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STATE-OF-THE-ART PAPER

Contraceptive Hormone Use and Cardiovascular Disease

Women's Heart Center, Division of Cardiology, Department of Medicine, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.

Manuscript received August 4, 2008; revised manuscript received September 23, 2008, accepted September 30, 2008.

^_* Reprint requests and correspondence: Dr. C. Noel Bairey Merz, Department of Medicine, Cedars-Sinai Medical Center, 444 South San Vicente Boulevard, Suite 600, Los Angeles, California 90048 (Email: merz{at}cshs.org).

Contraceptive hormones, most commonly prescribed as oral contraceptives (OCs), are a widely utilized method to prevent ovulation, implantation, and, therefore, pregnancy. The Women's Health Initiative demonstrated cardiovascular risk linked to menopausal hormone therapy among women without pre-existing cardiovascular disease, prompting a review of the safety, efficacy, and side effects of other forms of hormone therapy. A variety of basic science, animal, and human data suggests that contraceptive hormones have antiatheromatous effects; however, relatively less is known regarding the impact on atherosclerosis, thrombosis, vasomotion, and arrhythmogenesis. Newer generation OC formulations in use indicate no increased myocardial infarction risk for current users, but a persistent increased risk of venous thromboembolism. There are no cardiovascular data available for the newest generation contraceptive hormone formulations, including those that contain newer progestins that lower blood pressure, as well as the nonoral routes (transdermal and vaginal). Current guidelines indicate that, as with all medication, contraceptive hormones should be selected and initiated by weighing risks and benefits for the individual patient. Women 35 years and older should be assessed for cardiovascular risk factors including hypertension, smoking, diabetes, nephropathy, and other vascular diseases, including migraines, prior to use. Existing data are mixed with regard to possible protection from OCs for atherosclerosis and cardiovascular events; longer-term cardiovascular follow-up of menopausal women with regard to prior OC use, including subgroup information regarding adequacy of ovulatory cycling, the presence of hyperandrogenic conditions, and the presence of prothrombotic genetic disorders is needed to address this important issue.

Key Words: hormones • contraception • cardiovascular disease

Abbreviations and Acronyms   ACOG = American College of Obstetrician and Gynecologists   CI = confidence interval   EE = ethinyl estradiol   ER = estrogen receptor   HDL-C = high-density lipoprotein cholesterol   LDL-C = low-density lipoprotein cholesterol   LNG = levonorgestrel   MI = myocardial infarction   OC = oral contraceptive   RR = risk ratio   VTE = venous thromboembolism

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