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  • Title: Contraceptive Steroids, age, and the cardiovascular system.
    Author: Plunkett ER.
    Journal: Am J Obstet Gynecol; 1982 Mar 15; 142(6 Pt 2):747-51. PubMed ID: 7065055.
    Abstract:
    There is evidence that women who use oral contraceptives may be at slightly greater risk of cardiovascular complications as their age increased beyond 35 years. Popular opinion has held that these risks were largely estrogen-related. At the same time, however, postmenopausal women taking natural estrogen alone or in association with minimal amounts of progestogen have not exhibited these increased risk when compared with untreated control subjects. New clinical data indicate that there is a progestogen dose-related decrease in high-density lipoprotein cholesterol. There is also some evidence that relates progestogen dosage to morbidity rates from circulatory disease. Therefore the smallest dose of both estrogen and progestogen consistent with contraceptive efficacy and reasonable cycle control must be sought for all steroid combinations. This applies particularly to oral contraception for the woman beyond 35 years of age. Evidence suggests that cardiovascular complications may develop in oral contraceptive (OC) users as their age increases beyond 35 years. This paper reviews the risks, clinical problems, and possible solutions for women who require estrogens or estrogens/progestogens after age 35. Tietze and Lewit pointed out the increasing risks associated with pregnancy and increasing age. Nonsmoking OC users aged 15-29 were found to have a mortality rate between 0.6-1.6/100,000 woman years, increasing to 9 and 17.7 in the 35-39 and 40-44 age groups respectively. A combination of smoking and pill use increases the risks in the latter 2 groups to 31.3 and 60.9 respectively. The Royal College of General Practitioners (RCGP) study published mortality data in 1977 based on 56 OC users and 43 controls. Major causes of death among the users were circulatory with a relative risk (RR) of 4.7 over the controls. The RR rose to 9.7 when OC use lasted more than 5 years. A 1981 RCGP report of the mortality data of 156 "ever users" and 93 controls again showed circulatory complications as the major problem, with an overall RR of 4.2. Overall mortality rate from all causes was 87.7 in the OC group and 64.4 in the controls; relative overall risk was 1.4. In March 1981, Vessey et al., of the Oxford Family Planning Association Study, reported that of the 81 deaths reviewed, OC users showed a mortality rate of 12.3/100,000 woman/years compared to 29.9 in the RCGP report. Other studies showed no increased risk of OC use for certain cardiovascular diseases (Walnut Creek Contraceptive Drug Study, Nachtigall et al., Hammon et al.). The most significant complication of OC use is the increased risk of circulatory diseases; smoking and age are 2 of the most consistent and significant contributing risk factors. Surgical sterilization is the safest and most practical approach for the more mature woman who needs contraception. Others may use IUDs and other barrier method with therapeutic abortion as backup. Older women who need steroid contraceptives should be checked for existing risk factors, advised to stop smoking, followed closely, and given the lowest progestin dose. In postmenopausal women, the addition of progestogen may reduce the risk of developing endometrial carcinoma.
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