Venous thromboembolism in women using hormonal contraceptives

Summary

There is scarce information on the clinical characteristics of contraceptive users who develop venous thromboembolism (VTE). RIETE is an ongoing registry of consecutive patients with symptomatic, objectively confirmed, acute VTE. We analyzed the clinical characteristics and additional risk factors for VTE in all enrolled women aged <50 years who were using or not using contraceptives at presentation with VTE. Of 1,667 women aged <50 years enrolled in RIETE as of December 2007, 593 (36%) were contraceptive users. Of 270 aged <25 years, 190 (70%) were users. Ninety-two contraceptive users (16%) had over-weight, 89 (15%) were obese. Of 951 women with no additional risk factors for VTE (i.e. recent surgery, immobility or cancer) 457 (48%) were contraceptive users. Eighty-seven (15%) users had recent immobility for ≥4 days, 44 (7.4%) were postoperative. The most common reason for immobility was lower limb trauma not requiring surgery; 25% of users with recent immobility had received thromboprophylaxis. The most common type of surgery was non-major orthopaedic surgery. Twenty-one (48%) users with postoperative VTE had received prophylaxis. The percentage of users and non-users who tested positive for thrombophilia was similar. Contraceptive use remains the most frequent risk factor for VTE in women at fertile age. Identifying those at increased risk for VTE seems to be difficult. In the meanwhile, a higher use of thromboprophylaxis during immobility or minor surgery should be warranted.

Keywords

Contraceptives - venous thromboembolism - prevention

• References

• 1 Sidney S, Petitti DB, Soff GA. et al. Venous thromboembolic disease in users of low-estrogen combined estrogen-progestin oral contraceptives. Contraception 2004; 70: 3-10.
• 2 WHO.. Cardiovascular disease and steroid hormone contraception. Report of a WHO Scientific group. WHO Technical Report Series 877. Geneva: WHO; 1998. pp. 1-89.
• 3 Battaglioli T, Martinelli I. Hormone therapy and thromboembolic disease. Curr Opin Hematol 2007; 14: 488-493.
• 4 Kemmeren JM, Algra A, Grobbee DE. Third generation oral contraceptives and risk of venous thromboembolism: meta-analysis. Br Med J 2001; 323: 131-134.
• 5 Lidegaard O, Edström B, Kreiner S. Oral contraceptives and venous thromboembolism: a five-year national case-control study. Contraception 2002; 65: 187-196.
• 6 Gomes MPV, Deitcher SR. Risk of venous thromboembolic disease associated with hormonal contraceptives and hormone replacement therapy. A clinical review. Arch Intern Med 2004; 164: 1965-1976.
• 7 Cushman M, Glynn RJ, Goldhaber SZ. et al. Hormonal factors and risk of recurrent venous thrombosis: the Prevention of Recurrent Venous Thromboembolism trial. J Thromb Haemost 2006; 4: 2199-2203.
• 8 Cole JA, Norman H, Doherty M. et al. Venous thromboembolism, myocardial infarction, and stroke among transdermal contraceptive system users. Obstet Gynecol 2007; 109: 339-346.
• 9 Abdollahi M, Cushman M, Rosendaal FR. Obesity: risk of venous thrombosis and the interaction with coagulation factor levels and oral contraceptive use. Thromb Haemost 2003; 89: 493-498.
• 10 Pomp ER, le Cessie S, Rosendaal FR. et al. Risk of venous thrombosis : obesity and its joint effect with oral contraceptive use and prothrombotic mutations. Br J Haematol 2007; 139: 289-296.
• 11 Canonico M, Plu-Bureau G, Lowe GD, Scarabin PY. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. Br Med J 2008; 336: 1227-1231.
• 12 Monreal M, Falgá C, Valle R. et al., for the RIETE Investigators. Venous thromboembolism in patients with renal insufficiency. Findings from the RIETE Registry. Am J Med 2006; 119: 1073-1079.
• 13 Falgà C, Capdevila JA, Soler S. et al., for the RIETE Investigators. Clinical outcome of patients with venous thromboembolism and renal insufficiency. Findings from the RIETE Registry. Thromb Haemost 2007; 98: 771-776.
• 14 Blanco-Molina A, Trujillo-Santos J, Criado J. et al., and the RIETE Investigators. Venous thrombo-embolism during pregnancy or postpartum: Findings from the RIETE Registry. Thromb Haemost 2007; 97: 186-190.
• 15 Ruiz-Giménez N, Suárez C, González R. et al., and the RIETE Investigators. Predictive variables for major bleeding in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost 2008; 100: 26-31.
• 16 Laporte S, Mismetti P, Décousus H. et al. and the RIETE investigators. Predictive factors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism. Findings from the RIETE registry. Circulation 2008; 117: 1711-1716.
• 17 ACOG Practice Bulletin N 73.. Use of hormonal contraception in women with coexisting medical conditions Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol 2006; 107: 1453-1472.
• 18 Bloemenkamp KWM, Rosendaal FR, Helmersorst FM. et al. Higher risk of venous thrombosis during early use of oral contraceptives in women with inherited clotting defects. Arch Intern Med 2000; 160: 49-52.
• 19 Scarabin P-Y, Oger E, Plu-Bureau G. for the ESTHER study group. Differential association of oral and transdermal oestrogen-replacement therapy with venous thromboembolism risk. Lancet 2003; 362: 428-432.
• 20 Geerts WH, Bergqvist D, Pineo GF. et al. Prevention of venous thromboembolism. American College of Chest Physicians Evidence-based Clinical Practice Guidelines (8^th Edition). Chest 2008; 133: 381s-453s.
• 21 ACOG Practice Bulletin N 73.. Use of hormonal contraception in women with coexisting medical conditions Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol 2006; 107: 1453-1472.