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Hamostaseologie 2019; 39(01): 042-048
DOI: 10.1055/s-0039-1677806
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Birth Control Pills and Thrombotic Risks: Differences of Contraception Methods with and without Estrogen

Hannelore Rott
1   Coagulation Center Rhein-Ruhr, Duisburg, Germany
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Publication History

29 November 2018

08 January 2019

Publication Date:
22 January 2019 (online)

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Abstract

In Germany one-third of the women in fertile age use combined oral contraceptives (COCs), which consist mostly of ethinylestradiol (EE) and a synthetic progestin. Older COCs with norethisterone or levonorgestrel have a lower risk for venous thromboembolism (VTE) than newer COCs with desogestrel, drospirenone, or gestodene. This is also true for nonoral combined hormonal contraceptives. The risk of newer COCs containing estradiol instead of EE is not clear due to missing data. Progestin-only hormonal contraception is not associated with a significant increase of the risk for VTE with the exception of depot medroxyprogesterone acetate. Emergency contraceptions, which do not contain EE, but only levonorgestrel or ulipristal acetate, do not result in a higher risk for VTE. Oral desogestrel- or levonorgestrel-only contraceptives, intrauterine device, and etonogestrel implants are the contraception of choice in women with a history of VTE and/or suffering from thrombophilia. These safe contraceptives should be offered to women with high risk of VTE due to the much higher VTE risk in pregnancy and postpartum. The screening for thrombophilia is not indicated in every woman with the wish for contraception. This should be restricted to certain cases, for example to women with a positive history for VTE or with close relatives suffering from VTE in younger than 50 years.

Zusammenfassung

Etwa 20 Millionen Frauen befinden sich aktuell im reproduktiven Alter. Ein Drittel von ihnen wendet kombinierte hormonelle Kontrazeptiva an (COC), welche meist aus Ethinylestradiol und einem synthetischen Gestagen bestehen. Das Grundrisiko für venöse Thromboembolien (VTE) für Frauen im reproduktiven Alter ist gering, steigt aber deutlich an durch Anwendung von COC oder auch in der Schwangerschaft/Wochenbett. Dies gilt auch für nichtorale COC. Hierdurch haben junge Frauen ein merklich höheres VTE Risiko als Männer bis zum Alter von 35 Jahren, danach gleicht sich das VTE-Risiko zwischen den Geschlechtern an.

Die Erhöhung des VTE Risikos hängt vom verwendeten COC ab. Ältere COC mit Norethisteron oder Levonorgestrel als Gestagen haben ein niedrigeres VTE-Risiko als neuere COC. In vielen internationalen Leitlinien gelten daher mittlerweile die älteren COC als erste Wahl. Neuere COC sollten daher nur noch verordnet werden, wenn besondere Gründe hierfür vorliegen. Das VTE-Risiko von COC mit Estradiol bzw. Estradiolvalerat statt EE ist noch ungeklärt. Die Anwendung von rein gestagenhaltiger Kontrazeption erhöht das VTE-Risiko nicht signifikant mit Ausnahme von Depot-Medroxyprogesteronacetat (DMPA). Die Notfallkontrazeption („Pille danach“), welche keine Östrogene, sondern nur Levonorgestrel bzw. Ulipristalacetat enthalten, erhöhen das VTE-Risiko nicht.

Orale reine Gestagenkontrazeptiva (mit Desogestrel oder Levonorgestrel), Intrauterine Kontrazeption und Etonogestrel Implantate sind die Verhütungsmittel der Wahl bei Frauen mit erhöhtem VTE-Risiko.

Ein Thrombophilie-Screening ist nicht bei jeder Frau mit Kontrazeptionswunsch indiziert. Diese Testung sollte auf Frauen mit positiver VTE Eigenanamnese oder auf Frauen mit VTE-Fällen in der nächsten Verwandtschaft im Alter von unter 50 Jahren limitiert werden.

Keywords

venous thromboembolism - combined contraception - emergency contraception - pregnancy

Schlüsselwörter

venöse Thromboembolie (VTE) - Thrombose - kombinierte Kontrazeptiva - Gestagene - reine Gestagen-Kontrazeptiva - Notfall-Kontrazeption - Schwangerschaft
 

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