A prospective study of past use of oral contraceptive agents and risk of cardiovascular diseases

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Endogenous estradiol contributes to vascular endothelial dysfunction in premenopausal women with type 1 diabetes

BACKGROUND

Endogenous estrogen is cardio-protective in healthy premenopausal women. Despite this favorable action of estrogen, animal models depict a detrimental effect of estradiol on vascular function in the presence of diabetes. The present study sought to determine the role of endogenous estradiol on endothelial function in women with type 1 diabetes.

METHOD

32 women with type 1 diabetes (HbA1c = 8.6 ± 1.7%) and 25 apparently healthy women (HbA1c = 5.2 ± 0.3%) participated. Flow-mediated dilation (FMD), a bioassay of nitric-oxide bioavailability and endothelial function was performed during menses (M) and the late follicular (LF) phase of the menstrual cycle to represent low and high concentrations of estrogen, respectively. In addition, a venous blood sample was collected at each visit to determine circulating concentrations of estradiol, thiobarbituric acid reactive substances (TBARS), and nitrate/nitrite (NOx), biomarkers of oxidative stress and nitric oxide, respectively. Data were collected in (1) 9 additional women with type 1 diabetes using oral hormonal birth control (HBC) (HbA1c = 8.3 ± 2.1%) during the placebo pill week and second active pill week, and (2) a subgroup of 9 demographically matched women with type 1 diabetes not using HBC (HbA1c = 8.9 ± 2.1%).

RESULTS

Overall, estradiol was significantly increased during the LF phase compared to M in both type 1 diabetes (Δestradiol = 75 ± 86 pg/mL) and controls (Δestradiol = 71 ± 76 pg/mL); however, an increase in TBARS was only observed in patients with type 1 diabetes (ΔTBARS = 3 ± 13 µM) compared to controls (ΔTBARS = 0 ± 4 µM). FMD was similar (p = 0.406) between groups at M. In addition, FMD increased significantly from M to the LF phase in controls (p = 0.024), whereas a decrease was observed in type 1 diabetes. FMD was greater (p = 0.015) in patients using HBC compared to those not on HBC, independent of menstrual cycle phase.

CONCLUSION

Endogenous estradiol increases oxidative stress and contributes to endothelial dysfunction in women with diabetes. Additionally, HBC use appears to be beneficial to endothelial function in type 1 diabetes.

Associations of Oral Contraceptive Use With Cardiovascular Disease and All-Cause Death: Evidence From the UK Biobank Cohort Study

Background The associations of oral contraceptive (OC) use with cardiovascular disease (CVD) and all-cause death remains unclear. We aimed to determine the associations of OC use with incident CVD and all-cause death. Methods and Results This cohort study included 161 017 women who had no CVD at baseline and reported their OC use. We divided OC use into ever use and never use. Cox proportional hazard models were used to calculate hazard ratios and 95% CIs for cardiovascular outcomes and death. Overall, 131 131 (81.4%) of 161 017 participants reported OC use at baseline. The multivariable-adjusted hazard ratios for OC ever users versus never users were 0.92 (95% CI, 0.86-0.99) for all-cause death, 0.91 (95% CI, 0.87-0.96) for incident CVD events, 0.88 (95% CI, 0.81-0.95) for coronary heart disease, 0.87 (95% CI, 0.76-0.99) for heart failure, and 0.92 (95% CI, 0.84-0.99) for atrial fibrillation. However, no significant associations of OC use with CVD death, myocardial infarction, or stroke were observed. Furthermore, the associations of OC use with CVD events were stronger among participants with longer durations of use (P for trend<0.001). Conclusions OC use was not associated with an increased risk of CVD events and all-cause death in women and may even produce an apparent net benefit. In addition, the beneficial effects appeared to be more apparent in participants with longer durations of use.

The drospirenone (DRSP)-only pill: clinical implications in the daily use

OBJECTIVES

Progestins used in contraception are either components of combined hormonal contraceptives or are used as a single active ingredient. Progestins are highly effective in long-term contraception and have a very good safety profile with very few contraindications.

METHODS

An oestrogen-free ovulation inhibitor POP has been authorised in the USA and the EU. It contains 4 mg of drospirenone (DRSP). The hormone administration regimen of 24 days followed by a 4-day hormone-free period was chosen to improve bleeding control and to maintain oestradiol concentrations at early follicular- phase levels, preventing oestrogen deficiency.

RESULTS

Clinical trials have demonstrated high contraceptive effectiveness, a very low risk of cardiovascular risk events and a favourable bleeding pattern. Due to the long half-life of DRSP (30-34 h), the effectiveness is maintained even in case of a forgotten pill on a single occasion. Studies involving deliberate 4 days in one cycle 24-hour delays in taking a pill have demonstrated that ovulation inhibition is maintained if a single pill is missed.

CONCLUSIONS

This review article will describe the clinical impact in the daily use of the 4 mg DRSP only pill and the resulting data on the effectiveness and safety of this hormonal contraceptive.

Early Prediction in Classification of Cardiovascular Diseases with Machine Learning, Neuro-Fuzzy and Statistical Methods

Timely and accurate detection of cardiovascular diseases (CVDs) is critically important to minimize the risk of a myocardial infarction. Relations between factors of CVDs are complex, ill-defined and nonlinear, justifying the use of artificial intelligence tools. These tools aid in predicting and classifying CVDs. In this article, we propose a methodology using machine learning (ML) approaches to predict, classify and improve the diagnostic accuracy of CVDs, including support vector regression (SVR), multivariate adaptive regression splines, the M5Tree model and neural networks for the training process. Moreover, adaptive neuro-fuzzy and statistical approaches, nearest neighbor/naive Bayes classifiers and adaptive neuro-fuzzy inference system (ANFIS) are used to predict seventeen CVD risk factors. Mixed-data transformation and classification methods are employed for categorical and continuous variables predicting CVD risk. We compare our hybrid models and existing ML techniques on a CVD real dataset collected from a hospital. A sensitivity analysis is performed to determine the influence and exhibit the essential variables with regard to CVDs, such as the patient's age, cholesterol level and glucose level. Our results report that the proposed methodology outperformed well known statistical and ML approaches, showing their versatility and utility in CVD classification. Our investigation indicates that the prediction accuracy of ANFIS for the training process is 96.56%, followed by SVR with 91.95% prediction accuracy. Our study includes a comprehensive comparison of results obtained for the mentioned methods.

Oral Contraceptives, Hormone Replacement Therapy, and Stroke Risk

BACKGROUND

Millions of women worldwide use exogenous hormones as oral contraceptives or hormone replacement therapy. Still, time-dependent and long-term consequences of exogenous hormones on stroke risk remains unclear.

METHODS

We examined the association between self-reported oral contraceptive and hormone replacement therapy use and stroke risk in 257 194 women from the UK Biobank, born between 1939 and 1970. Outcomes included any type of stroke, ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Exposures were analyzed as time-varying variables in Cox regression models.

RESULTS

During first year of oral contraceptive use, an increased event rate of any stroke was observed (hazard ratio [HR], 2.49 [95% CI, 1.44-4.30]), while the hazards were found to be comparable during remaining years of use (HR, 1.00 [95% CI, 0.86-1.14]), compared with nonusers. Similarly, first year of hormone replacement therapy use was associated with higher hazard rates of any stroke (HR, 2.12 [95% CI, 1.66-2.70]), as well as cause-specific stroke, including ischemic stroke (HR, 1.93 [95% CI, 1.05-3.57]) and subarachnoid hemorrhage (HR, 2.17 [95% CI, 1.25-3.78]), which remained increased for any stroke during remaining years of use (HR, 1.18 [95% CI, 1.05-1.31]), and after discontinuation (HR, 1.16 [95% CI, 1.02-1.32]).

CONCLUSIONS

Oral contraceptive use and hormone replacement therapy were associated with an increased risk of stroke, especially during the first year of use, possibly due to immediate changes in hemostatic balance. This study provides new insights on the effects of hormone exposure on stroke risk and provide evidence of not only an overall risk but also a pronounced effects seen in the beginning of treatment.

Bleeding profile of women with cardiovascular risk factors using a drospirenone only pill with 4 mg over nine cycles compared to desogestrel 0.075 mg

OBJECTIVE

Progestin-only pills are associated with irregular bleeding patterns, including amenorrhea. Desogestrel (DSG) 75 mcg, a pill that inhibits ovulation, shows poor cycle control that may harm acceptability and compliance. A Drospirenone (DRSP)-only pill was developed with 24 & 4 days of active & placebo days every 28-day cycle to improve cycle control.

STUDY DESIGN

A phase III study in healthy women aged 18 to 45 years was performed to compare the bleeding profile of women taking a DRSP versus DSG over nine cycles. 249 women were older > 35 years: 173 using DRSP and 73 DSG. 259 women had a BMI > 25 kg/m²: 189 using DRSP and 70 DSG and 340 women were smokers: 237 using DRSP and 103 DSG. The amount of unscheduled bleeding/spotting days was analyzed in each of these sub-groups and compared statistically.

RESULTS

Age: During cycles 2-4, the mean number of unscheduled bleeding days and spotting was 8.1 (SD10.53) for DRSP and 20.1 (19.41) for DSG; p = .0089. BMI > 25 kg/m²: During cycles 2-4 the mean number of unscheduled bleeding days and spotting was 7.8 (SD 12.18) for DRSP and 17.7 for DSG (SD 19.39); p = .0001. Smokers: During cycles 2-4, the mean number of unscheduled bleeding days and spotting was 9.6 (SD 11.69) for DRSP and 17.4 for DSG (SD 17.47); p = .0016.

CONCLUSIONS

These analyses show the improvement in the bleeding profile of women with specific cardiovascular risk factors using the DRSP only oral contraceptive product compared to DSG.ImplicationsAn improvement in the bleeding profile of women with specific cardiovascular risk factors like age > 35 years, BMI > 25kg/m², and smokers using the DRSP only oral contraceptive product is described.Herby a higher contraceptive efficacy in these patients that additionally benefit from estrogen-free contraceptive methods is expected.

Association between past oral contraceptive use and the prevalence of hypertension in postmenopausal women: the fifth (2010-2012) Korea National Health and Nutrition Examination Survey (KNHANES V)

BACKGROUND

There is little evidence as to whether the use of oral contraceptives(OC) during the fertile years affects the development of postmenopausal hypertension. This study aimed to evaluate the association between past use of OC and development of hypertension in postmenopausal women.

METHODS

This was a cross-sectional study conducted using data from the Fifth Korea National Health and Nutrition Examination Survey of postmenopausal women. Subjects were classified into three groups based on past OC use duration: nonusers, short-term users(0-30 months), and long-term users(≥ 30 months). We evaluated the development of hypertension in women after menopause. A multivariable logistic regression model was used to identify the association between the use of OC during the fertile years and the prevalence of hypertension after menopause following adjustment for potential confounding factors.

RESULTS

Of the 3,386 postmenopausal women, 2,713 were nonusers of OC, 489 were short-term users, and 184 were long-term users. Women who had used OC for 30 months or more had a significantly greater prevalence of hypertension after menopause than those who had never taken OC. The association between taking OC for 30 months or more during the fertile years and the prevalence of hypertension after menopause was significant following adjustment for potential confounding factors (adjusted OR:1.75; 95%CI:1.12-2.74).

CONCLUSION

This study identified an association between past OC use and an increased prevalence of hypertension in postmenopausal women. Our results suggest that long-term use of OC during the fertile years can be an important risk factor for subsequent hypertension after menopause.

Birth Weight and Adult-Onset Hearing Loss

OBJECTIVES

Among low-birth-weight infants, exposure to stress or undernutrition in utero may adversely affect cochlear development. As cochlear reserve declines, the risk of hearing loss may increase with age. While low birth weight is associated with a higher risk of neonatal hearing loss, our objective was to examine whether birth weight was associated with adult-onset, self-reported hearing loss in the Nurses' Health Studies (NHS) I and II (n = 113,130).

DESIGN

We used Cox proportional hazards regression to prospectively examine whether birth weight, as well as gestational age at birth, is associated with adult-onset hearing loss. Participants reported their birth weight in 1992 in NHS I and 1991 in NHS II. Mothers of NHS II participants reported gestational age at birth in a substudy (n = 28,590). The primary outcome was adult-onset, self-reported moderate or greater hearing loss, based on questionnaires administered in 2012/2016 in NHS I and 2009/2013 in NHS II.

RESULTS

Our results suggested a higher risk of hearing loss among those with birth weight <5.5 lbs compared with birth weight 7 to <8.5 lbs (pooled multivariable-adjusted hazard ratio 1.14, 95% confidence interval = 1.04-1.23; p trend = 0.01). Additionally, participants with gestational age at birth ≥42 weeks had a higher risk of hearing loss, compared with gestational age 38 to <42 weeks (multivariable-adjusted hazard ratio 1.33, 95% confidence interval = 1.06-1.65).

CONCLUSIONS

Birth weight <5.5 lbs was independently associated with higher risk of self-reported, adult-onset hearing loss. In addition, gestational age at birth ≥42 weeks was also associated with higher risk.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

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.

Prior Oral Contraceptive Use and Longer Term Mortality Outcomes in Women with Suspected Ischemic Heart Disease

Background: Previous Women's Ischemia Syndrome Evaluation (WISE) work demonstrated prior oral contraceptive (OC) use was associated with lower coronary artery disease (CAD) in women with suspected ischemia. The association of prior OC use with longer term all-cause and cardiovascular disease (CVD) mortality is unclear. Materials and Methods: WISE women undergoing coronary angiography for suspected ischemia (enrolled 1996-2001) with prior OC use history and 10-year follow-up data were analyzed. A blinded core laboratory assessed atherosclerotic CAD severity. Kaplan-Meier analyses evaluated prior OC use relative to all-cause and CVD mortality. Cox regression analyses adjusted for baseline differences. Mediation, interaction, and multicollinearity were analyzed. Results: Our 686 women had a mean age 62.5 ± 9.6 years, multiple cardiac risk factors, and 39% previously used OC. Prior OC users were younger, with less lipid-lowering medication use and lower atherosclerotic CAD severity scores (all p < 0.05). Prior OC use was associated with lower 10-year all-cause (p = 0.007) and CVD mortality (p = 0.019). After adjustment, this was no longer significant (p = 0.77 and p = 0.90, respectively). Atherosclerotic CAD severity score mediated one-third of the observed association. Prior OC use was associated with increased CVD mortality among women with very elevated menopausal systolic blood pressure (SBP). Conclusions: Unadjusted prior OC use was associated with lower longer-term all-cause and CVD mortality. One-third of this observed effect appears mediated by the atherosclerotic CAD severity score. Prior OC was adversely associated with CVD mortality in women with very elevated menopausal SBP. Additional investigation is needed to understand the potential benefits and harms of prior OC use. Clinical Trial Number: NCT00000554, or https://www.clinicaltrials.gov/ct2/show/NCT00000554.

Socio-economic and reproductive concomitants of abdominal adiposity and hypertension: A study on Bengali-speaking Hindu women of Habra, North 24 Parganas, West Bengal, India

Obesity and hypertension have become a global epidemic among the women, especially as they experience additional stressful events compared to men. The epidemiology of these two metabolic disorders is regulated by various biological, socio-economic, reproductive and lifestyle factors related to women. However, inconsistency in the nature and magnitude of the effects of these traits indicates exploring the areas where little emphasis has been given. In this context, the present study attempted to determine the effect of socio-economic and reproductive traits on hypertension and abdominal adiposity among women living in the North 24 Parganas district of West Bengal, India. Data on socio-demographic and reproductive traits were collected from 319 adult women from both rural and urban sectors of Habra block I. Anthropometric measurements and Blood pressure levels were measured following standard protocols. Results highlighted that the prevalence of obese individuals and hypertensive individuals were 73.4 and 50.5 per cent respectively. Women with low income (OR=0.51) were at lower risk and post-menopausal women (OR=1.71) were at higher risk of developing abdominal adiposity. The risk of developing hypertension increased with higher educational attainment (OR=2.43). Post-menopausal women (OR=0.46) and shifting workers (OR=0.40) were at lower risk of developing hypertension. The risk also decreased with increased age (OR=0.96). Present study revealed that menopause is a significant event to predict abdominal adiposity and hypertension among Bengali-speaking Hindu women.

Association between hypertensive pregnancy disorders and future risk of stroke in Taiwan: a Nationwide population-based retrospective case-control study

Background

The incidence of female stroke has increased gradually and has begun occurring at a younger age in recent years. Given that women live longer than men, stroke would cause more negative and longer-term impacts on the rest of the lives of women. There are few related studies on Asian women. We aimed to evaluate stroke risk in Asian women following hypertensive pregnancy disorders.

Methods

Using the Taiwan National Health Insurance database, we designed a retrospective study that included pregnant women between 2000 and 2013. We selected an age-matched control group of women without hypertensive pregnancy disorders at a 1:3 ratio. The endpoint was any episode of stroke; otherwise, the patients were tracked until December 31, 2013. After the index date until the end of 2013, Cox proportional hazards analysis was used to compare the risk of incident stroke. The risk factors for stroke were determined using Cox proportional regression to calculate the hazard ratio (HR) compared with the control group.

Results

During the follow-up period, the Kaplan-Meier analysis indicated that patients with hypertensive pregnancy disorders had a significantly higher risk of developing stroke than did patients without hypertensive pregnancy disorders (log-rank test P < 0.001). Multivariate Cox regression analysis demonstrated that the case group had a 2.134-fold increased risk of stroke (HR = 2.134; 95% CI = 1.817–2.505; P < 0.001).

Conclusion

Our study provided evidence of an increased risk of stroke in patients with hypertensive pregnancy disorders. Compared with those without such disorders, the patients who had experienced the disorders had a 2.134-fold (P < 0.001) higher risk of developing stroke in the future.

Approaches to limit systemic antibiotic use in acne: Systemic alternatives, emerging topical therapies, dietary modification, and laser and light-based treatments

Acne is one of the most common diseases worldwide and affects ∼50 million individuals in the United States. Oral antibiotics are the most common systemic agent prescribed for the treatment of acne. However, their use might be associated with a variety of adverse outcomes including bacterial resistance and disruption of the microbiome. As a result, multiple treatment guidelines call for limiting the use of oral antibiotics in the treatment of acne, although actual prescribing often does not follow these guidelines. In this review, the rationale for concerns regarding the use of oral antibiotics for the management of acne is reviewed. In addition, we will discuss our approach to complying with the intent of the guidelines, with a focus on novel topical agents, dietary modification, laser and light-based modalities, and systemic medications, such as spironolactone, combined oral contraceptives, and oral isotretinoin.

Association between progestin-only contraceptive use and cardiometabolic outcomes: A systematic review and meta-analysis

Aims The association between progestin-only contraceptive (POC) use and the risk of various cardiometabolic outcomes has rarely been studied. We performed a systematic review and meta-analysis to determine the impact of POC use on cardiometabolic outcomes including venous thromboembolism, myocardial infarction, stroke, hypertension and diabetes. Methods and results Nineteen observational studies (seven cohort and 12 case-control) were included in this systematic review. Of those, nine studies reported the risk of venous thromboembolism, six reported the risk of myocardial infarction, six reported the risk of stroke, three reported the risk of hypertension and two studies reported the risk of developing diabetes with POC use. The pooled adjusted relative risks (RRs) for venous thromboembolism, myocardial infarction and stroke for oral POC users versus non-users based on the random effects model were 1.06 (95% confidence interval (CI) 0.70-1.62), 0.98 (95% CI 0.66-1.47) and 1.02 (95% CI 0.72-1.44), respectively. Stratified analysis by route of administration showed that injectable POC with a RR of 2.62 (95% CI 1.74-3.94), but not oral POCs (RR 1.06, 95% CI 0.7-1.62), was associated with an increased risk of venous thromboembolism. A decreased risk of venous thromboembolism in a subgroup of women using an intrauterine levonorgestrel device was observed with a RR of 0.53 (95% CI 0.32-0.89). No effect of POC use on blood pressure was found, but there was an indication for an increased risk of diabetes with injectable POCs, albeit non-significant. Conclusions This systematic review and meta-analysis suggests that oral POC use is not associated with an increased risk of developing various cardiometabolic outcomes, whereas injectable POC use might increase the risk of venous thromboembolism.

Risks, benefits size and clinical implications of combined oral contraceptive use in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is a complex condition with high risk for dyslipidemia, dysglycemia, venous thromboembolism, cardiovascular disease and metabolic syndrome. Because the combined oral contraceptive (COC) use has also been associated with impaired fasting glucose, insulin resistance and increased risk of thromboembolism disease, it is rationale to think that the combination of oral contraceptive and PCOS could make it worse or increase the risks.

OBJECTIVE

To examine the current data regarding potential additional risks and benefits of contraceptive use, highlights the major gap in knowledge for designing future studies and, when possible, suggests an adequate COC formulation for a determined PCOS phenotype.

METHODS

English-language publications reporting on the influence of COCS in the development of venous thromboembolism in PCOS patients published until 2017 were searched using PubMed, Cochrane database, and hand search of references found in consulted articles. Ranges of collected data are given; the pooled data are presented as median and first and third quartiles. Wilcoxon signed-ranks test for paired samples was used to compare before-after original data. P value was set at 0.05.

RESULTS

Most of COCs preparations significantly decrease androgens, and increase sex-hormone binding globulin. Therefore, the benefits of COCs are clear in patients with proved hyperandrogenemia. Regarding the impact of COCs on carbohydrate metabolism of PCOS subjects, the data were inconsistent but they tended to show no additional risk. Regarding lipids, most COCs consistently increased high-density lipoprotein cholesterol, triglycerides and total cholesterol concentrations but the clinical implications of these changes need additional studies.

CONCLUSION

The review showed consistent beneficial effect of COCs, particularly for hyperandrogenemic PCOS patients. The benefit size of COC's use by normoandrogenemic PCOS patients is uncertain and need more investigation. The effects of COC use on carbohydrate metabolism of women with PCOS are still unresolved since most studies are observational but the current results demonstrated that COCs do not make their levels worse and may improve insulin sensitivity. The impact of COCs on lipids of PCOS patients seems to be clearer and most preparations increase total cholesterol, high-density lipoprotein cholesterol and triglycerides. In summary, it is important to balance the potential benefits and risks of the COCs individually before prescribing them for PCOS women.

[Coronary disease in women: The role of sexual hormones]

During their lives, women go through three different phases during which sex hormones play a fundamental role in contributing to specific cardiovascular and coronary risks. To evaluate this risk, we must take into account these various phases with their associated cardiovascular risk factors, and this during three key steps: contraception, pregnancy and menopause. Arterial risk linked to estrogen combined with progestin contraception, depends on the dosage of estrogen. The main cardiovascular risk factor responsible for increasing the risk of myocardial infarction is tobacco, especially after 35 years of age, contraindicating estrogen combined with progestin contraception at the benefit of progestin. Spontaneous dissections and coronary emboli are the most common coronary lesions linked with oestroprogestative contraception. Acute myocardial infarction during pregnancy occurs mostly in the peripartum or postpartum period; and is often caused by spontaneous coronary dissection lesions. Fertility treatment is not associated with an increased risk of developing cardiovascular disease later in life. Hormone therapy during menopause does not increase coronary risk in the first 10 years after menopause and may even have a protective effect, by sustaining arterial integrity. The transdermal route is to be preferred for its metabolic effect. Hormonal treatment during menopause is nonetheless contraindicated in the case of proven coronary disease and uncontrolled cardiovascular risk factors.

Exogenous Hormone Use: Oral Contraceptives, Postmenopausal Hormone Therapy, and Health Outcomes in the Nurses' Health Study

OBJECTIVES

To review the contribution of the Nurses' Health Study (NHS) to our understanding of the complex relationship between exogenous hormones and health outcomes in women.

METHODS

We performed a narrative review of the publications of the NHS and NHS II from 1976 to 2016.

RESULTS

Oral contraceptive and postmenopausal hormone use were studied in relation to major health outcomes, including cardiovascular disease and cancer. Current or recent oral contraceptive use is associated with a higher risk of cardiovascular disease (mainly among smokers), melanoma, and breast cancer, and a lower risk of colorectal and ovarian cancer. Although hormone therapy is not indicated primarily for chronic disease prevention, findings from the NHS and a recent analysis of the Women's Health Initiative indicate that younger women who are closer to menopause onset have a more favorable risk-benefit profile than do older women from use of hormone therapy for relief of vasomotor symptoms.

CONCLUSIONS

With updated information on hormone use, lifestyle factors, and other variables, the NHS and NHS II continue to contribute to our understanding of the complex relationship between exogenous hormones and health outcomes in women.

Low dose oestrogen combined oral contraception and risk of pulmonary embolism, stroke, and myocardial infarction in five million French women: cohort study

OBJECTIVE

To assess the risk of pulmonary embolism, ischaemic stroke, and myocardial infarction associated with combined oral contraceptives according to dose of oestrogen (ethinylestradiol) and progestogen.

DESIGN

Observational cohort study.

SETTING

Data from the French national health insurance database linked with data from the French national hospital discharge database.

PARTICIPANTS

4 945 088 women aged 15-49 years, living in France, with at least one reimbursement for oral contraceptives and no previous hospital admission for cancer, pulmonary embolism, ischaemic stroke, or myocardial infarction, between July 2010 and September 2012.

MAIN OUTCOME MEASURES

Relative and absolute risks of first pulmonary embolism, ischaemic stroke, and myocardial infarction.

RESULTS

The cohort generated 5 443 916 women years of oral contraceptive use, and 3253 events were observed: 1800 pulmonary embolisms (33 per 100 000 women years), 1046 ischaemic strokes (19 per 100 000 women years), and 407 myocardial infarctions (7 per 100 000 women years). After adjustment for progestogen and risk factors, the relative risks for women using low dose oestrogen (20 µg v 30-40 µg) were 0.75 (95% confidence interval 0.67 to 0.85) for pulmonary embolism, 0.82 (0.70 to 0.96) for ischaemic stroke, and 0.56 (0.39 to 0.79) for myocardial infarction. After adjustment for oestrogen dose and risk factors, desogestrel and gestodene were associated with statistically significantly higher relative risks for pulmonary embolism (2.16, 1.93 to 2.41 and 1.63, 1.34 to 1.97, respectively) compared with levonorgestrel. Levonorgestrel combined with 20 µg oestrogen was associated with a statistically significantly lower risk than levonorgestrel with 30-40 µg oestrogen for each of the three serious adverse events.

CONCLUSIONS

For the same dose of oestrogen, desogestrel and gestodene were associated with statistically significantly higher risks of pulmonary embolism but not arterial thromboembolism compared with levonorgestrel. For the same type of progestogen, an oestrogen dose of 20 µg versus 30-40 µg was associated with lower risks of pulmonary embolism, ischaemic stroke, and myocardial infarction.

Dyslipidemia and cardiovascular disease in women

Cardiovascular disease is the major cause of death in women in developed countries. Dyslipidemia is highly prevalent in women, particularly after the menopause. Elevated low-density lipoprotein cholesterol (LDL-C) has been identified as the key lipid parameter in both genders whereas HDL-cholesterol and triglycerides have been more closely associated, in some studies, with cardiovascular risk in women. Menopause has been shown to be associated with an increase in total and LDL-cholesterol and a decrease in HDL-cholesterol (predominantly in the HDL2 subfraction). Despite its beneficial effects on the lipid profile, hormone replacement therapy is not recommended for primary or secondary prevention of cardiovascular disease in women. The latest meta-analysis of statin trials with gender-specific outcomes showed a similar benefit in women and men. The addition of ezetimibe to simvastatin in patients with acute coronary syndromes showed a further reduction of the primary endpoint in both genders. While there are no gender-related differences in drug treatment of dyslipidemia, current guidelines, to avoid overtreatment, strongly suggest risk estimation before initiating lipid-lowering treatment in women without manifest cardiovascular disease.

Hormonal contraception, thrombosis and age

INTRODUCTION

This paper reviews the risk of thrombosis with use of different types of hormonal contraception in women of different ages.

AREAS COVERED

Combined hormonal contraceptives with desogestrel, gestodene, drospirenone or cyproterone acetate (high-risk products) confer a sixfold increased risk of venous thromboembolism as compared with nonusers, and about twice the risk as compared with users of products with norethisterone, levonorgestrel or norgestimate (low-risk products). Transdermal patches and vaginal ring belong to high-risk products. The risk of thrombotic stroke and myocardial infarction is increased 50 - 100% with use of combined products, with little difference in risk between different progestins. Progestin-only products do not confer any increased risk of venous or arterial thrombosis, except for progestin depot, which may double the risk of venous thrombosis.

EXPERT OPINION

First choice in women below 35 years should be a combined low-risk pill, that is, with a second-generation progestin, with the lowest compliable dose of estrogen. Young women with risk factors of thrombosis such as age above 35 years, genetic predispositions, adiposity, polycystic ovary syndrome, diabetes, smoking, hypertension or migraine with aura should not use high-risk products, but should primarily consider progestin-only products, and be careful to use low-risk combined products.

Past oral contraceptive use and self-reported high blood pressure in postmenopausal women

Background

Studies have reported current hormonal contraceptive use is associated with adverse cardiovascular outcomes, including high blood pressure. The aim of this study was to determine the association between past hormonal contraception use and high blood pressure in Australian postmenopausal women.

Methods

Women were recruited from the 45 and Up Study, an observational cross-sectional study, conducted from February 2006 to December 2009, NSW Australia. All of the variables used in this study were derived from self-reported data. These women reported being postmenopausal, having an intact uterus, and had given birth to one or more children. Odds ratios and 99% confidence intervals for the association between past hormonal contraceptive use and current treatment for high blood pressure, stratified by current age (<58 yrs, 58–66 yrs, and ≥67 yrs) were estimated using logistic regression, adjusted for income, country of origin, BMI, smoking, alcohol, exercise, family history of high blood pressure, menopausal hormone therapy use, number of children, whether they breastfed, and age of menopause.

Results

A total of 34,289 women were included in the study. No association between past hormonal contraception use and odds of having high blood pressure were seen in any of the age groups (<58 yrs: odds ratio (OR) 1.1, 99% confidence interval (CI) 0.8 to 1.5, p = 0.36; 58–66 yrs: OR 0.9, 99% CI 0.7 to 1.1, p = 0.11; and ≥67 yrs: OR 0.9, 99% CI 0.8 to 1.0. p = 0.06). In women with a history of hormonal contraception use, no association between duration of hormonal contraception use and high blood pressure was observed.

Conclusions

Past hormonal contraception use and duration of use is not associated with high blood pressure in postmenopausal women.

Antifertility efficacy of Drynaria quercifolia (L.) J. Smith on female Wister albino rats

ETHNOPHARMACOLOGICAL RELEVANCE

Plant based traditional medicines for birth control has been in practice in rural populations of North-East India, since time immemorial. Fresh rhizome of Drynaria quercifolia (L.) J. Smith is one of the plant parts used traditionally by different ethnic communities in Tripura, India for birth control. The present investigation is aimed to justify the scientific basis in traditional use of Drynaria quercifolia rhizome as anti-fertility agent.

MATERIALS AND METHODS

Ex-vivo uterotonic activity was done on uterine tissue. Acute toxicity test of the plant extract was carried out in rats of both sexes. The abortifacient and anti-implantation activities of the extract were investigated, in-vivo and estimated the level of different hormones release.

RESULTS

The result revealed the effectiveness of methanol (87%) and aqueous (68%) extract of the plant on uterotonic activity. The extracts showed relatively non-toxic effect in acute toxicity study. Methanolic extract has shown higher efficacy for both abortifacient (**p<0.01) and anti-implantation performance (**p<0.01) and also effected hormone release level (**p<0.01).

CONCLUSION

Methanolic extract of Drynaria quercifolia (L.) J. Smith rhizome has been proved to have significant anti-fertility activity.

Thrombotic stroke and myocardial infarction with hormonal contraception

BACKGROUND

Although several studies have assessed the risk of venous thromboembolism with newer hormonal contraception, few have examined thrombotic stroke and myocardial infarction, and results have been conflicting.

METHODS

In this 15-year Danish historical cohort study, we followed nonpregnant women, 15 to 49 years old, with no history of cardiovascular disease or cancer. Data on use of hormonal contraception, clinical end points, and potential confounders were obtained from four national registries.

RESULTS

A total of 1,626,158 women contributed 14,251,063 person-years of observation, during which 3311 thrombotic strokes (21.4 per 100,000 person-years) and 1725 myocardial infarctions (10.1 per 100,000 person-years) occurred. As compared with nonuse, current use of oral contraceptives that included ethinyl estradiol at a dose of 30 to 40 μg was associated with the following relative risks (and 95% confidence intervals) for thrombotic stroke and myocardial infarction, according to progestin type: norethindrone, 2.2 (1.5 to 3.2) and 2.3 (1.3 to 3.9); levonorgestrel, 1.7 (1.4 to 2.0) and 2.0 (1.6 to 2.5); norgestimate, 1.5 (1.2 to 1.9) and 1.3 (0.9 to 1.9); desogestrel, 2.2 (1.8 to 2.7) and 2.1 (1.5 to 2.8); gestodene, 1.8 (1.6 to 2.0) and 1.9 (1.6 to 2.3); and drospirenone, 1.6 (1.2 to 2.2) and 1.7 (1.0 to 2.6), respectively. With ethinyl estradiol at a dose of 20 μg, the corresponding relative risks according to progestin type were as follows: desogestrel, 1.5 (1.3 to 1.9) and 1.6 (1.1 to 2.1); gestodene, 1.7 (1.4 to 2.1) and 1.2 (0.8 to 1.9); and drospirenone, 0.9 (0.2 to 3.5) and 0.0. For transdermal patches, the corresponding relative risks were 3.2 (0.8 to 12.6) and 0.0, and for a vaginal ring, 2.5 (1.4 to 4.4) and 2.1 (0.7 to 6.5).

CONCLUSIONS

Although the absolute risks of thrombotic stroke and myocardial infarction associated with the use of hormonal contraception were low, the risk was increased by a factor of 0.9 to 1.7 with oral contraceptives that included ethinyl estradiol at a dose of 20 μg and by a factor of 1.3 to 2.3 with those that included ethinyl estradiol at a dose of 30 to 40 μg, with relatively small differences in risk according to progestin type. (Funded by the Danish Heart Association.).

Evaluation of the Coagulation Profile Among Oral and Vaginal Combined Hormonal Contraceptive Users Using Sonoclot Coagulation Analyzer

Combined hormonal contraceptives possess an inherent risk of thrombus-related events. The purpose of this study is to elucidate alterations in the coagulation profile among young women using combined oral contraceptive (COC) or combined vaginal contraceptive (CVC) compared to a normal, healthy, female control group using the Sonoclot coagulation analyzer. We enrolled 159 participants (64 control individuals, 51 COC users, and 44 CVC users). Each participant completed a survey of medical history, family medical history, and lifestyle choices. Citrated venous whole blood was collected and analyzed using the Sonoclot coagulation analyzer. After adjusting for age, race, alcohol consumption, sleeping habits, and family history of cardiovascular disease, and stroke, we observed COC and CVC users had mostly similar coagulation profiles except when compared to the control, and COC and CVC users had an elevated glass bead peak signal while COC users had a shorter peak time.

Increased plasma viscosity in young women with polycystic ovary syndrome using an oral contraceptive containing 35 μg ethinyl estradiol and 2 mg cyproterone acetate

OBJECTIVES

To investigate the influence of 6 months of treatment with an oral contraceptive (OC) containing 35 μ g ethinyl estradiol and 2 mg cyproterone acetate on plasma viscosity (PV) in young women with polycystic ovary syndrome (PCOS).

DESIGN

Patients with PCOS were assessed for PV before and after 6 months of treatment with an OC containing 35 μg ethinyl estradiol and 2 mg cyproterone acetate. PV was determined by a viscometer Type 53610/I SCHOTT-Instruments, Mainz at 37°C.

SETTINGS

Subjects were recruited from the Department of Obstetrics and Gynaecology, Division of Reproductive Endocrinology at the University Hospital of Patras, Greece.

PATIENTS

The study included 66 young women with PCOS.

MAIN OUTCOME MEASURES

PV.

RESULTS

In PCOS women as a whole, PV at baseline was 1.249 ± 0.049 mm(2)/s (n = 66). After 6 months of treatment with an OC containing 35 μg ethinyl estradiol and 2 mg cyproterone acetate, PV was increased to 1.268 ± 0.065 mm(2)/s (p = 0.038). The difference between PV before and after 6 months of treatment with an OC containing 35 μg ethinyl estradiol and 2 mg cyproterone acetate (Δviscosity) was 0.01864 ± 0.071452 mm(2)/s. ΔViscosity was related to ?fibrinogen (r = 0.270, p = 0.046), to Δhematocrit (r = 0.514, p = 0.09) and to Δtriglycerides (r = 0.292, p = 0.021).

CONCLUSION

Young women with PCOS presented an increased PV under OC treatment with 35 μg ethinyl estradiol and 2 mg cyproterone acetate.

Blood pressure effects of the oral contraceptive and postmenopausal hormone therapies

Oral contraceptives and postmenopausal hormone therapy may induce hypertension through multiple mechanisms, including sodium and volume retention. Numerous studies have shown significant increases in blood pressure (BP) with the chronic administration of oral contraceptives as well as reversibility with discontinuation. The effects of different classes of oral contraceptive agents and hormonal replacement therapy on BP and associated effects on other cardiovascular risk factors are covered in this article. Novel hormonal replacement therapy that lowers BP is also discussed.

Gender differences in risk factors for coronary heart disease

Coronary heart disease (CHD), traditionally considered a male disease, is also a major threat to women. This review article addresses independent risk factors for CHD that are specific for women as well as non-gender-specific risk factors and how their effects differ between men and women. Although polycystic ovary syndrome (PCOS) in women is associated with an adverse metabolic risk profile, current evidence regarding future risk of CHD is conflicting. Preeclampsia is consistently associated with higher risk of CHD later in life. Menopause is associated with an increased risk of CHD, and the earlier the onset of menopause, the larger the risk. Existing data on postmenopausal hormone therapy (HT) was inconclusive with regard to possible protection when HT is initiated close to menopause in young peri- or postmenopausal women. Evidence on use of low-dose oral contraceptives strongly suggests no increased risk of CHD. Although levels of physical inactivity are similar for men and women, the higher prevalences of hypertension, diabetes, and obesity in older women portends a greater risk in women than in men. Additionally, risk factors like smoking, hypertriglyceridemia and low high-density lipoprotein cholesterol levels have greater impact in women than in men. This review indicates that acknowledgement of non-gender-specific risk factors in addition to those that are unique to women would help optimize diagnosis, treatment and earlier prevention of CHD in women. Further research is needed to ascertain if incorporating these gender-specific risks into a clinically used risk stratification model would change outcome in women.

Progestogen-Only Contraceptives and the Risk of Stroke

Background and Purpose— The association between combined oral contraceptives (OC) use and increased risk of stroke has been reported. While progestogen-only contraceptives (POC) are commonly used worldwide, their impact on cardiovascular disease remains unclear.

Methods— A meta-analysis based on EMBASE and MEDLINE referenced literature corresponding to OCs marketed since 1960 was carried out. Eligible articles assessing the risk of stroke in relation to OC or POC were reviewed, and relevant studies were extracted. All types of POC and routes of administration were taken into account in the meta-analysis.

Results— Six case-control studies were identified. The combined odd ratio (OR) showed no increase in the risk of stroke among POC users (OR=0.96; 95% confidence interval: 0.70 to 1.31). This result was similar according to the route of administration (either implant or injectable or oral POC).

Conclusion— Data from observational studies show that POC use is not associated with an increased risk of stroke. However, these results are based on limited data. Further investigations are needed in women with risk factors of stroke.

Contraceptive hormone use and cardiovascular disease

Contraceptive hormones, most commonly prescribed as oral contraceptives (OCs), are a widely utilized method to prevent ovulation, implantation, and, therefore, pregnancy. The Women's Health Initiative demonstrated cardiovascular risk linked to menopausal hormone therapy among women without pre-existing cardiovascular disease, prompting a review of the safety, efficacy, and side effects of other forms of hormone therapy. A variety of basic science, animal, and human data suggests that contraceptive hormones have antiatheromatous effects; however, relatively less is known regarding the impact on atherosclerosis, thrombosis, vasomotion, and arrhythmogenesis. Newer generation OC formulations in use indicate no increased myocardial infarction risk for current users, but a persistent increased risk of venous thromboembolism. There are no cardiovascular data available for the newest generation contraceptive hormone formulations, including those that contain newer progestins that lower blood pressure, as well as the nonoral routes (transdermal and vaginal). Current guidelines indicate that, as with all medication, contraceptive hormones should be selected and initiated by weighing risks and benefits for the individual patient. Women 35 years and older should be assessed for cardiovascular risk factors including hypertension, smoking, diabetes, nephropathy, and other vascular diseases, including migraines, prior to use. Existing data are mixed with regard to possible protection from OCs for atherosclerosis and cardiovascular events; longer-term cardiovascular follow-up of menopausal women with regard to prior OC use, including subgroup information regarding adequacy of ovulatory cycling, the presence of hyperandrogenic conditions, and the presence of prothrombotic genetic disorders is needed to address this important issue.

A prospective study of oral contraceptive use and risk of myocardial infarction among Swedish women

OBJECTIVE

To determine the risk for incident myocardial infarction (MI) in women exposed to modern formulations of oral contraceptives (OCs).

DESIGN

Population-based, prospective cohort study begun in 1991 with follow-up through 2002 for an average of 11 years.

PATIENT(S)

A total of 48,321 Swedish women aged 30-49 randomly selected from the population residing in the Uppsala Health Care Region of Sweden in 1990-91.

MAIN OUTCOME MEASURE(S)

Fatal and nonfatal MI ascertained through linkages with nationwide health registries for death, hospitalization, and emigration.

RESULT(S)

There were 214 incident cases of MI. Compared with never users, neither former (relative risk, 1.0; 95% confidence interval, 0.7-1.4) nor current (relative risk, 0.7; 95% confidence interval, 0.4-1.4) OC users at study enrollment had an elevated risk of future MI in models adjusted for coronary heart disease risk factors. Risk of MI was not elevated by prolonged use or in subgroups defined by characteristics of the women or types of OC.

CONCLUSION(S)

Use of OC was not associated with an increased risk of MI in this prospective study, in which most current users of OC were taking low-dose estrogen and second- or third-generation progestins.

Past oral contraceptive use and angiographic coronary artery disease in postmenopausal women: data from the National Heart, Lung, and Blood Institute–sponsored Women’s Ischemia Syndrome Evaluation

OBJECTIVE

To evaluate past oral contraceptive use and angiographic coronary artery disease in women.

SETTING

Academic medical centers.

PATIENT(S)

Six hundred seventy-two postmenopausal women enrolled in the Women's Ischemia Syndrome Evaluation (WISE) with coronary risk factors undergoing coronary angiography for suspected myocardial ischemia.

INTERVENTION(S)

Past oral contraceptive use, assessed by reproductive questionnaire.

MAIN OUTCOME MEASURE(S)

Quantitative coronary artery disease, assessed by a core angiography laboratory.

RESULT(S)

Past oral contraceptive use was associated with a lower mean coronary artery disease severity index score (mean +/- SD: 11.8 +/- 10.3 vs. 18.7 +/- 17.3) compared with non-prior users, despite age adjustment. Past oral contraceptive use remained a significant independent negative predictor of coronary artery disease severity when adjusting for coronary risk factors, including age, diabetes mellitus, triglycerides, low-density lipoprotein cholesterol, smoking, aspirin use, and lipid-lowering medication (model R2 = 0.19). The modeling indicated that past oral contraceptive use was associated with a 2.44 lower coronary artery disease severity score index. There was no apparent relationship between duration of past oral contraceptive use and the coronary artery disease severity index score.

CONCLUSION(S)

Past oral contraceptive use is associated with less coronary artery disease, measured by quantitative coronary angiography, among postmenopausal women with suspected myocardial ischemia. These findings suggest that a prospective study should address the hypothesis that past oral contraceptive use during the premenopausal years might offer women protection from atherosclerotic coronary disease later in life.

Treatment with combined oral contraceptives induces a rise in serum C-reactive protein in the absence of a general inflammatory response

BACKGROUND

The role of inflammation in the pathogenesis of cardiovascular disease is well established. C-reactive protein (CRP) is the strongest independent predictor of myocardial infarction and stroke in women. Recent studies have indicated that CRP levels are raised during use of combined oral contraceptives (COCs).

OBJECTIVES

The aim of the study was to investigate the effect of COCs on serum CRP levels and to indicate the underlying mechanisms of an expected increase.

METHOD

In a prospective randomized cross over-study 35 women used two different preparations of COC, one second and one third generation. Serum levels of CRP, serum amyloid A (SAA), interleukin-6 (IL-6), tumor necrosis factor alpha (TNFalpha), antibodies against oxidized LDL, insulin and insulin-like growth factor-I (IGF-I) along with insulin-like growth factor binding protein-1 (IGFBP-1) and IGFBP-3 were analyzed before and during the two treatments. E-selectin, von Willebrand factor and factor VIII concentrations in plasma were also measured.

RESULTS

A rise in serum CRP was observed during both treatments; the median level increased from 0.45 mg L(-1) at baseline to 1.48 mg L(-1) with second generation and to 2.02 mg L(-1) with third generation COC. The serum levels of SAA increased slightly during treatment with the third generation COC. IL-6 and TNFalpha were unaffected by treatment. Both preparations lowered IGF-I and raised IGFBP-1 and IGFBP-3 concentrations.

CONCLUSION

The raised serum CRP concentration during treatment with COCs appears to be related to a direct effect on hepatocyte CRP synthesis and does not reflect IL-6 mediated inflammation, endothelial activation or induction of insulin resistance.

Risk factors for coronary heart disease in women

The increased focus on risk factors for CHD in women has greatly improved our understanding of this disease in women. The evidence against cigarette smoking, elevated serum cholesterol, and high blood pressure is strong, and sustained campaigns are underway to prevent and appropriately manage these conditions. The importance of adequate physical activity and weight control is well established, and research continues on other emerging risk factors. The focus of future research will be on clarifying the role of these factors, particularly for women and ethnic minorities.