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Contraception. Key slides 1 Risks of hormonal contraception Venous thromboembolism (VTE), Myocardial infarction (MI), Stroke Various cancers. The language of risk. Theme issues 27 th September 2003. See relevant NPCi floor:

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Contraception

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Contraception

Key slides 1

Risks of hormonal contraception

Venous thromboembolism (VTE), Myocardial infarction (MI), Stroke

Various cancers


The language of risk

Theme issues 27th September 2003

See relevant NPCi floor:

Information Mastery 4 - Communicating Risks & Benefitswww.npci.org.uk/therapeutics/mastery/mast4/room_mast4.php


Risks of hormonal contraceptives:venous thromboembolism (VTE)Current Problems in Pharmacovigilance 1999;25:12, Drug Safety Update Vol. 1, Issue 9, April 2008, Drug Safety Update Vol. 3, Issue 9, April 2010

  • All combined hormonal contraceptives increase risk of VTE

  • Risk associated with COCs containing desogestrel or gestodene (and possibly norgestimate, drospirenone, and the contraceptive patch Evra) is greater than that associated with COCs containing levonorgestrel

  • But, in absolute terms, risk of VTE is still low and is lower than risk in pregnancy

  • Caution when considering any COC for women who have a higher baseline risk of VTE, such as an older woman who smokes

    • see UK Medical Eligibility Criteria (UKMEC) for details www.fsrh.org/admin/uploads/UKMEC2009.pdf


Absolute risks of VTECurrent Problems in Pharmacovigilance 1999;25:12, Drug Safety Update Vol. 1, Issue 9, April 2008, Drug Safety Update Vol. 3, Issue 9, April 2010

  • Risk of VTE associated with COCs containing:

    • desogestrel or gestodene (2.5 per 10,000 woman-years)

    • levonorgestrel (1.5 per 10,000 woman-years)

  • Risk of VTE in:

    • never-users (0.5 to 1 per 10,000 woman-years)

    • pregnancy (6 per 10,000 woman-years)

  • Risk of VTE associated with Evra may be slightly higher than with second generation COCs

  • Risk of VTE associated with Yasmin somewhere between risk with second and third generation (desogestrel or gestodene) COCs

  • Cates plot on next slide shows risk per 10,000 women per 10 years, assuming constant, cumulative annual risk to permit representation


Women any age, using COCs for 10 years: risk of VTE over 10 years

see Contraception Patient Decision aid on www.npci.org.uk/pda

images produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net

These 15 women will develop VTE whether they take a COC containing desogestrel or gestodene, or a COC containing levonorgestrel. 5 to 10 of them would develop VTE if they did not take either type of COC

These 10 women will develop VTE as a result of taking a COC containing desogestrel or gestodene

These 9975 women will not develop VTE, whether or not they take a COC of either type


Risks of hormonal contraceptives: MI and stroke

Small, if any, increase in MI or stroke risk with oral contraceptive use

Important points:

  • Absolute risk of an MI or stroke in young women is very low

  • Smoking and OC use increases risk significantly

    Advice to older women

    Brechin S, Gebbie A. Perimenopausal contraception. Faculty of Family Planning and

    Reproductive Health Care of the RCOG – Review No. 2000/01

  • Healthy non-smoking women with no cardiovascular risk factors may continue to use a low-dose COC until 50 years

  • Women who smoke are best advised to discontinue COCs and find another contraceptive method at 35 years

  • See also UK Medical Eligibility Criteria (UKMEC)

    • www.fsrh.org/admin/uploads/UKMEC2009.pdf


Risks of hormonal contraceptives: cancer (1)

  • Observational data suggest oral contraceptive use does not increase a woman’s overall risk of cancer

    • oral contraceptives are associated with a reduction in both the risk of cancer and death from cancer BUT risk for individual cancers varies

      Hannaford PC, et al. BMJ 2007;335:651 and BMJ 2010;340:c927

  • Small, if any, increase in risk of breast cancer, but this is in addition to background risk which increases with age

    • current use (RR 1.24, 95%CI 1.15 to 1.33) but no increased risk 10 years after stopping (Lancet 1996; 347:1713-27)

    • RCGP oral contraception cohort study: no increased risk of breast cancer with OC use, even for many years

      (Hannaford PC, et al. BMJ 2007;335:651)


Women aged 20–24 years using COCs for five years: cumulative risk of breast cancer during use and for up to 10 years afterwards

see Contraception Patient Decision aid on www.npci.org.uk/pda

images produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net

These 16 women will be diagnosed with breast cancer whether or not they take a COC

These 2 women will be diagnosed with breast cancer as a result of taking a COC

These 9982 women will not be diagnosed with breast cancer, whether or not they take a COC


Women aged 24–29 years using COCs for five years: cumulative risk of breast cancer during use and for up to 10 years afterwards

see Contraception Patient Decision aid on www.npci.org.uk/pda

images produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net

These 5 women will be diagnosed with breast cancer as a result of taking a COC

These 44 women will be diagnosed with breast cancer whether or not they take a COC

These 9951 women will not be diagnosed with breast cancer, whether or not they take a COC


Risks of hormonal contraceptives: cancer (2)

  • Small increase in risk of cervical cancer

    (International Collaboration of Epidemiological Studies of Cervical Cancer Lancet 2007; 370:1609-21)

    • women who use COCs for 5 years from age 20 have an extra 2 cases per 10,000 of cervical cancer at age 50

    • women who use COCs for 10 years from age 20 have an extra 7 cases per 10,000 of cervical cancer at age 50

  • Encourage women to attend cervical screening

  • Girls now being vaccinated against HPV infection

    • See www.dh.gov.uk/en/Publichealth/Healthprotection/ immunisation/Keyvaccineinformation/DH_104010

  • Decrease in risk of ovarian cancer

    (Collaborative group on Epidemiological Studies of Ovarian Cancer. Lancet 2008; 371: 303-14)

    • RR 0.73, 95%CI 0.70 to 0.76 (ever vs. never use)


Women using COCs for 5 years from age 20 years: cumulative risk of cervical cancer at age 50 yearssee Contraception Patient Decision aid on www.npci.org.uk/pdaimages produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net

These 38 women will be diagnosed with cervical cancer whether or not they take a COC

These 2 women will be diagnosed with cervical cancer as a result of taking a COC

These 9960 women will not be diagnosed with cervical cancer, whether or not they take a COC


Summary

  • All combined hormonal contraceptives increase risk of VTE. But, in absolute terms, risk of VTE is still low and lower than risk in pregnancy

  • Small, if any, increase in MI or stroke risk with oral contraceptive use – again absolute risks in younger women remain very low

  • Overall, observational data suggest oral contraceptives reduce risk of, and death from, cancer – but risk for individual cancers vary:

    • Small, if any, increase in risk of breast cancer, but in addition to background risk which increases with age

    • Small increase in risk of cervical cancer – women should participate in usual screening programmes, and girls should be vaccinated

    • Decrease in risk of ovarian cancer


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