Question:
A patient came with h/o cerebral aneurysm (stable) and h/o pre-eclampsia years ago. She wanted a RF on her coc’s but I was not original prescriber. I felt too risky and put her on SLYND.
Thoughts?
Also, what is your feeling about coc’s with women who’s blood pressure is 130-139 range 80-89 range now considered Stage 1 HTN?
Answer:
Patients with stable aneurysms are advised to avoid smoking, heavy alcohol consumption, stimulant medications, illicit drugs and excessive straining or Valsalva maneuvers as these may increase the risk of rupture. Since preeclampsia appears to increase long-term risk of adverse cardiovascular outcomes, it is appropriate to be aware of this in the patient’s history.
The concern with an estrogen containing pill relates to vascular effects. In the case of stroke, the CDC guidance on use of contraceptives, known as the Medical Eligibility Criteria, clearly states not to use an estrogen-containing contraceptive method.
But the CDC does not give guidance for the appropriate choice of methods in people with aneurysms. However, aneurysms may also increase the risk of blood clots forming in the ballooned vessel. Therefore, I agree with you that it is prudent to avoid an oral contraceptive because of the risk of blood clots.
It is controversial whether certain POPs increase the risk for blood clots, although the risk is substantially less than with COCs. I agree with your choice of a progestin only birth control pill instead of a combination birth control pill for a patient with a stable aneurysm. When studying combined birth control pills with drospirenone there is a very small increased risk of venous thromboembolism in some studies compared with pills containing progestins such as levonorgestrel. Slynd may or may not have a slightly increased risk of VTE over a norethindrone (NET pill). If you wanted to choose the safest possible pill for your patient, that may be a NET pill.
I always like reminding people about the condition in the CDC MEC called “multiple risk factors for atherosclerotic cardiovascular disease.†These include older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels. Perhaps knowing the patient’s history of preeclampsia would fit into your decision making from this type of perspective.
The CDC’s comment on this category for estrogen containing methods is: “When a woman has multiple major risk factors, any of which alone would substantially increase her risk for cardiovascular disease, use of CHCs might increase her risk to an unacceptable level. However, a simple addition of categories for multiple risk factors is not intended; for example, a combination of two category 2 risk factors might not necessarily warrant a higher category.â€
The CDC’s comment on this category for progestin-only methods is: “When multiple major risk factors exist, risk for cardiovascular disease might increase substantially. Certain POCs might increase the risk for thrombosis, although this increase is substantially less than with COCs. The effects of DMPA might persist for some time after discontinuation.â€
Your question about hypertension is intriguing. In the past we didn’t consider the BP range of systolic 130-139 or diastolic 80-90 as hypertensive. And currently these values are still not considered hypertensive by the European Society of HTN or the International Society of Hypertension.
The point of restricting combined pills in people with these ranges of HTN would be to minimize associated CV risks. According to the American Heart Association, the likelihood of an adverse CV outcome increases with increasing blood pressure, such that it is estimated that with BP of 130-139 and 85-89 the hazard ratio for CV events was 1.5-2.0. However the absolute risk for an otherwise young healthy woman with no other medical problems using a COC is very low.
The current CDC MEC guidance only considers higher values of blood pressure as concerning. Specifically, the CDC assigns a BP of systolic 140-149 or diastolic 90-99 as MEC category three where the disadvantages of prescribing CHC generally outweigh the advantages but makes no mention of these lower BP ranges.
I would manage this person taking into account the CDC category I mentioned earlier, “multiple risk factors for CVD,†as to whether someone should avoid CHC. If they are otherwise young and healthy, I would provide CHC but make sure the person is under good primary care follow up for hypertension to ensure she is getting appropriate management and that her BP remains well controlled.
We will have to await the new edition of the MEC to see whether they extend this caution to the lower BP ranges or 130-140 and 80-90.
Please let me know if you have additional questions,
– Dr. Z
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