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Obstetrics and Gynecology. 2008 Sep; 112(3):572-8.OBJECTIVE: To estimate how well a convenience sample of women from the general population could self-screen for contraindications to combined oral contraceptives using a medical checklist. METHODS: Women 18-49 years old (N=1,271) were recruited at two shopping malls and a flea market in El Paso, Texas, and asked first whether they thought birth control pills were medically safe for them. They then used a checklist to determine the presence of level 3 or 4 contraindications to combined oral contraceptives according to the World Health Organization Medical Eligibility Criteria. The women then were interviewed by a blinded nurse practitioner, who also measured blood pressure. RESULTS: The sensitivity of the unaided self-screen to detect true contraindications was 56.2% (95% confidence interval [CI] 51.7-60.6%), and specificity was 57.6% (95% CI 54.0-61.1%). The sensitivity of the checklist to detect true contraindications was 83.2% (95% CI 79.5-86.3%), and specificity was 88.8% (95% CI 86.3-90.9%). Using the checklist, 6.6% (95% CI 5.2-8.0%) of women incorrectly thought they were eligible for use when, in fact, they were contraindicated, largely because of unrecognized hypertension. Seven percent (95% CI 5.4-8.2%) of women incorrectly thought they were contraindicated when they truly were not, primarily because of misclassification of migraine headaches. In regression analysis, younger women, more educated women, and Spanish speakers were significantly more likely to correctly self-screen (P<.05). CONCLUSION: Self-screening for contraindications to oral contraceptives using a medical checklist is relatively accurate. Unaided screening is inaccurate and reflects common misperceptions about the safety of oral contraceptives. Over-the-counter provision of this method likely would be safe, especially for younger women and if independent blood pressure screening were encouraged.
Geneva, Switzerland, WHO, Department of Reproductive Health and Research, 2007.  p. (Provider Brief)Hormonal contraceptives, which include birth control pills, injections, implants, the patch and the vaginal ring, all use hormones to keep a woman from getting pregnant. These hormones can have other health effects for women, many of them beneficial, besides just preventing pregnancy. However, some questions have been raised about how particular hormonal contraceptives, DMPA (depot medroxyprogesterone acetate with trade names of Depo-Provera, Depo-Clinovir and others) and NET-EN (norethisterone enantate or Noristerat, Norigest, Doryxas and others), may affect the health of women's bone. (excerpt)
Contraception. 2006 May; 73(5):443-444.Steroid hormonal contraceptives, including oral contraceptives, injectables and implants, are highly effective and widely used. These contraceptives have important health benefits, including contraceptive and noncontraceptive benefits, and some health risks. For most women, the health benefits of use clearly exceed the health risks. Questions have been raised regarding the association between use of one particular hormonal contraceptive, depot medroxyprogesterone acetate (DMPA) and the risk of bone loss. In response, WHO convened a consultation in Geneva, on June 20-21, 2005, to assess current evidence on the relationship between the use of steroid hormonal contraceptives and bone health. (excerpt)
Contraception. 2006 Feb; 73(2):154-165.Previous research has suggested that hormonal contraceptive users, compared with nonusers, may be at increased risk for acquiring sexually transmitted infections (STIs). We searched the MEDLINE and EMBASE databases for all articles from January 1966 through February 2005 for evidence relevant to all hormonal contraceptives and STIs (including cervical chlamydial and gonococcal infection, human papillomavirus, trichomoniasis, herpes and syphilis). We used standard abstract forms and grading systems to summarize and assess the quality of 83 identified studies. Studies of combined oral contraceptive and depot medroxyprogesterone use generally reported positive associations with cervical chlamydial infection, although not all associations were statistically significant. For other STIs, the findings suggested no association between hormonal contraceptive use and STI acquisition, or the results were too limited to draw any conclusions. Evidence was generally limited in both amount and quality, including inadequate adjustment for confounding, lack of appropriate control groups and small sample sizes. The observed positive associations may be due to a true association or to bias, such as differential exposure to STIs by contraceptive use or increased likelihood of STI detection among hormonal contraceptive users. (author's)
Use of combined oral contraceptives among women with migraine and nonmigrainous headaches: a systematic review.
Contraception. 2006 Feb; 73(2):189-194.This systematic review examines evidence evaluating whether women with headaches who use combined oral contraceptives (COCs) have a greater risk of stroke than women with headaches who do not use COCs. We searched MEDLINE for articles published from 1966 through March 2005 relevant to headaches and COC use as risk factors for stroke. Of the 79 articles identified, nine met our selection criteria (eight reports of six observational studies plus one meta-analysis). All studies reported specifically on migraine headaches. Evidence from six case-control studies suggested that COC users with a history of migraine were two to four times as likely to have an ischemic stroke as nonusers with a history of migraine. The odds ratios for ischemic stroke ranged from 6 to almost 14 for COC users with migraine compared with nonusers without migraine. The three studies that provided evidence on hemorrhagic stroke reported low or no risk associated with migraine or with COC use. (author's)
Contraception. 2006 Feb; 73(2):179-188.Women with hypertension are at increased risk for cardiovascular events. Combined oral contraceptive (COC) use, even among low-dose users, has been associated with a small excess risk for cardiovascular events among healthy women. In this systematic review, we examined cardiovascular risks among COC users with hypertension. After searching MEDLINE for all articles published from 1966 through February 2005 relevant to COC use, hypertension and cardiovascular disease, we identified 25 articles for this review. Overall, these studies showed that hypertensive COC users were at higher risk for stroke and acute myocardial infarction (AMI) than hypertensive non-COC users, but that they were not at higher risk for venous thromboembolism (VTE). Women who did not have their blood pressure measured before initiating COC use were at higher risk for ischemic stroke and AMI, but not for hemorrhagic stroke or VTE, than COC users who did not have their blood pressure measured. (author's)
Current Opinion in Obstetrics and Gynecology. 2004 Feb; 16(1):27-29.The issue of whether there might be an increased risk of cervical cancer associated with the use of oral contraceptives has been debated for decades. Early studies found a modest association with long-term use. A literature review was performed over the past 3 years, to establish whether there is any new evidence linking cervical cancer with the use of oral contraceptives. A new analysis from eight studies conducted by the International Agency for Research on Cancer and a systematic review of cervical cancer and the use of hormonal contraceptives are two recent major epidemiological links strongly suggesting the increased risk of cervical cancer (up to twofold), but only for women who were both long-term users (5 years or more) and who had persistent human papilloma virus infections of the cervix. These findings seem biologically plausible, but weighing the various risks and benefits, the World Health Organization does not recommend any change in oral contraceptive use or practice. (author's)
Geneva, Switzerland, WHO, 2002 Apr 3.  p.Whether use of oral contraceptives is causally associated with an increased risk of cervical cancer has long been debated and remains uncertain. On 11 March 2002, WHO’s Department of Reproductive Health and Research convened an international group of experts to review new information on the subject, including research findings from WHO’s International Agency for Research on Cancer (IARC) and several reviews commissioned by WHO. The reviews included a meta-analysis of existing published epidemiological data on the association between combined oral contraceptive use and the risk of cervical cancer; a summary of the biological basis for any association between oral contraceptives and cervical cancer; and a mathematical model assessing risks and benefits of different contraceptive methods. Questions about the relationship between oral contraceptive use and the risk of cervical cancer were addressed in 1990 as part of a comprehensive review of steroid hormone contraception and neoplasia. One of the main conclusions of the 1990 review was that use of oral contraceptives for more than 5 years was associated with a modest (1.3- to 1.8-fold) increased risk of cervical cancer, but that it was unclear whether the increased risk reflected a biological relationship or was attributable to other factors (such as lifestyle differences between users of different contraceptive methods, including differential risk of sexually transmitted infections, particularly Human Papillomavirus [HPV] infection). (excerpt)
Geneva, Switzerland, WHO, 1978. (World Health Organization Technical Report Series No. 619) 54 pStudies on steroid contraception (SC) and risk of neoplasia are reviewed. Methodological issues in neoplasia etiology studies include: 1) possibility of a latent period between exposure to cause and disease development; 2) cumulative effects of prolonged or repeated SC exposure; 3) discontinued drugs or dosage schedules; 4) time of exposure (adolescence or prenatal, e.g.); 5) isolation of specific causes among multiple risks; and 6) variations in neoplasma diagnoses. The 4 epidemiological approaches to SC-associated neoplasia studies have inherent shortcomings, but cohorts yield significant associations. Relative risk (ratio of disease incidence among exposed vs. nonexposed persons) is an index of association only, not evidence of cause and effect. Benign breast neoplasia risk was reduced by current SC use of >2 years, and weak evidence points to a residual protective effect, apparently associated with progestogen dose. Aggregated breast cancer data show no clear adverse or beneficial effect of SC use; however, evidence suggests SCs may increase breast cancer risk in population subgroups (e.g., young women). Only short-term evidence is available; hence, no inference of long-term SC breast cancer effects is possible. No beneficial effect of SCs on uterine fibroids is evident, but sequential SCs, no longer marketed, may have increased risk to endometrial carcinoma. Inconclusive data suggest SCs may decrease ovarian cancer risk. Increased risk of cervical dysplasia and carcinoma in situ is associated with SC use, especially long-term use by women with predisposing factors. Risk of hepatocellular adenoma of the liver increases with prolonged SC exposure, especially high dose. Relevance of existing data from more developed countries to disease risk in less developed ones is discussed, and recommendations made.
Obstetrics and Gynecology. 2002 Jun; 99(6):1100-1112.The objective of this study is to review new evidence regarding 10 controversial issues in the use of contraceptive methods among women with special conditions and to present WHO recommendations derived in part from this evidence. The authors searched MEDLINE and PREMEDLINE databases for English-language articles, published between January 1995 and December 2001, for evidence relevant to 10 key contraceptive method and condition combinations: combined oral contraceptive (OC) use among women with hypertension or headaches, combined OC use for emergency contraception and adverse events, progestogen-only contraception use among young women and among breastfeeding women, tubal sterilization among young women, hormonal contraception and IUD use among women who are HIV positive, have AIDS, or are at high risk of HIV infection. Search terms included: "contraception," "contraceptives, oral," "progestational hormones," "medroxyprogesterone-17" acetate," "norenthindrone," "levonorgestrel," "Norplant," "contraceptives, postcoital," "sterilization, tubal," "IUDs," "hypertension," "stroke," "myocardial infarction," "thrombosis," "headache," "migraine," "adverse effects," "bone mineral density," "breastfeeding," "lactation," "age factors," "regret," and "HIV". From 205 articles, the authors identified 33 studies published in peer-reviewed journals that specifically examined risks of contraceptive use among women with pre-existing conditions. Combined OC users with hypertension appear to be at increased risk of myocardial infarction and stroke relative to users without hypertension. Combined OC users with migraine appear to be at increased risk of stroke relative to non-users with migraine. The evidence for the other eight method and condition combinations was either insufficient to draw conclusions or identified no excess risk. Of the 10 contraceptive method and condition combinations assessed, the evidence supported an increased risk of cardiovascular complications with combined OC use by women with hypertension or migraine. As a new evidence becomes available, assessment of risk and recommendations for use of contraceptive methods can be revised accordingly. (author's)
WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES.. 1998; (877):v-vii, 1-89.This report presents conclusions and recommendations of the WHO Scientific Group relating to various cardiovascular diseases in women of reproductive age, particularly those using steroid hormone contraception. Chapter 1 presents an introduction on the subject, while chapter 2 describes the epidemiological approaches used to examine the safety of steroid contraceptives and the measurement and interpretation of relative and absolute risks. It also discusses the epidemiological evaluation of the cardiovascular effects of the hormonal contents of combined oral contraceptives (COCs). Chapters 3 to 7 examine data on acute myocardial infarction, ischemic and hemorrhagic stroke, and venous thromboembolism obtained from case-control and cohort studies. Chapter 8 reviews possible biological mechanisms for cardiovascular effects of COCs, including the interplay between glucose and insulin metabolism, lipid and lipoprotein metabolism, the hemostatic system, and blood pressure. Chapter 9 studies the factors which may increase the risk of cardiovascular diseases from COC use and presents a model for assessing the risk of cardiovascular disease among users of COC in different parts of the world. Moreover, this chapter looks at the other considerations concerning the safety of COCs, including the role of screening in reducing the risk of cardiovascular disease, as well the importance of disseminating research findings. This report ends with recommendations for further research.
The use of a large-scale surveillance system in Planned Parenthood Federation of America clinics to monitor cardiovascular events in users of combination oral contraceptives.
International Journal of Fertility and Women's Medicine. 1999 Jan-Feb; 44(1):19-30.In response to studies reporting an excess of thrombotic events in women who used oral contraceptives (OCs) containing third-generation progestins, the Planned Parenthood Federation of America (PPFA) launched a retrospective review of clients at all PPFA-affiliated centers during 1993-95. During the 3-year study period, 2,265,087 woman-years of OC use were recorded in clinic drug sale records. All OCs prescribed in this period contained 30 or 35 mcg of estrogen and either norgestimate (21.0%), desogestrel (8.9%), norethindrone (46.6%), or levonorgestrel (23.6%) as the progestin. 70 major thrombotic events among clients using OCs (3 vascular complications per 100,000 woman-years of OC use) were reported to PPFA's risk management division during 1993-95; these included 25 cases of deep vein thrombosis, 20 cases of pulmonary embolism, 22 cerebrovascular accidents, and 3 myocardial infarctions. There were 5 deaths (0.22/100,000 woman-years of use), all from pulmonary emboli. The thrombotic event rates were calculated as the relative risk of complication, comparing the risk of each event for one progestin relative to the other three classes of progestins. The overall risk varied from a low of 1.895 events/100,000 woman-years for norgestimate OC users to a high of 3.969 events/100,000 woman-years for desogestrel OC users, but these differences were not statistically significant. In the progestin comparison, desogestrel users showed elevated risks for pulmonary emboli and fatalities, norgestrel use was associated with an increased risk of deep vein thrombosis, and norgestimate an increased risk of deep vein thrombosis and pulmonary embolism. Generally, these four groups of low-dose OCs appear safer than any previously published study has indicated. In part, this may reflect PPFA's careful prescribing guidelines. In addition to following US Food and Drug Administration contraindications, PPFA affiliates do not provide OCs to women over 35 years of age who smoke more than 15 cigarettes a day.
SEXUALIDADE E PLANEAMENTO FAMILIAR. 1995 Jul-Sep; (7):17-8.The Portuguese Association of Family Planning has learned about a study of the World Health Organization that associated certain types of combined oral contraceptives (OCs) with an increased risk of cardiovascular diseases, notably deep venous thrombosis. The position of the International Medical Advisory Panel (IMAP) of the IPPF, however, was that such conclusions were not definitive and new studies should be conducted to confirm or refute these conclusions. Furthermore, since the risk is rare, those using OCs should have regular medical examinations. For the majority of OC users the benefits outweigh the risks. The author of one of the two studies that hinted at the cardiovascular risks of third-generation progestagens stated that the British authorities incorrectly interpreted the data, which were preliminary. In fact, these data suggest that the new generation of OCs protects against cardiac attack and associated mortality. Even the WHO took the position that these results should be confirmed by independent studies. The polemic mounted when the British authorities issued an alert about the possible negative effects of seven types of OCs containing progestagens which putatively doubled the risk of venous thrombosis. This was based on the findings of three studies: two of them were incomplete, one was done at the initiative of the WHO, one was carried out in Europe, and the third one was done in the UK. At the meeting of the Committee of Pharmaceutical Specialties of the European Agency of Medicaments in October 1995 in London the position was taken that it is not appropriate to withdraw such OCs; investigators should analyze these data in depth and perform new studies; the three companies that manufacture such OCs should submit more information by the end of 1995; and physicians should take into account thromboembolic risk factors when prescribing such OCs.
Invasive cervical cancer and combined oral contraceptives. WHO Collaborative Study of Neoplasia and Steroid Contraceptives.
BMJ. British Medical Journal. 1985 Mar 30; 290(6473):961-5.This paper presents the preliminary results of a multicenter case-control study conducted under the auspices of the World Health Organzation to determine whether combined oral contraceptives (OCs) increase the risk of malignant neoplasms of the breast, cervix, endometrium, ovary, and liver. Initial results on the relationship between combined OCs and invasive cervical carcinoma in 726 cases and 5246 controls indicate a relative risk of 1.19 (95% confidence interval, 0.99-1.44) in women who had ever used OCs. The risk increased to 1.53 after 5 years of OC use. The analysis made adjustments for various potentially confounding variables, including age, center, number of pregnancies, age at 1st intercourse, number of sexual relations, and history of vaginal discharge. The relative risk obtained in this study, of borderline significance, could be explained on the basis of incomplete control for the confounding effect wf sexual variables. In addition, the implications of these findings for women who are currently using combined OCs are uncertain; most wf the women in this study were exposed to preparations containing higher doses of estrogen and progestogens than products now in use. Future analyses of data from this investigation, bases on lager numbers of patents, will include controls for smoking and infection by sexually transmitted agents.
Indian Journal of Medical Research. October 1978; 68(Suppl):80-87.Cross-sectional and longitudinal studies were made to assess vitamin nutritional status of women using oral contraceptives (OCs). In the cross-sectional study, data obtained on 20 women, who had used Ovulen 50 for 6-12 months, were compared with data obtained on matched controls who had never used OCs. In the longitudinal study, 23 women were examined initially (before OC use) and again at 1 or more points during the next 6 months of OC use. Changes were found in several parameters of nutrition tested. 1) OC use produced a highly significant rise in plasma vitamin A within 1 month of treatment. 2) Thiamine activity measurements showed a slight fall, but did not affect the TPP effect, suggesting that OCs did not seriously alter thiamine status. 3) Erythrocyte riboflavin concentration showed a fall, revealing a very high incidence (> 80%) of biochemical riboflavin deficiency in women before starting OCs which was further reduced after treatment. 4) There was a marked rise in urinary excretion of xanthuremic and kynurenic acids after a standard tryptophan load, indicating impaired tryptophan metabolism due to pyridoxine deficiency. 5) Erythrocyte folate levels showed a small but significant fall. These observations on Indian women belonging to low income groups show clearly that OC use does affect the vitamin economy of the body adversely. Biochemical evidence presented argues that OCs alter vitamin economy through rise in levels of some proteins which bind vitamins. Vitamin supplements are recommended not only for patient benefit but for program acceptability.