Results

Case study 50: Individualising hormonal contraception

December 2007

NPS is an independent, non-profit organisation for Quality Use of Medicines funded by the Australian Government Department of Health and Ageing. ABN 61 082 034 393 | Level 7/418A Elizabeth Street Surry Hills 2010 | PO Box 1147 Strawberry Hills 2012 Phone: 02 8217 8700 | Fax: 02 9211 7578 | email: info@nps.org.au | web: www.nps.org.au

NPSCS0442

Inside Case study 50: Individualising hormonal contraception Scenario and questions Summary of results page 3 page 4 Results in detail Oral contraceptive use when migraine occurs Suitability of long-term contraception Family history of venous thromboembolism and contraceptive choice Commentaries Dr Deirdre O’Dea Dr Terri Foran References page 11 page 13 page 16 page 6 page 8 page 9 The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence. Any treatment decision based on this information should be made in the context of the clinical circumstances of each patient. Declarations of interest have been sought from all commentators. 2 .

hepatic disease. a) Do you think Sandra would be a good candidate for long-term contraception (i. migraine. It did not occur to her that this was due to her oral contraceptive until you mentioned it. On probing. As there are no plans to have any children in the next few years. please list Sandra’s new contraceptive regimen. Sandra presents with a history of several episodes of a persistent. Sandra started on a combined oral contraceptive pill. a) Would you recommend a different contraceptive to ethinyloestradiol 35 micrograms /norethisterone 1 mg (Brevinor-1 or Norimin-1) if Sandra had a family history of venous thromboembolism (i. please list Sandra’s new contraceptive regimen. please list Sandra’s new regimen (include existing drug if continuing). she mentions that she has experienced the headache at least 5 times in the last 6 months when she has a period (i. Drug Dose Frequencyiiiiii 3 .e. a) Given Sandra’s migraines. 1. Drug Dose Frequencyiiiiii 3. during the inactive pill / pill-free week). b) If yes. Sandra struggles to control her weight and is anxious about potential weight gain from any new medicine. b) If yes. implant. Her blood pressure is 118/75 mmHg and BMI 26 kg/m2. b) If yes. She is newly married and has a daughter from a previous relationship. She is not using any other medicines. cardiovascular disease or cancer. would you recommend any changes to her oral contraceptive? Yes No Please state why OR why not. There is no family or personal history of diabetes. There has been no weight gain or any other oestrogenic/progestogenic effect. throbbing headache which started when she commenced the new pill. Drug Dose Frequencyiiiiii 2. Further questioning and examination do not suggest another diagnosis and the symptoms are consistent with migraine without aura associated with oral contraceptive use. if her mother had suffered from a spontaneous deep vein thrombosis 10 years ago) and no personal history of migraine? Yes No Please state why OR why not. depot injection or intrauterine device)? Yes No Please state why OR why not.e. ethinyloestradiol 35 micrograms/norethisterone 1 mg (Brevinor-1 or Norimin-1) 6 months ago.Case study 50: Individualising hormonal contraception Scenario Sandra is a 34-year-old non-smoker who recently moved to Australia from the United Kingdom.e.

Many respondents advised that they would discuss the options with the patient before deciding on the management plan.5% of respondents considered that long-term contraception would be suitable.1%) — using a triphasic oral contraceptive (8.e.0%). low-dose combined oral contraceptive) (17.2%). no risk of oestrogenic adverse effects (22. levonorgestrel-releasing intrauterine device (Mirena).8%). because of potential weight gain (28. Her blood pressure is 118/75 mmHg and BMI 26 kg/m2.) Impact of migraine on contraceptive choice • • 99.1% selected etonorgestrel implant (Implanon) and 32. migraine. There is no family or personal history of diabetes. Of those who thought that long-term contraception was suitable. This report summarises responses from 200 general practitioners. a 34-year-old non-smoker presented with migraine without aura associated with oral contraceptive use (migraine occurs during the pill-free week). Respondents who felt that long-term contraception was inappropriate did so because the patient may want further pregnancies (45. She started on ethinyloestradiol 35 microgram / norethisterone 1 mg (Brevinor-1 or Norimin-1) six months ago. • • * Long-term contraception options include etonogestrel implant (Implanon).3%) — reducing the oestrogen and progestogen component of the contraceptive (i.0% did not and 2. The main changes recommended were: — tricycling the original contraceptive (i. 4 .6%).Summary of results At the time of publication.6%). Main reasons for using a long-term contraceptive were: no plans for having a child in the next few years (38. 820 responses had been received. having a pill-free interval of 3–7 days only once every 3 months)1 (30. 60.2%) and because there were no contraindications (6.e. hepatic disease. There has been no weight gain or any other oestrogenic or progestogenic effect. 21. Case synopsis Sandra. because the patient was parous (7.7%) — adding an oestrogen during the pill-free week (9.5%) — using a progestogen-only pill (9.5%). • Suitability of long-term contraception* • • 76. cardiovascular disease or cancer.2%). to reduce risk of weight gain (7. to reduce migraine/headache (19.1% selected levonorgestrel-releasing intrauterine device (Mirena). copper intrauterine devices. depot medroxyprogesterone acetate (Depo-Provera) and ethinyloestradiol/etonorgestrel-releasing vaginal ring (NuvaRing).0% of respondents reported that they would change Sandra’s oral contraceptive after presentation of migraine without aura to stop or reduce the headaches.5% of respondents thought the decision depended on additional factors. (See page 3 for more details.5%) and because there were no cardiovascular risk factors to warrant a change in her oral contraceptive. She is not using any other medicines.

0% would not.e. Interestingly. 16. Most respondents would select a progestogen-only pill to decrease the risk of venous thromboembolism.4% were satisfied with a low-dose combined oral contraceptive.0% of respondents would recommend a different contraceptive from the monophasic combined oral contraceptive if there was a family history of venous thromboembolism and no history of migraine.8% of respondents indicated that they would not make a treatment decision until Sandra was screened for thrombogenic mutations (i. factor V Leiden).Family history of venous thromboembolism and contraceptive choice • 72. while 19. while 27. • • 5 .

Table 1 Reason for changing/regimen recommended To stop or reduce migraine/headache Oestrogen withdrawal during pill-free week may be the cause of the headaches Tricycling pills will avoid the pill-free week To avoid the pill-free week by adding oestrogen during pill-free week or by tricycling her pills Lower oestrogen dose as higher oestrogen content triggered the adverse effect *Respondents may have more than one response % of respondents* (n = 198) 38. while table 2 analyses the medicines recommended by respondents and the rationale behind these recommendations.1 7.8 14. 5.625 mg) to ethinyloestradiol (10–30 microgram) Rationale may not have been explicit in responses 6 .5 9.3 17. Several respondents acknowledged that there were many different options to manage this condition.1 8.1 9.1 Table 2 % of respondents* (n = 198) 30.7 Medicine/regimen Tricycle the original contraceptive† Change to a low-dose oral contraceptive (mostly ethinyloestradiol 20 microgram / levonorgestrel 100 microgram [Microgynon 20]) Add an oestrogen during the pill-free week Use a progestogen-only pill (mostly levonorgestrel 30 microgram [Microlut]) Use a triphasic oral contraceptive (mostly ethinyloestradiol 30/40/30microgram / levonorgestrel 50/75/125 microgram [Triphasil]) *Respondents may have more than one response † ‡ § ‡ Rationale § Avoid withdrawal headaches Reduce the oestrogen and progestogen component of the contraceptive to reduce headache Decrease hormonal fluctuation thus reducing headache Stop the oestrogen content to decrease headache and risk of stroke Mimic the cyclical pathway of endogenous hormones to reduce headache 9. Table 1 groups the responses according to reason for the recommended changes.5 13.0% of respondents reported that they would change Sandra’s oral contraceptive after presentation of migraine without aura.6 Duration for tricycling ranged from 6 weeks to 4 months Oestrogen type and dose ranged from conjugated oestrogens (0.5% of respondents provided a second choice of oral contraceptive.3–0.Results in detail Oral contraceptive use when migraine occurs • • • 99.

3 Contraindications for use of COCs in women with migraine are based on limited evidence and expert opinion. the risks of continuing the COC may outweigh the benefit. Depo-Ralovera].4 As Sandra is < 35 years old and did not have the migraines until she started the new COC. Other options for patients with migraine without aura after starting a COC include the progestogenonly preparations (progestogen-only pill. hyperlipidaemia.e. and family history of arterial disease before age 452 If more than 1 additional risk factor for stroke.2 Besides use of COCs. barrier and natural methods. levonorgestrel-releasing intrauterine system [Mirena]). the risk of stroke outweigh the advantages (strong relative contraindication). headache and hormonal contraception Diagnosis • Migraine with aura before starting COC • Migraine with aura during use of COC No history of migraine before starting COC AND migraine without aura develops during use of COC (i. the risks generally outweigh the advantages.e. diabetes mellitus. • • • • • • Table 3: Migraine. BMI > 30 kg/m2.e. Consider progestogen-only contraceptive or non-hormonal methods2 In women < 35 years. if no other risk factors. stop the combined oral contraceptive (COC).Practice points • There is a 2–4-fold increased risk of stroke in women who experience migraine (with or without aura) while using combined oral contraceptives (COCs) compared with those who experience migraine but do not use COCs. 2. additional risk factors for stroke are noted in the summary table below. the advantages of COC generally outweigh the disadvantages2 If 1 additional risk factor for stroke. (Strong relative contraindication) 5 Exercise clinical judgement if other risk factors for cardiovascular disease are present (i. depot medroxyprogesterone acetate (DMPA) injection [Depo-Provera.3 For women who develop migraine without aura after starting a COC. copper intrauterine device (copper IUD). Consider progestogen-only contraceptive or non-hormonal methods2 7 .2. 100 microgram oestrogen patch or equivalent) Tri-cycle pills to avoid the pill-free week2 *NPS would like to thank Dr Christine Read (Family Planning NSW) for her assistance in putting this table together Recommendation Stop COC. stop the COC. Table 3 summarises COC use in women with migraine or headache. Consider progestogen-only contraceptive or non-hormonal methods2 Headache in the pill-free week (no migraine) Add oestrogen daily during pill-free week (e. Sandra’s case) In women > 35 years. diabetes) 2 History of migraine without aura before starting COC In women < 35 years. hypertension. the disadvantages of COC generally outweigh the advantages but the COC may be used with caution.4 Currently there is no evidence to suggest that the effects of non-oral combined contraception (i. vaginal ring) are any different from those of COCs. smoking. smoking.g.2 Risk factors for stroke include age > 35 years. etonorgestrel implant [Implanon].

2 28. Reasons long-term contraception is suitable No plans on having children in the next few years No risk of oestrogenic adverse effects Reduce occurrence of headache/migraine May reduce risk of weight gain Parous No contraindication to long-term contraceptive use % of respondents* (n = 153) 38.6 • 8 . 60.2 6.1% selected levonorgestrel-releasing intrauterine device (Mirena).5% of respondents felt that long-term contraception would be suitable.5 9.1% selected etonorgestrel implant (Implanon) and 32. DMPA has the most effect on weight gain (2–3 kg increase in 1 year) while there is no evidence of significant weight change among users of copper IUDs or levonorgestrel-releasing IUD (Mirena) in European studies.5 Reasons long-term contraception is unsuitable May want further pregnancies Increased risk of weight gain from long-term contraception No cardiovascular risk factors to warrant a change *Respondents may have more than one response † † % of respondents* (n = 42) 45. It is important that risk factors for osteoporosis are evaluated. There is insufficient evidence to suggest weight gain with the etonorgestrel implant (Implanon).2 19.5% specifically referred to depot medroxyprogesterone acetate (Depo-Provera. Practice points • Bone mineral density loss has been reported in users of depot medroxyprogesterone acetate (DMPA).5 9. Depo-Ralovera) • Of those who thought long-term contraception was suitable. especially in women aged < 18 years or those at risk of osteoporosis (> 45 years).Suitability of long-term contraception • 76.0 7. and recommend weight-bearing exercise and smoking cessation.2 Encourage adequate calcium and vitamin D intake.8 7.5% of respondents thought the choice depended on other factors. 21.6 22.0% did not and 2.1 There are limited studies on the effects of long-term contraception on weight gain.

especially in the first 4 months of COC use.0% of respondents would recommend a different contraceptive from the monophasic combined oral contraceptive if there was a family history of venous thromboembolism and no history of migraine. having considered other contraceptive methods. which may increase her DVT risk % of respondents* (n = 144) 24.0 16.9% said they would screen for factor V Leiden mutation as well Alternative drugs Progestogen-only pill [mostly levonorgestrel 30 microgram (Microlut)] Levonorgestrel-releasing intrauterine device (Mirena) Etonorgestrel implant (Implanon) Low-dose combined oral contraceptive [mostly ethinyloestradiol 20 microgram / levonorgestrel 100 microgram (Microgynon 20)] *Respondents may have more than one response % of respondents* (n = 144) 26.2 Provide written information and encourage patients to read consumer medicine information.8 13.8 21. still wishes to use a COC.8 9.6 18. a thrombophilia screen should be performed. Reasons for changing from the original contraceptive† Lower oestrogen dose may reduce deep vein thrombosis (DVT) risk Decreased risk of venous thromboembolism (including DVT) Family history may increase risk of DVT Removes oestrogenic adverse effects Sandra is approaching 35 years of age. Be wary of increased risk of DVT and pulmonary embolism.5 19. There is limited evidence on the risk of venous thromboembolism associated with etonorgestrel implant (Implanon) or levonorgestrel-releasing IUD (Mirena).0 Reasons for continuing the original contraceptive No evidence that current contraceptive has a higher risk of venous thromboembolism compared with other contraceptives Consider screening for thrombogenic mutation (i.4 Practice points • • • • All combined oral contraceptives may increase the risk of venous thromboembolism (VTE).0 7.1 9. factor V Leiden) before making treatment decision The absolute risk of venous thromboembolism is very small for combined oral contraceptives Not a smoker *Respondents may have more than one response † % of respondents* (n = 54) 26.4 4.5 20.Family history of venous thromboembolism and contraceptive choice • 72.0% would not. It is good practice to consult with a haematologist or other expert when interpreting a thrombophilia screen. If a woman has a family history of VTE in a 1st-degree relative under age 45 who. 27.7 9 . Routine thrombophilia screening is not recommended before prescribing COC. which provide information on warning signs of VTE.3 23.e.

• 10 . such as age. a history of VTE or heavy smoking.• There is limited data on the cardiovascular effects of progestogen-only pills. moderate to severe hypertension. migraine with aura. Progestogen-only pills may be suitable for women who want to use an oral contraceptive but who have risk factors for cardiovascular complications with the COC.8 Other options to consider in women at high risk of VTE are barrier methods and natural family planning. diabetes. these women should be closely screened and monitored. At the same time. obesity.

and this low-dose pill could be tricycled.000. Screening in other situations is not cost-effective. This rises to 56 for women who experience more than 1 migraine per month. having a pill-free interval of 3–7 days only once every 3 months) 11 . • Stop the COC and use another form of contraception.000. as the scenario suggests. as the fluctuations in hormone levels may act as a trigger.9 The theoretical disadvantage of this would be that more oestrogen is ingested per year of COC use. The background annual risk of thrombotic stroke for women aged 20 years is 2 in 100. • Migraine without aura developing during combined oral contraceptive (COC) use is a relative contraindication to the use of COC.e.10 Despite this. this rises to 10 in 100. If the management plan we developed with Sandra was to tricycle the COC at present. *Tricycling the original contraceptive (i.000.Commentary 1 Key points • Contraception and possible side effects of contraception are common GP consultations. Impact of migraine on contraceptive choice Two of our core GP skills are developing a shared management plan with our patients and being available to review this over time. (’Absolute contraindication‘). • Thrombophilia screening in COC users is indicated with a family history of idiopathic venous thromboembolism in a parent or sibling under 45 years of age. I imagine that Sandra would be keen to review her oral contraceptive after making the link that her migraines were occurring during the pill-free week. Sandra’s options are: • Limit the fluctuation in oestrogen levels. Respondents clearly recognised that Sandra’s migraines were linked to the drop in oestrogen levels during the pill-free week. Contraception: an Australian Clinical Practice Handbook1 states that if migraine without aura develops during COC use it is automatically a World Health Organization category 3 (’Strong relative contraindication‘) regarding COC use and. if you are over 35. I would encourage her not to put it off for ’the next few years‘. But at age 40 the background risk is 20 in 100. It would be interesting to know if she hopes for children from this new relationship. Adding the COC increases the annual risk to 100 in 100. either by tricycling* the COC to avoid the pill-free week or by taking oestrogen during the pill-free week. or 1 in 1000. If she does. there would need to be a clear understanding that this was not her ideal long-term contraceptive option. The challenges in Sandra’s case are her age and her new-onset migraines. The reason for this caution is that risk of thrombotic stroke rises with age. There is dispute over whether migraine without aura is truly a risk factor for thrombotic stroke. These are not usually recommended for women who get headaches. it is WHO category 4. Almost 20% of respondents suggested reducing the oestrogen and progesterone component of the contraceptive. Dr Deirdre O’Dea General Practitioner Sydney NSW A small number of respondents suggested changing to a triphasic pill.000. The first option (tricycling or adding oestrogen in the pill-free week) was suggested by nearly 40% of respondents and is consistent with the advice in Table 2 of NPS News 54.10 With more than 1 migraine per month and COC use.

compared with pill uses without this predisposition. your questions answered.10 For GPs looking for a user friendly reference about Contraception I would recommend Sexual Health and Family Planning Australia’s Contraception: an Australian Practice Handbook2 and John Guillebaud’s comprehensive Contraception. However. of respondents would not recommend the COC. Among those who felt that long-term contraception was unsuitable. Sandra is worried about potential weight gain. almost three-quarters 12 . factor V Leiden. About 15% of respondents suggested screening for the most common thrombophilia. and almost all these recommended either Implanon or Mirena. Family history of VTE in a parent or sibling aged > 45 years is classified as WHO 2 (generally safe to use)10. almost half cited concerns about a possible delayed return to fertility. this conservative approach is reasonable. so Depo-Provera is out. A copper IUD would be another option. there is no evidence of a delay in return to fertility for Implanon or IUD users 10.Would Sandra be a good candidate for long-term contraception? More than 75% of respondents considered long-term contraception to be suitable.10 Family history of venous thromboembolism and contraceptive choice If Sandra had a family history of venous thromboembolism (VTE). As Sandra is approaching age 35. Idiopathic VTE in a parent or sibling aged < 45 years is an indication for thrombophilia screening if available. The ethinyloestradiol/ etonorgestrel-releasing vaginal ring (NuvaRing) would have the same disadvantages as the COC. Each year there are only 3 extra cases of VTE among 1000 pill takers with factor V Leiden mutation. Screening in other situations is not cost-effective and a negative thrombophilia screen cannot be entirely reassuring.

provided there are no other risk factors present.5 The most conservative approach in Sandra’s case. • Migraine with aura remains an absolute contraindication to combined oral contraceptive pill use. as it increases the risk of ischaemic stroke. is unlikely to be effective because she will still experience an inevitable drop in oestrogen levels during the pill-free week. Though lower in dosage.13 The background risk of stroke in all women aged 30-34 years on the COC is 5 in 100. or to a triphasic. in which her migraines appear to have arisen for the very first time at initiation of hormonal contraceptive use. and there is a good physiological explanation for their occurrence. I would be inclined to explore 13 . particularly if there are any other risk factors present for stroke or heart disease. and use of combined contraception in women with migraine.000. Sandra was keen to persist with a combined pill. A past history of DVT or pulmonary embolus. but a history of common migraine doubles this risk.15 Age is also a factor. the vaginal ring is also contraindicated in women with migraine with aura. since these migraines occur exclusively during the pill-free week.11 Many women with common migraine report an improvement in symptoms on the pill but. except in rare cases when the first attack occurs after starting the 5 regimen. If. or the presence of a known thrombogenic mutation. • Progestogen-only hormonal contraception is considered generally safe to use in women with migraine with aura. they are more likely in the hormone-free week. which is believed to be due to a relative oestrogen deficiency at this time. • Combined contraceptive methods are generally considered safe to use in women with migraine without aura who are under 35 years of age. In Sandra’s case simply changing to a combined pill with a lower dose of oestrogen. Dr Terri Foran Sexual Health Physician University of NSW Management of migraine in the pill-free week Sandra gives a typical history of headache triggered by oestrogen withdrawal during the pill-free week of the combined pill. Migraine arising for the first time with initiation of a COC is more concerning. would be to recommend stopping combined contraception. becomes less advisable after age 35. However. Such attacks are usually migraines without aura and typically start a couple of days after the active pills are stopped. remain absolute contraindications to combined 5 contraceptive use.00014 .12. I am not surprised that only a minority of respondents suggested this. A history of spontaneous thromboembolism in several relatives would be even more compelling. For those with migraine with aura this risk increases to 29 in 100. • A family history of VTE in one 1st-degree relative would generally still make the COC generally safe to use. even without aura. In people who experience migraine without hormonal contraception there is often an increase in the frequency and severity of attacks in the latter half of the cycle. which is generally considered unacceptable. • Progestogen-only hormonal contraception is generally safe to use even in those with a past history of DVT or pulmonary embolism 5 or a known thrombogenic mutation.Commentary 2 Key points • Migraine occurring exclusively in the pill-free week of the combined contraceptive pill appears to be triggered by falling levels of oestrogen. although some clinicians might wish to order a screen for the known thrombogenic mutations before starting the pill. when attacks do occur. after discussion of the possible risks.

some women find that their headaches settle with dosages as low as 25 micrograms/24 hours. If she prefers to have regular withdrawal bleeds or finds that she needs to take scheduled breaks with extended pill use. diaphragms and fertility awareness. in particular the possibility of irregular bleeding. Sandra’s presentation provides an opportunity to review her contraceptive options generally. Role of progestogen-only contraception After discussing the potential risks related to oestrogen use Sandra may wish to explore the possible benefits of progestogen-only contraception (progestogen-only pill. the convenience and effectiveness of these longer-acting methods may well appeal to her. oestradiol gel 1 mg.16 This provides protection from hormonally triggered migraines while still allowing for withdrawal bleeding. Combining these two strategies is also possible. as Sandra appears to be at low risk of sexually transmitted infections. daily during the pill-free week are possible alternatives.strategies that would mitigate the sudden fall in oestrogen during the pill-free week. Though the oestrogen dose is lower it is presently considered to have the same risks as the combined pill and it is likely that she would need to employ similar strategies to avoid oestrogenwithdrawal migraines. If patches are unacceptable. I would. It should be noted that all the above preparations would require a private prescription. although she may not consider these effective enough considering her desire to avoid pregnancy in the next few years. depot medroxyprogesterone acetate [DMPA] injection). as identified by the respondents. it is much less likely in users of the other progestogen-only methods. This would also be advisable if she continued to experience migraines on the extended pill regimen described above. As there are no immediate plans for a pregnancy. The higher failure rate of the progestogen-only pill and its strict dosing regimen mean that few modern women consider it a viable option except during lactation. progestogen IUD. but she should be warned that she could experience heavier menstrual bleeding while using it. As this will mean fewer ’periods‘ it may be necessary to reassure Sandra that such manipulation of her cycle will not involve any risks to her future fertility. 14 . As identified by some respondents. In view of Sandra’s concerns regarding weight gain it would be important to discuss that. contraceptive implant. as migraine prevention is not a PBS indication for their use. or 1–2 mg oral oestradiol valerate. It would be important to monitor Sandra closely if she chooses to continue with combined contraception. The progestogen in the pill Sandra is taking suppresses endometrial proliferation particularly well and it may in fact be possible to run packets together for many months — perhaps indefinitely — without the problem of breakthrough bleeding. Though 50-100 micrograms is the usual recommended dose16. although significant weight gain may be a problem for some DMPA users. I would suggest that she consider use of a natural oestrogen preparation during the pill-free week. while the other long-acting contraceptive methods are all rapidly reversible. Sandra could also consider other non-hormonal contraceptive methods such as condoms. For this reason the long delay in the resumption of fertility after DMPA use would make it a less appealing option. In making this choice she would need to be carefully counselled about other potential side effects. however. A weekly oestradiol patch is probably the most convenient option. As a more convenient alternative she might consider the use of a vaginal contraceptive ring. A copper IUD would be another option. I would discuss both the possibility of running cycles of the pill together and the use of a low-dose oestrogen preparation in the pill-free week. gently advise her that at 34 years of age she should not push her plans for further children too far into the future.

The risk is higher with the newer progestogens. Even if the results are negative Sandra may wish to consider a lower-dose combined method such as a 20 microgram pill or a vaginal ring.VTE risk and combined oral contraception The last issue raised in this case is that of a family history of spontaneous DVT in a 1st-degree relative. protein S. This increases her risk of VTE to about 3 times her background rate. progestogen-only contraception is generally considered safe to use in those with a personal or family history of thromboembolism. It is also important to remember that Sandra is planning a pregnancy in the next few years. In summary. If any of these results indicated an increased risk of thrombophilia it may be prudent to arrange a consultation with a haematologist and to recommend an alternative to combined contraception. as pregnancy itself represents a 12-fold increase in the risk of VTE. Sandra’s case illustrates that the choice of a contraceptive method is an extremely personalised one in which all risks and benefits must be carefully weighed up by both the user and the clinician. 15 . antithrombin deficiency). Her family history of DVT may be even more important in this situation. as the risk of VTE increases with age. the advantages of oestrogen-containing contraception usually outweigh the risks. this consultation may be an ideal opportunity to discuss the various alternative contraceptive options available to Sandra as she moves into her late 30s and 40s. Sandra is using a pill that contains one of the older progestogens. protein C. However. Although evidence is limited. This would be even more important if she develops any other risk factors for cardiovascular disease. WHO guidelines5suggest that for someone with a 1st-degree relative with a history of VTE but no other risk factors. If Sandra was keen to remain on the combined pill there would be a case for arranging a thrombophilia screen (factor V Leiden. prothrombin mutation.

15:36–40. http://www. Incidence of migraine relative to menstrual cycle phases of rising and falling estrogen. Kudrow L. 5. Headache: The Journal of Head and Face Pain 1975.php?content=/html/news.who. WHO Medical Eligibility Criteria for contraception use. Clinical Knowledge Summaries. Long-acting reversible contraception. NPS News 54. http://www. 16. Becker WJ. Australian Medicines Handbook.pdf (accessed 8 August 2007). 8.hcn. Hormonal contraceptives: tailoring for the individual. 16 .27:49–52.amh.au/ (accessed 26 July 2007). 2004. Prevention of migraine in the pill-free interval of combined oral contraceptives: A double-blind. NICE. Risk of ischaemic stroke in people with migraine: systematic review and meta-analysis of observational studies. BMJ 2005. et al.References 1. National Prescribing Service Ltd. WHO.net.28:27–31. 2004. http://www. Hackshaw A. http://www.nice. Royal College of Obstetricians and Gynaecologists. Consumers' Association. Sydney: Sexual health and Family Planning Australia.67:2154–8. 2004. Isorna FC. Etminan M. 11. Venous thromboembolism and hormonal contraception.330:63–6. MacGregor EA. Drug Ther Bull 2000. October 2005. McNamee K. 4.php&news=/resources/NPS_News/news54 (accessed 29 November 2007).uk/resources/Public/pdf/VTE_hormonal_contraception. J Fam Plan Reprod Health Care 2002.org. January 2007. Neurology 1999. Read C. Ryan RE. Contraception: an Australian Clinical Practice Handbook. http://www.pdf (accessed 21 November 2007). Guillebaud J.org. Oral contraceptives and cardiovascular risk. 2006. 12. Use of oral contraceptives in patients with migraine.pdf (accessed 9 November 2007).nps.nhs. Contraception Your Questions answered. 2. 6. 10.org. MacGregor E. 3. 4th ed: Elsevier Health Services. placebo-controlled pilot study using natural oestrogen supplements. Harvey C. Headache: The Journal of Head and Face Pain 1978.au/site. A Controlled Study of the Effect of Oral Contraceptives on Migraine.17:250–2. et al. 7. Frith A. Hormonal contraception and migraine. MacGregor EA. J Fam Plan Reprod Health Care 2001. 2007. 13. Contraception http://cks.int/reproductive-health/publications/mec/mec. Takkouche B. Ellis J.rcog. The relationship of headache frequency to hormone use in migraine.library. 9.38. Neurology 2006.53:S19–25. 15.uk/DRAFT_Contraception/In_depth/Management_issues (accessed 12 October 2007).uk/nicemedia/pdf/CG030fullguideline. 14.