular effects. This contemporary review provides a comprehensive summary of available contraceptive methods to practicing cardiologists and aims to be used as a resource to guide cardiovascular specialists on contraception in the context of cardiovascular disease.

Dienogest versus norethisterone acetate in management of endometrial hyperplasia without atypia

OBJECTIVES

To compare the effectiveness of dienogest (DIE) and norethisterone acetate (NETA) regimens in the treatment of endometrial hyperplasia (EH) without atypia.

METHODS

Participants were premenopausal women with irregular uterine bleeding, and endometrial hyperplasia without atypia on endometrial biopsy. Enrolled patients were randomly allocated into two groups: group I got DIE 2 mg/day (orally Visanne) for 14 days (10th to the 25th day of cycle) while group II received between the 16th and 25th day of the cycle, norethisterone acetate (NETA) 15 mg/d (orally Primolut Nor) was administered for 10 days. Both groups continued the therapy for six months.

RESULTS

The DIE group showed a higher resolution (32.7%) and regression (57.7%) than NETA group (31% & 37.9%, respectively) with significant regression (p = 0.039). No progression in DIE group while four (6.9%) women in NETA group were recorded a progression to complex type without a significance. Also, NETA group showed a significant persistence rate (22.5%) than DIE group (3.8%) (p = 0.005). Also number in NETA group managed by hysterectomy with significant difference (p = 0.042).

CONCLUSION

If used as first-line treatment, Dienogest produces a better rate of regression and a lower incidence of hysterectomy than Norethisterone Acetate does when used in EH without atypia.

Relationship of Ethinylestradiol/Drospirenone Prescription on Work Productivity and Activity Impairment Among Women With Menstruation-Related Symptoms: A Multicenter Prospective Observational Study

OBJECTIVE

The aim of the study is to examine changes in work productivity and daily activity impairment among women by starting ethinylestradiol (EE)/drospirenone (DRSP) for perimenstrual symptoms.

METHODS

Participants were women who were newly prescribed EE/DRSP at 25 gynecological clinics in Japan. Eligible participants recorded daily intake of EE/DRSP and the Work Productivity Activity Impairment Questionnaire General Health every 2 weeks for 3 months by smartphone app. A linear mixed-effects model was used to see changes in work productivity impairment and activity impairment relative to baseline.

RESULTS

A total of 222 participants were eligible. Work productivity impairment recovered by 20.0% (95% confidence interval, 14.1%-26.0%) at 1 m and maintained for 2 months. Activity impairment recovered by 20.1% (95% confidence interval, 15.5%-24.7%) at 1 m and thereafter.

CONCLUSIONS

Improvements in work productivity and daily activities were observed at 1 m after EE/DRSP initiation, with a sustained effect thereafter.

Management of obesity across women's life course: FIGO Best Practice Advice

Obesity is a chronic, progressive, relapsing, and treatable multifactorial, neurobehavioral disease. According to the World Health Organization, obesity affects 15% of women and has long-term effects on women's health. The focus of care in patients with obesity should be on optimizing health outcomes rather than on weight loss. Appropriate and common language, considering cultural sensitivity and trauma-informed care, is needed to discuss obesity. Pregnancy is a time of significant physiological change. Pre-, ante-, and postpartum clinical encounters provide opportunities for health optimization for parents with obesity in terms of, but not limited to, fertility and breastfeeding. Pre-existing conditions may also be identified and managed. Beyond pregnancy, women with obesity are at an increased risk for gastrointestinal and liver diseases, impaired kidney function, obstructive sleep apnea, and venous thromboembolism. Gynecological and reproductive health of women living with obesity cannot be dismissed, with accommodations needed for preventive health screenings and consideration of increased risk for gynecologic malignancies. Mental wellness, specifically depression, should be screened and managed appropriately. Obesity is a complex condition and is increasing in prevalence with failure of public health interventions to achieve significant decrease. Future research efforts should focus on interprofessional care and discovering effective interventions for health optimization.

Contraception During Perimenopause: Practical Guidance

Climacteric is by no means in itself a contraindication to safe contraception. On the contrary, there are several conditions related to the perimenopause that could benefit from the use of modern contraceptives, mainly hormonal, with the goals of avoiding unintended pregnancies and giving further possible benefits beyond contraception (menstrual cycle control, a reduction of vasomotor symptoms and menstrual migraines, a protection against bone loss, a positive oncological risk/benefit balance). This narrative review aims to provide practical guidance on their possible use in this particular life stage, both short- and long-acting reversible contraceptives, and to assist clinicians for women transitioning from contraception to their menopausal years, including the possible initiation of postmenopausal hormone therapy. Comprehensive contraceptive counselling is an essential aspect of the overall health and wellbeing of women and should be addressed with each such patient irrespective of age.

Venous thromboembolism associated with combined oral contraceptive use: a single-institution experience

OBJECTIVE

Combined oral contraceptives (COCs) are used for various reasons. However, venous thromboembolism (VTE), a significant side effect, can be fatal. This study reports the first case series in Korea involving patients with COC-associated VTE registered at a university hospital.

METHODS

This study recruited 13 patients diagnosed with COC-associated VTE between June 2006 and May 2018. Risk factors, including age, body mass index, smoking habits, estrogen dosage, type of progestin, and duration of COC use, were evaluated.

RESULTS

Among patients with VTE, 9 showed pulmonary embolism (PE) concomitant with deep vein thrombosis (DVT). However, the remaining patients showed DVT (1 patient), PE (1 patient), and cerebral venous thrombosis (2 patients). The median duration between the onset of symptoms and a hospital visit was 3 days, and it sometimes took as long as 32 days. Among the 10 patients with PE, 1 high-risk group and 2 intermediate-high risk groups were treated with tissue plasminogen activators before anticoagulants. There were no cases of recurrence among patients who continued to take anticoagulants for 3 months.

CONCLUSION

These findings emphasize that healthcare professionals who prescribe or dispense COCs to women must inform them of the risk of VTE, including the risk factors, differences in risk depending on the type of progestin present in the product, and pertinent signs and symptoms. Efforts should also be made to inform patients of VTE, even through information campaigns such as brochures. Most importantly, women should remain alert for signs and symptoms of VTE when using COCs.

The epidemiological characteristics of thromboembolism related to oral contraceptives in Japan: Results of a national survey

AIM

The aim of this study was to reveal the epidemiological characteristics of thromboembolism related to combined oral contraceptives (COCs) in Japan.

METHODS

A survey of confirmed thromboembolism patients among Japanese COC users was conducted at randomly selected hospitals from across Japan. The survey examined six types of venous thromboembolism (VTE) and arterial thromboembolism (ATE) in all COC users: pulmonary embolism, deep vein thrombosis, other venous thrombosis, cerebral infarction, myocardial infarction, and other arterial thrombosis. The survey covered 5 years from 2009 to 2013. This study was approved in an ethical review by Hamamatsu University School of Medicine.

RESULTS

Four hundred and twenty-five cases clearly related to COCs were analyzed. The annual estimated incidence rates per 10 000 person-years of VTE, ATE and all thromboembolisms in all COC users were 1.17, 0.33 and 1.50, respectively. The incidence of thromboembolism was 35.2% within 30 days from the start of COCs, 53.8% within 90 days, 66.9% within 180 days and 78.2% within 360 days regardless of progestin type. Age adjusted odds ratios in the obese and underweight groups were 2.33 and 0.98 for overall thromboembolism, 2.59 and 0.77 for VTE, and 1.11 and 1.28 for ATE compared with the standard group, respectively. Odds ratios for thromboembolism in non-O blood groups were 1.89 for overall thromboembolism, 2.16 for VTE, and 1.35 for ATE, when compared with the O blood group.

CONCLUSION

The epidemiological characteristics of COC-related thromboembolisms were revealed in this national survey covering the years from 2009 to 2013.

NAMS 2019 Pre-Meeting Symposium, September 2019, Chicago Illinois: The Perimenopause

The North American Menopause Society held the 2019 Pre-Meeting Symposium on September 25, 2019, in Chicago, Illinois, to review the current state of the science related to the physiology of the perimenopause and to address management of the most prevalent and pressing clinical issues. The perimenopause, as defined by the Stages of Reproductive Aging Workshop + 10, encompasses the menopause transition as well as the first year following menopause, the final menstrual period. This phase in the continuum of women's reproductive lives had been one of the least well understood. Fortunately, contributions from a number of prospective, longitudinal, decades-long studies have provided a better understanding of the perimenopause, whereas posing important new questions related to symptom interaction and linkages between symptoms and long-term health. There is now added clarity to distinguish the effects of reproductive hormonal changes from aging. The variation in symptoms, including vasomotor symptoms, among women over time including differences in experiences by ethnicity and race, provides paradigm shifts in clinical perspective. Refinements in understanding the character, timing, and potential predictive markers for menstrual cycles during the transition have emerged. From the perspective of myriad clinical management challenges, significant progress in recommendations for evaluation and therapeutic approaches has been achieved. Finally, recognizing the menopause transition as an opportunity to initiate positive lifestyle changes to enhance future health was emphasized.

Effects of low-dose combined oral contraceptives and protein S K196E mutation on anticoagulation factors: a prospective observational study

The association between low-dose combined oral contraceptives (COCs) and anticoagulation factors in Japanese women has been rarely studied. A total of 394 Japanese women with a new beginning cycle of COC use were enrolled, of whom 335 women visited the clinic within 4 weeks after starting the first cycle of COC. Visits occurred in the active phase (272 women) and the placebo phase (63 women). Free protein S (PS) antigen and activity levels and antithrombin activity levels decreased significantly in both the active and placebo phase groups. Protein C (PC) activity levels increased significantly in both groups. Larger reductions in free PS antigen and activity levels occurred with COC comprising either 30 µg ethinylestradiol/desogestrel or 20 µg ethinylestradiol/drospirenone than that comprising 35 µg ethinylestradiol/norethisterone. In four women with the Japanese-specific PS K196E mutation, mean PS activity was 65% before COC use and 57% during COC use, indicating further decrease with COC use. In conclusion, decreased antigen and activity levels of PS and antithrombin and increased activity levels of PC were observed even during the first cycle of low-dose COC use. The effects on PS and PC activities were also observed in the hormone-free interval.

Overview of perimenopausal contraception

The perimenopause is accompanied by important biological and psychosocial changes. The choice of contraceptive methods for women in the perimenopause, none of which is limited by age alone, will depend on the efficacy, safety, tolerability, and potential benefit of each method in relation to the biopsychosocial profile of the individual woman. Copper intrauterine devices are highly effective in the typical user and are a very safe method with, in general, good tolerability but are of limited use in women with heavy menstrual bleeding and subserous myomata. An additional benefit of copper intrauterine devices is protection against endometrial cancer. All progestogen-based methods share a favorable cardiovascular profile, making their use safe in most perimenopausal women. Long-acting implants and intrauterine systems are user independent and highly effective. Injectables and pills depend on user compliance. There is no evidence of a significant impact on breast cancer. Their impact on the endometrium can be either a negative side-effect (irregularity) or a benefit regarding reduction of heavy menstrual bleeding. Combined hormonal contraceptives have the highest cardiovascular risk. They can act as a promoting factor for breast cancer and cervical cancer, but they have the strongest potential regarding benefits (protection against endometrial and ovarian cancer, positive effect on bone mineral density, menstrual complaints, hyperandrogenic symptoms, hot flushes, and reduced risk regarding benign ovarian cysts and benign breast tumors).

The incidence and prognosis of thromboembolism associated with oral contraceptives: Age-dependent difference in Japanese population

Aim

We analyzed the incidence and prognosis of thromboembolism associated with combined oral contraceptives (COCs) by age groups in Japan.

Methods

A total of 581 events of venous thromboembolism (VTE) and arterial thromboembolism (ATE) associated with COCs were analyzed from the Pharmaceuticals and Medical Devices Agency database from 2004 to 2013. In a statistical analysis, a good‐prognosis group included recovery cases and a poor‐prognosis group involved unrecovered cases with some sequela and fatal cases. The significant difference between these two groups was calculated by Pearson's chi‐square test, and the age‐specific tendency and the trend of differences in prognosis according to different hormonal contraceptives were examined by Cochran–Armitage trend test.

Results

A total of 543 events were analyzed except 38 events due to unknown age, in which DVT only was the most frequent, followed by cerebral infarction, PE with DVT, PE only, cerebral vein thromboses. ATE ratio for overall thromboembolism tended to increase with advancing age (P = 0.0041). Good‐prognosis group was common (291 cases in VTE and 83 cases in ATE), followed by poor‐prognosis group (46 cases in VTE and 34 cases in ATE). All ATE cases had a significantly poorer prognosis in comparison with all VTE cases (P < 0.0001). Types of progestin and age difference, however, showed no trend in the differences between good‐prognosis group and poor‐prognosis group (P = 0.3548 and P = 0.6097).

Conclusion

Thromboembolic events were the most frequent in the 40s. The ATE ratio for overall thromboembolism tended to increase with advancing age. All ATE cases had a significantly poorer prognosis in comparison with all VTE cases.

Ten Years of Experience in Contraception Options for Teenagers in a Family Planning Center in Thrace and Review of the Literature

Introduction: The goal of our study was to investigate and evaluate the contraceptive behavior in teenagers from our family planning centre that services two different religious and socioeconomic populations living in the Thrace area. Methods: During the last 10 years 115 Christian Orthodox (group A) and 53 Muslim teenagers (group B) were enrolled in our retrospective study. Contraceptive practice attitudes were assessed by a questionnaire. Religion, demographics, socio-economic characteristics were key factors used to discuss contraception and avoid unplanned pregnancy in each group and to compare with the contraceptive method used. Results: The most used contraceptive method—about two times more frequently—among Christian Orthodox participants was the oral contraceptive pill (p = 0.015; OR = 1.81, 95% CI = 1.13–2.90), while in the other group the use of condoms and IUDs was seven and three times more frequent, respectively. Our family planning centre was the main source of information for contraception. Conclusions: During adolescence, the existence of a family planning centre and participation in family planning programs plays a crucial role to help the teenagers to improve their knowledge and choose an effective contraception method.

Safety of hormonal contraception for obese women

INTRODUCTION

Obese women have special safety requirements for contraceptive choice, but the evidence supporting such decision is dispersed and sometimes conflicting. Despite being effective, well tolerated and safe for most women, hormonal contraceptives are underused by obese women due to fear of contraceptive failure, weight gain and venous thrombosis. Areas covered: We performed a comprehensive literature search to identify studies about hormonal contraception in overweight and obese women, including safety concerns. We considered the safety of hormonal contraceptives for otherwise healthy obese women and for those with comorbidities such as hypertension, diabetes, vascular disease, or a history of deep venous thrombosis. Expert opinion: Over time there is no convincing evidence that obesity increases the risk of contraceptive failure. Hormonal contraceptive users may have a modest weight gain that is comparable to that of non-users. Current evidence supports the safe use of combined hormonal contraceptives by obese women after detailed clinical screening to exclude comorbidities that may contraindicate the use of estrogens. Progestin-only methods are generally safe, and long-acting reversible contraceptives hold the best combination of efficacy, safety and convenience for this group, although individualization is advisable.

Risks of thromboembolism associated with hormone contraceptives in Japanese compared with Western women

We extracted 581 thromboembolic events associated with combined oral contraceptives (COC) that occurred between 2004 and 2013 in Japan, from the Pharmaceuticals and Medical Devices Agency database. The most common thromboembolic events associated with COC were deep vein thrombosis, pulmonary embolism and their combination. The reported thromboembolic events increased year by year, in association with an increase in the quantity of prescribed low-dose estrogen progestin after approval for health insurance coverage for dysmenorrhea in 2008 in Japan. The incidence of venous thromboembolism (VTE) in Japanese COC users is estimated to be lower compared with their Western counterparts. In contrast, the frequency of all thromboembolic events peaked at 90 days from the start of COC, as in Western studies. The risk of VTE in the overweight group (body mass index ≥ 25 kg/m² ) was more than twofold higher than in the standard group, and age-specific incidence rate rose sharply after the age of 40. There were different VTE risks according to progestin type in Japan as in Western countries, but a definite conclusion about risk according to progestin type was not able to be reached at present. As for the risk of arterial embolism and thrombosis, the difference by progestin type was small, but it became higher at ≥50 years of age. Last, mortality rate caused by thromboembolism is extremely low among COC users.

Combined hormonal contraceptive use among obese women and risk for cardiovascular events: A systematic review

CONTEXT

Combined hormonal contraceptive (CHC) use may modify the risk of cardiovascular events in obese [body mass index (BMI) ≥30kg/m²] women.

OBJECTIVE

The objective was to evaluate from the literature whether CHC use modifies the risk of acute myocardial infarction (AMI), stroke, cerebral venous thrombosis (CVT) and venous thromboembolism (VTE) in obese women and to evaluate evidence for a dose-response relationship between BMI and VTE.

METHODS

We searched PubMed for all articles published between database inception and February 2016 providing direct evidence on BMI, CHCs, and cardiovascular outcomes. We also searched for indirect evidence related to a dose-response relationship between BMI and risk of VTE in the general population, as these data were lacking for CHC users. The quality of each individual study was assessed using the system for grading evidence developed by the United States Preventive Services Task Force.

RESULTS

The direct evidence search yielded 3 pooled analyses, 11 case-control studies and 1 cohort study. There was conflicting evidence about the risk of AMI or stroke among obese combined oral contraceptive (COC) users compared to obese nonusers, with one study finding no increased risk for AMI or stroke for COC users overall or stratified by BMI. A second study found significantly increased risk of AMI and stroke for COC users, with the highest risk estimates for high-BMI COC users. A single study suggested that obese COC users may be at higher risk for CVT compared with normal-weight nonusers. For VTE, obese COC users consistently had a risk that was 5 to 8 times that of obese nonusers and approximately 10 times that of nonobese nonusers. Five prospective cohort studies were identified as indirect evidence, and all found increased risk for VTE as BMI increased, suggesting a dose-response relationship between BMI and risk for VTE. No studies on the contraceptive patch or vaginal ring were identified that met the inclusion criteria.

CONCLUSION

Limited evidence of Level II-2, fair quality, concerning whether CHC use modifies the risk of AMI and stroke in obese women is inconclusive, while a single study of Level II-2, poor quality, found that obese COC users may be at higher risk for CVT compared with normal-weight nonusers. Both COC use and higher BMI increase risk for VTE, and the greatest relative risks are for those with both risk factors based on a body of evidence graded as Level II-2, fair to poor quality. It is not possible to estimate absolute risk of VTE among women with both of these risk factors; however, the absolute risk of VTE in healthy women of reproductive age is small.