The Recommended Use of COCs and POPs
In this video, Michael J. Bloch, MD, discusses the use of combined oral contraceptives, which are the most common forms of birth control used by women in the United States, oral estrogen-free progestin-only pills, and their benefits and risks.
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TRANSCRIPTION:
Michael J. Bloch, MD: My name is Dr Michael Bloch. I am a vascular medicine specialist from Reno, Nevada.
Combined oral contraceptives, that is those that contain estrogen and progestin, are the most common form of birth control used by women in this country. They're safe and they are very effective. And one of the things that we recognize is that pregnancy can be a risk in certain at-risk women who have cardiovascular disease. So certainly the benefits of a safe and effective means of oral contraception are very important.
But like any intervention that we have in medicine, there are some risks. We know that estrogen has really multiple different effects on cardiovascular structure and function, and many times they're competing. Some are beneficial, some are less beneficial. In general, we know that estrogen causes endothelial relaxation, and decreases inflammation in most women, but we do know that it can increase blood pressure a little bit, and it can increase thrombogenesis, the risk of blood clots, both in the arterial and venous circulation, so they can increase cardiovascular risk in certain at-risk women. So in every woman, it's that balance of risks and benefits. For the vast majority of women, it is going to be a very safe and effective form of contraception, but there are women that we need to be a little bit more careful with.
So yes, there are definitely women who already have a history of established cardiovascular events, particularly a history of a DVT or pulmonary embolism where we wouldn't want to use COCs. Women who've had a stroke or heart attack, would not want to use COCs. And then women who have cardiovascular risk factors. So in general, women who are over the age of 35 who smoke more than 15 cigarettes a day, and women who have these two cardiovascular risk factors like diabetes, hypertension, and dyslipidemia are all women that we generally would avoid oral contraceptives. A little bit more of a gray area are patients who have hypertension. As I mentioned earlier, estrogen-containing oral contraceptives can raise blood pressure a little bit in some women, and so they may not be suitable for all women with hypertension.
So estrogen-free progesterone-only pills or patches are an alternative to COCs. Because they don't have estrogen, they don't have those effects on blood pressure and on thrombogenesis, we don't believe. So they may be a little bit safer in women who are at cardiovascular risk. However, they can be associated with some other side effects that make them a little bit less attractive for some women than a COC.
I think that it is just important that it's an individual risk assessment in each patient, just like we would with any other intervention, and if any of our participants, they're interested, there are a couple of great documents that are out there. There's a WHO document and a CDC document that really, I think speaks to the risks that are associated with COCs and the type of women that may be a good candidate and may not be a good candidate for COCs.