CEREBROVASCULAR ACCIDENTS AND ORAL CONTRACEPTION

Contraceptives and Thrombosis: An Intertwined Revolutionary Road

The development of oral contraceptives (OCs) began in 1921 and continued in the following years until the first regulatory approval from the Food and Drug Administration was granted in 1960. However, it took several years to realize that OCs presented an important but not frequent risk of venous thrombosis. Several reports ignored this dangerous effect and only in 1967 the Medical Research Council clearly stated this as an important risk. Later, research led to the formulation of second-generation OCs containing progestins, which nevertheless presented an increased thrombotic risk. In early 1980s, OCs containing third-generation progestins were introduced into the market. Only in 1995, it became clear that these new compounds induced a higher thrombotic risk than that related to the second-generation progestins. It appeared clear that the modulating action of progestins was against the procoagulant activity of estrogens. Lastly, at the end of the 2000s, OCs containing natural estrogens and a fourth-generation progestin (dienogest) became available. The prothrombotic effect of those natural products was not different from that of preparations containing second-generation progestins. Moreover, research over the years has produced much data on risk factors associated with OCs use such as age, obesity, cigarette smoking, and thrombophilia. These findings allowed us to better assess the individual thrombotic risk (both arterial and thrombotic) of each woman before offering an OC. Furthermore, research has shown that in high-risk people the use of single progestin is not dangerous as far as thrombosis is concerned. In conclusion, the OCs road has been long and difficult but has led to a great and unthinkable scientific and social enrichment since the 1960s.

Spontaneous bilateral recanalization in bilateral internal carotid artery occlusion

The authors report a young woman with bilateral internal carotid artery occlusion shown by carotid angiography. There was spontaneous bilateral recanalization demonstrated radiographically. The possible causes, e.g. the intake of oral contraceptive drugs, a spontaneous intimal dissection and other etiological features are discussed and the literature is reviewed.

Use of oral contraceptives, cigarette smoking, and risk of subarachnoid haemorrhage

In a large cohort of women, the risk of subarachnoid haemorrhage was significantly associated both with cigarette smoking and with use of oral contraceptives (O.C.S.). The risk of cigarette smokers was 5.7 times that of non-smokers; for current users of O.C.S. the risk was 6.5 times that of non-users. The risk in women who both smoked cigarettes and used O.C.S was 22 times that of women who neither smoked nor used O.C.S. Past use of O.C.S was also significantly associated with increased risk of subarachnoid haemorrhage, the relative risk being 5.3. There was some evidence that risk may increase with duration of O.C. use. In this series no significant associations were found between occurrence of subarachnoid haemorrhage and history of hypertension or of migraine headache.

Involuntary movements in patients taking oral contraceptives

Involuntary movements developed in five women taking oral contraceptives. In one, the sudden onset of a unilateral disturbance suggested a cerebral thrombosis; this case is considered to be a further example of the increased risk of cerebrovascular disease associated with oral contraception. The four other patients suffered a relapse of Sydenham's chorea between one and four months after starting an oral contraceptive regimen. Possibly an underlying vascular mechanism was responsible for these relapses.

Twelve cases of fatal cerebral infarction due to arterial occlusion in the absence of atheromatous stenosis or embolism

Images

Ocular Manifestations After Enovid

Presented is a case of bilateral retinal edema in a patient with a ventricular septal defect. The edema absorbed after cessation of Enovid and treatment with ACTH. It is hoped that this case presentation will stimulate the reporting by ophthalmologists of any similar experience.