{"id":1065,"date":"2016-06-03T14:40:21","date_gmt":"2016-06-03T14:40:21","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=1065"},"modified":"2017-08-21T10:53:58","modified_gmt":"2017-08-21T10:53:58","slug":"primary-care-corner-with-geoffrey-modest-md-oral-contraceptives","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/06\/03\/primary-care-corner-with-geoffrey-modest-md-oral-contraceptives\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Oral Contraceptives"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest <\/strong><\/p>\n<p>A huge observational study was done in France looking at women on oral contraceptives (OCs), looking at the relative dose of the hormones and the risk of pulmonary embolism (PE), ischemic stroke and MI (<a href=\"http:\/\/www.bmj.com\/content\/353\/bmj.i2002\">http:\/\/www.bmj.com\/content\/353\/bmj.i2002<\/a> ).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>4,945,088 women aged 15-49 with at least one reimbursement for OCs and no prior history of cancer, PE, ischemic stroke or MI, between 2010-2012<\/li>\n<li>Mean age 28, 34% used oral contraceptive with\u00a020\u00a0mg\u00a0estrogen,<\/li>\n<li>Risk factors used in models:\u00a0age, socioeconomic data (SES), hypertension, diabetes, and some indirect measures of smoking (e.g., getting nicotine replacement therapy) though smoking\u00a0was not directly assessed\u00a0in the database. The incidence of hypertension, diabetes or being prescribed nicotine replacement therapy were each &lt;2%.<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>5,443,916 women-years of OC use<\/li>\n<li>1800 PEs (33\/100K women-years), 1046 ischemic strokes\u00a0(19\/100K women-years), 407 MIs\u00a0(7\/100K women-years)<\/li>\n<li>Women &gt;35 yo had 26.1% of all OC usage and 56.7% of these serious adverse events<\/li>\n<li>Women in the lowest SES had 1.4-fold higher risk of PE, 1.5-fold increase in stroke and 2.5-fold increase in MI<\/li>\n<li>By estrogen dose (ethinyl-estradiol), adjusting for progestogen and risk factors, and compared to levonorgestrel:<\/li>\n<li>Low dose (20\u00a0mg vs 30-40 mg): 25% decrease\u00a0PEs [RR 0.75 (0.67-0.85)]; 18% decrease ischemic strokes\u00a0[RR 0.82(0.70-0.96)]; 46% decrease in MI\u00a0[RR 0.56 (0.39-0.79)]<\/li>\n<li>By progestin type, adjusting for estrogen dose and risk factors:<\/li>\n<li>Desogestrel associated with 116% higher\u00a0risk for PE\u00a0[RR 2.16\u00a0(1.93-2.41)]; gestodene 63% higher risk\u00a0[RR\u00a01.63 (1.34-1.97)]; no significant difference for MI or stroke<\/li>\n<li>Levonorgestrel combined with\u00a020\u00a0mg estrogen was statistically better than\u00a0levonorgestrel combined with\u00a030-40\u00a0mg estrogen<\/li>\n<\/ul>\n<p>This is\u00a0an observational study, but a really large one, with several inherent\u00a0limitations:<\/p>\n<ul>\n<li>Short follow-up period of max 2 years,\u00a03 months. Likely that the arterial events (MI and stroke) take longer to manifest themselves than\u00a0PE (which might suggest that longer follow-up may have produced even more bad events with the higher doses estrogen\/use of desogestrel or gestodene)<\/li>\n<li>No start dates\u00a0(a concern since\u00a0the incidence of PE is highest early on, esp\u00a0in the first 3 months). So, unclear when people were started on\u00a0the low\u00a0dose estrogens, and in fact\u00a0these were\u00a0available in France only\u00a0more recently. However, when\u00a0analysis was limited to postpartum women who have a pretty clear\u00a0start date, the results were\u00a0similar to the\u00a0overall group<\/li>\n<li>Possible\u00a0confounding by indication: did doctors choose different OCs depending on BMI, or family predisposition to venous\/arterial disease? Or those they felt to be at higher cardiovascular risk? This bias would, however, lead to more use of lower dose OCs and would therefore likely decrease the magnitude of the protective effect found with low-dose OCs.<\/li>\n<li>One of the biggest deficiencies is the lack of clear smoking data, but again these women were likely to be put on the lowest dose OCs, which would tend to understate their risk (of note,\u00a0other studies have not found that smoking modified the risk much)<\/li>\n<li>Also, they only looked at PE, not other venous thrombotic events (e.g.,\u00a0DVTs)<\/li>\n<li>So, it seems that the stars continue to align on this (and, see blog from last year on another large study finding that\u00a0the newer OCs had much higher rates of venous thromboembolic disease:\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/06\/23\/primary-care-corner-with-geoffrey-modest-md-new-vs-old-ocps-and-thromboembolism\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/06\/23\/primary-care-corner-with-geoffrey-modest-md-new-vs-old-ocps-and-thromboembolism\/<\/a>\u00a0. To me, it makes sense to use OCs with levonorgestrel unless there is a pretty compelling reason not to, and with whatever progestogen, use the lowest dose of estrogen one can.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Oral Contraceptives  [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2016\/06\/03\/primary-care-corner-with-geoffrey-modest-md-oral-contraceptives\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-1065","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1065","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=1065"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/1065\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=1065"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=1065"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=1065"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}