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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 l.jpg

Contraception

Key slides 1

Risks of hormonal contraception

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

Various cancers


The language of risk l.jpg

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


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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


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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


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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


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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


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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)


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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


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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


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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)


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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


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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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