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Contraception

Contraception

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Contraception

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  1. Contraception Key slides 1 Risks of hormonal contraception Venous thromboembolism (VTE), Myocardial infarction (MI), Stroke Various cancers

  2. The language of risk Theme issues 27th September 2003 See relevant NPCi floor: Information Mastery 4 - Communicating Risks & Benefitswww.npci.org.uk/therapeutics/mastery/mast4/room_mast4.php

  3. Risks of hormonal contraceptives:venous thromboembolism (VTE)Current Problems in Pharmacovigilance 1999;25:12, Drug Safety Update Vol. 1, Issue 9, April 2008, Drug Safety Update Vol. 3, Issue 9, April 2010 • All combined hormonal contraceptives increase risk of VTE • Risk associated with COCs containing desogestrel or gestodene (and possibly norgestimate, drospirenone, and the contraceptive patch Evra) is greater than that associated with COCs containing levonorgestrel • But, in absolute terms, risk of VTE is still low and is lower than risk in pregnancy • Caution when considering any COC for women who have a higher baseline risk of VTE, such as an older woman who smokes • see UK Medical Eligibility Criteria (UKMEC) for details www.fsrh.org/admin/uploads/UKMEC2009.pdf

  4. Absolute risks of VTECurrent Problems in Pharmacovigilance 1999;25:12, Drug Safety Update Vol. 1, Issue 9, April 2008, Drug Safety Update Vol. 3, Issue 9, April 2010 • Risk of VTE associated with COCs containing: • desogestrel or gestodene (2.5 per 10,000 woman-years) • levonorgestrel (1.5 per 10,000 woman-years) • Risk of VTE in: • never-users (0.5 to 1 per 10,000 woman-years) • pregnancy (6 per 10,000 woman-years) • Risk of VTE associated with Evra may be slightly higher than with second generation COCs • Risk of VTE associated with Yasmin somewhere between risk with second and third generation (desogestrel or gestodene) COCs • Cates plot on next slide shows risk per 10,000 women per 10 years, assuming constant, cumulative annual risk to permit representation

  5. Women any age, using COCs for 10 years: risk of VTE over 10 years see Contraception Patient Decision aid on www.npci.org.uk/pda images produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net These 15 women will develop VTE whether they take a COC containing desogestrel or gestodene, or a COC containing levonorgestrel. 5 to 10 of them would develop VTE if they did not take either type of COC These 10 women will develop VTE as a result of taking a COC containing desogestrel or gestodene These 9975 women will not develop VTE, whether or not they take a COC of either type

  6. Risks of hormonal contraceptives: MI and stroke Small, if any, increase in MI or stroke risk with oral contraceptive use Important points: • Absolute risk of an MI or stroke in young women is very low • Smoking and OC use increases risk significantly Advice to older women Brechin S, Gebbie A. Perimenopausal contraception. Faculty of Family Planning and Reproductive Health Care of the RCOG – Review No. 2000/01 • Healthy non-smoking women with no cardiovascular risk factors may continue to use a low-dose COC until 50 years • Women who smoke are best advised to discontinue COCs and find another contraceptive method at 35 years • See also UK Medical Eligibility Criteria (UKMEC) • www.fsrh.org/admin/uploads/UKMEC2009.pdf

  7. Risks of hormonal contraceptives: cancer (1) • Observational data suggest oral contraceptive use does not increase a woman’s overall risk of cancer • oral contraceptives are associated with a reduction in both the risk of cancer and death from cancer BUT risk for individual cancers varies Hannaford PC, et al. BMJ 2007;335:651 and BMJ 2010;340:c927 • Small, if any, increase in risk of breast cancer, but this is in addition to background risk which increases with age • current use (RR 1.24, 95%CI 1.15 to 1.33) but no increased risk 10 years after stopping (Lancet 1996; 347:1713-27) • RCGP oral contraception cohort study: no increased risk of breast cancer with OC use, even for many years (Hannaford PC, et al. BMJ 2007;335:651)

  8. Women aged 20–24 years using COCs for five years: cumulative risk of breast cancer during use and for up to 10 years afterwards see Contraception Patient Decision aid on www.npci.org.uk/pda images produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net These 16 women will be diagnosed with breast cancer whether or not they take a COC These 2 women will be diagnosed with breast cancer as a result of taking a COC These 9982 women will not be diagnosed with breast cancer, whether or not they take a COC

  9. Women aged 24–29 years using COCs for five years: cumulative risk of breast cancer during use and for up to 10 years afterwards see Contraception Patient Decision aid on www.npci.org.uk/pda images produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net These 5 women will be diagnosed with breast cancer as a result of taking a COC These 44 women will be diagnosed with breast cancer whether or not they take a COC These 9951 women will not be diagnosed with breast cancer, whether or not they take a COC

  10. Risks of hormonal contraceptives: cancer (2) • Small increase in risk of cervical cancer (International Collaboration of Epidemiological Studies of Cervical Cancer Lancet 2007; 370:1609-21) • women who use COCs for 5 years from age 20 have an extra 2 cases per 10,000 of cervical cancer at age 50 • women who use COCs for 10 years from age 20 have an extra 7 cases per 10,000 of cervical cancer at age 50 • Encourage women to attend cervical screening • Girls now being vaccinated against HPV infection • See www.dh.gov.uk/en/Publichealth/Healthprotection/ immunisation/Keyvaccineinformation/DH_104010 • Decrease in risk of ovarian cancer (Collaborative group on Epidemiological Studies of Ovarian Cancer. Lancet 2008; 371: 303-14) • RR 0.73, 95%CI 0.70 to 0.76 (ever vs. never use)

  11. Women using COCs for 5 years from age 20 years: cumulative risk of cervical cancer at age 50 yearssee Contraception Patient Decision aid on www.npci.org.uk/pdaimages produced using Dr Chris Cates’s software VisualRx 3.0 see www.nntonline.net These 38 women will be diagnosed with cervical cancer whether or not they take a COC These 2 women will be diagnosed with cervical cancer as a result of taking a COC These 9960 women will not be diagnosed with cervical cancer, whether or not they take a COC

  12. Summary • All combined hormonal contraceptives increase risk of VTE. But, in absolute terms, risk of VTE is still low and lower than risk in pregnancy • Small, if any, increase in MI or stroke risk with oral contraceptive use – again absolute risks in younger women remain very low • Overall, observational data suggest oral contraceptives reduce risk of, and death from, cancer – but risk for individual cancers vary: • Small, if any, increase in risk of breast cancer, but in addition to background risk which increases with age • Small increase in risk of cervical cancer – women should participate in usual screening programmes, and girls should be vaccinated • Decrease in risk of ovarian cancer