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Wednesday, August 06, 2014
The Risks of Hormonal Contraception: Counseling for Context
Sarah Wallett, MD
Family Planning Fellow
University of Michigan
Ann Arbor, MI
 
Oral contraceptives are the most commonly used reversible form of birth control in the United States, with 27.5% of women choosing this method. Another 7.2% of women use some other hormonal contraceptive, including injectable progestin, the contraceptive patch, or the contraceptive ring.1 Serious adverse events with the use of hormonal contraception, mainly the perceived high risk of venous thromboembolism, remain a concern for patients, clinicians, and the public. Recently, concerns regarding the risk of venous thromboembolism with drospirenone-containing combined oral contraceptives, the contraceptive patch, and the contraceptive ring have all received substantial attention in the popular press and media.
  
A new study by Bergendal et al published in the September 2014 issue of Obstetrics & Gynecology adds to the medical literature surrounding this topic.2 In this case-control study, the risk of venous thromboembolism associated with use of hormonal contraception was noted to vary by type of progestin. Risk of venous thromboembolism was also shown to be higher among users of hormonal contraception with thrombophilic mutations, including Factor V Leiden and prothrombin gene mutations.
  
As obstetrician-gynecologists, it is critical for us to stay up-to-date on the medical literature surrounding this important topic in order to provide women with the highest quality patient care. However, it is also vital for us to learn how to effectively communicate the relative risks and benefits of hormonal contraception to our patients. Although the use of hormonal contraception does increase risk of venous thromboembolic disease when compared to risk among non-pregnant nonusers, the risk remains substantially lower than the risk during pregnancy and the postpartum period.3 Placing the risk of venous thromboembolic disease within the appropriate context for our patients and the public, while elucidating the benefits of hormonal contraception—including the prevention of unplanned pregnancies and their medical and social consequences—in the discussion, is an essential part of contraceptive counseling and risk communication.4
  
Ultimately, decisions regarding the use of any hormonal contraceptive method should be left up to an individual woman and her physician, taking into account her personal preferences, any risk factors for venous thromboembolic disease, and the benefits she might experience from its use. Resources to help with this discussion that are easily accessible to patients and clinicians include the ACOG-endorsed U.S. Medical Eligibility Criteria for Contraceptive Use (available both online and downloadable as a mobile app at http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm) and the You Decide Tool Kit developed by the Association of Reproductive Health Professionals (available at http://www.arhp.org/Publications-and-Resources/Clinical-Practice-Tools/You-Decide).5
 
References
  1. Jones J, Mosher WD, Daniels K. Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. National Health Statistics Reports. 2012; no. 60. Hyattsville, MD: National Center for Health Statistics. 2012. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf. Retrieved July 25, 2014.
  2. Bergendal A, Persson I, Odeberg J, Sundstrom A, Holmstrom M, Schulman S, et al. Association of venous thromboembolism with hormonal contraception and thrombophilic genotypes. Obstet Gynecol 2014;124:600–9.
  3. Risk of venous thromboembolism among users of drospirenone-containing oral contraceptive pills. Committee Opinion No. 540. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1239–42.
  4. Jensen J. Trussell J. Communicating risk: does scientific dabate compromise safety? Contraception 2012;86:327–9.
  5. Understanding and using the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Committee Opinion No. 505. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:754–60.
About the Author

William C. Dodson, MD
William C. Dodson, MD, is Professor of Obstetrics and Gynecology and Director of the Division of Reproductive Endocrinology and Infertility at Penn State College of Medicine. He completed his fellowship in reproductive endocrinology at Duke University. His research and clinical areas of focus include treatment of infertility, especially ovulation induction. He was previously on the Editorial Board of Obstetrics & Gynecology and has served as the Consultant Web Editor for Obstetrics & Gynecology since 2008.

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