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  • Title: [Combined contraceptives and cardiovascular risk].
    Author: Belaisch J, Hommais-loufrani B.
    Journal: Contracept Fertil Sex (Paris); 1987 Dec; 15(12 Suppl):1-8. PubMed ID: 12315199.
    Abstract:
    The main concern of physicians prescribing oral contraceptives (OCs) is the possibility of cardiovascular accidents, not because of their number but of their seriousness. Cardiovascular risk affects primarily women over 35. A 1986 survey of 600 physicians indicated that avoiding cardiovascular risk was their main objective when prescribing pills, with avoidance of modifications in lipid and glucose metabolism virtually as great a concern. Less than 50% were concerned with functional symptoms such as spotting which can be managed by therapeutic adjustments. Numerous cofactors participate in cardiovascular risk, including family history, life style, and intercurrent illness. The frequency of vascular accidents is only slightly higher among OC users than in the control population. Numerous Anglo-Saxon studies have found the risk of deep venous thrombosis to be multiplied by 4 or 5 for OC users and of superficial thrombosis to be multiplied by 2 or 3. Age and obesity play no role in the increased risk for OC users, smoking has a minor role, and family history and bed rest are the only major cofactors. Risk of venous thrombosis under OC use does not depend on duration of use and disappears the month after termination of use. The synthetic estrogen is primarily responsible because of the modifications it produces on coagulation factors. OC use increases the risk of coronary accidents by 3 or 4. 3 hypotheses have been advanced to explain the pathogenic mechanism: classic atherogenesis, alteration of the intima, or immunological factors. Atheromatous arterial accidents are related to age, smoking, problems of glucose or lipid metabolism, and blood pressure. The factors have a synergistic effect on each other. Risks increase with duration of use and dose level, and depend also on the biochemical properties of the estrogen and progestin. Some accidents in young women about 30 years old show no relation to duration of use or dose. The only elements differentiating the women involved are smoking, family histories of vascular accidents, and intense headaches in the days before a cerebrovascular accident. They seem to be associated not with atherogenesis but with thickening of the intima secondary to a proliferation of smooth muscle cells with subendothelial fibrosis. 90% of OC users experiencing vascular accidents have been found to have anti-ethinyl estradiol antibodies, compared to 30% of users never having vascular accidents and no nonusers. The practical import of this finding remains undetermined. Under some circumstances the causes of headaches should be investigated and OC use should be terminated. Careful attention to patient selection and development of new progestins with fewer androgenic and metabolic effects should reduce cardiovascular risks from OCs to a minimum. The new synthetic progestin gestodene has given very satisfactory results in a triphasic formulation and should be on the market soon.
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