Contraception Selection Guidelines Relating to Venous Thrombosis Risk

An expert in cardiology reviews the current contraception selection guidelines in women with higher BMIs and comments on the cardiovascular risk associated with hormonal contraceptive methods.

Harold Bays, MD: There are guidelines out there that help direct the clinicians and then by surrogate the patients as to what particular approach, or what particular composition of these oral contraception is the best. What are the types of things that these guidelines recommend? In the faculty of sexual reproductive health care guidelines it is stated that women with obesity should be informed that there is increased risk of thrombosis with increasing body mass index. We talked about that, whether it be the sick fat disease or the endocrinopathies or the immunopathology of dysfunctional fat, what we call sick fat, or adipose osteopathy, that increases the risk of thrombosis. Then, there’s also the fat mass side where you have potential compression of venous return and that’s going to increase the risk of thrombosis. For many reasons, there is an increased risk of thrombosis with increasing BMI and that’s reflected in the guidelines. Current combined hormonal contraceptive use is associated with increased risk of being a thrombosis. That’s part of the guideline. Having that education, ensuring that the patient gets that information, and that current combined hormonal contraceptive use is associated with a small increased risk of myocardial infarction in ischemic stroke. That is accentuated when you have a body mass index that’s greater than equal to 35 kilogram per meter squared. In those cases, when you have that patient-centered approach, a decision may be reached that maybe the risks of this particular type of therapy exceeds potential benefits, particularly if there are alternatives available. For example, different types of nonpharmacological contraception, or maybe the progestin-only approach. Those are alternative to estrogen containing oral contraception. This isn’t just me talking. This is what’s in published guidelines.

With regard to ongoing education of both clinicians and patients about therapeutics, such as oral contraceptives? There’s no way we could cover all of that in just this brief program. But certainly, there are medical organizations that if you go to their websites, and particularly the ob-gyn [obstetrician-gynecologist] societal websites, you’re going to find a wealth of information there. Educational programming, you could probably get a lot of that programming on your own if you just go and look at YouTube. The next big thing is artificial intelligence. If it’s not there already, I suspect that within coming months, and I’m not talking years, coming months you’ll have the opportunity to utilize artificial intelligence by just typing in a question and it’s going to give you a description with the information that you desire. The only caveat I would say to all of these things is to be sure that wherever you go to get your information, and this is for clinicians and for patients, you have to have some sort of filter and make the effort to ensure that wherever you’re getting information it’s going to come from a reputable source. You have to be very cautious about that because again, you might say, our artificial intelligence is the newest thing. That’s probably going to give you the latest information. Artificial intelligence is just taking the opinions of the infinity and trying to distill it down into information that’s good for the person who had the question. In most cases, probably going to be OK, but not in all cases. I would advise that whatever kind of information that a patient gets from the internet and such that they run it by their clinician just to be sure that they got it right and that somehow there wasn’t some glitch, some problem, or some misunderstanding. Just say, “Look, I researched this. I went to what I thought was reputable places. Here’s my understanding. What do you think?” Then, go to their cardiologist, or ob-gyn, or primary care clinician, or physician assistant, or nurse practitioner. Go to whoever the clinician is most directly in charge of that patient’s medical management and say here’s what I’ve come to learn. Here’s what I think that I’ve learned. Am I doing it right? Have I got it right? It’s always better to get another opinion. Make sure you got it nailed down, particularly if you want to remain in concert with the clinicians that are managing, in this case, the health of the female who has questions about contraceptives.

There are going to be differences. These differences are found within the context of medical science, but also within guidelines and contraceptives do differ with regard to potential efficacy in patients with an increase in body mass index as do the potential risks.

Transcript Edited for Clarity

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