Consider cardiometabolic risks when prescribing hormonal contraception

BOSTON — Among the increasing numbers of U.S. women with metabolic syndrome, choice of contraceptive method can influence their risk for cardiovascular disease, according to a presenter at the Cardiometabolic Health Congress.

Nieca Goldberg, MD, medical director of the Joan H. Tisch Center for Women's Health at New York University Langone Health and clinical associate professor at the New York University School of Medicine recommends health care providers ask several questions aimed at weighing risks to optimize a woman’s cardiometabolic health while meeting her needs for contraception.

Critical questions to ask, according to Goldberg, include the woman’s reasons for using contraception, the severity of her metabolic syndrome components and how her preferred contraceptive method affects these, and whether there are other, more “metabolic syndrome-friendly” alternatives that she would be willing to use.

Goldberg reviewed current evidence for the ffects of hormonal contraception on metabolic syndrome components, including BMI, lipids, blood pressure and glucose metabolism:

Obesity is the most common component of metabolic syndrome. Women with obesity who use hormonal contraception are at increased risk for venous thromboembolism, Goldberg said. There is conflicting evidence on whether women with obesity who use combination hormonal contraception are at elevated risk for acute myocardial infarction vs. women without obesity. The risk for stroke with combined hormonal contraception use does not appear to differ by BMI, she said.

Lipid effects of oral contraceptives differ by formulation, Goldberg said. Those higher in estrogen may increase circulating HDL, but also increase triglycerides, apolipoprotein B and A-1, insulin and C-reactive protein, “with most alterations associated with higher cardiometabolic risk,” Goldberg said. “When these formulations are discontinued, metabolic changes are reversed. Progestin-only contraceptives had little effect on inflammation factors or systemic metabolism.”

Blood pressure may increase with oral contraceptive use, but typically resolves when the pills are discontinued. Women who discontinue oral contraceptives but still have hypertension should be monitored, according to Goldberg.

Glucose metabolism is not affected by low-dose hormonal contraceptive use, according to Goldberg. Data do not consistently demonstrate a link between hormonal contraceptives and risk for developing diabetes, even among women with gestational diabetes, she said.

Goldberg said the health risks posed by metabolic syndrome necessitate a thorough conversation about contraceptive options.

“The relative risk of [women with metabolic syndrome] developing CVD compared to women without is 2.63%. That’s a level comparable to a two-pack a day smoker,” Goldberg said.

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She recommends asking patients about how much alcohol, soda, sugar and carbohydrates they consume and promoting components of a healthy lifestyle. These discussions must be two-sided, she said.

“When it comes to oral contraceptive therapy, like anything else we’re prescribing in our respective practices, it’s about shared decision-making and making sure the patient understands why we’re choosing the medication that we’re choosing.”

Goldberg noted that almost every clinician has a reproductive-aged patient affected by metabolic syndrome.

“The number of women using hormonal contraceptive with metabolic syndrome is probably unknown, but if 17.5 million women are using hormonal contraception and 10.7 million women aged 18 to 49 have metabolic syndrome then all of us see these patients," Goldberg said. – by Janel Miller

Reference:

Goldberg N. Choosing wisely: contraception in women with cardiometabolic risk. Presented at: Cardiometabolic Health Congress; Oct. 24-27, 2018; Boston.

Disclosure: Goldberg reports no relevant financial disclosures.