The incidence of venous thromboembolism with combined oral contraceptive is 20-30 per 1 lakh women years. Studies have shown that there is an increasing risk of VTE in current users and risk decreases with both time of use and decreasing estrogen dose. We report two cases in which both women had CVST triggered by combined oral contraceptive use. Before prescribing COCs, a complete personal and family history along with evaluation of risk factors for VTE and cardiovascular diseases is mandatory to ensure safe use of COCs.

Shree, Sneha

Singla, Anshuja

Yadav, Garima

English

International Journal of Reproduction, Contraception, Obstetrics and Gynecology

   http://dx.doi.org/10.5455/2320-1770.ijrcog20150253                                                                                     Volume 4 · Issue 1    Page 269 International Journal of Reproduction, Contraception, Obstetrics and Gynecology Singla A et al. Int J Reprod Contracept Obstet Gynecol. 2015 Feb;4(1):269-271 www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789 Case Report Combined oral contraceptives & cerebral venous                               sinus thrombosis: 2 cases and review Anshuja Singla*, Garima Yadav, Sneha Shree             INTRODUCTION Though rare, the risk of thrombotic events with Combined Oral Contraceptives (COC) is there and the safety, an issue of debate. The incidence of venous thromboembolism (VTE) with COC is 20-30 per 1 lakh women years. The highest risk is in the first year of use, suggesting the possibility of a predisposing condition, such as a carrier of a thrombogenic mutation or an alteration in the hemostatic variable like acquired resistance to protein C.1  Studies have shown that there is an increasing risk of VTE in current users and risk decreases with both time of use and decreasing estrogen dose.2,3  Though the risk is mainly related to the dose of estrogens, recent studies have indicated the role of progestins as well. Newer progestins like desogestrel or gestodene have a two-fold greater risk as compared to COC’S containing levonorgestrel (LNG) or norethisterone.4  CASE REPORT Case 1 A 31 year old parous lady presented to Gynaecology casualty with repeated episodes of headache and vomiting for one month. She had history of two episodes of loss of consciousness for which she did not seek any medical help. She started using LNG COC on her own two years back, which she stopped one month back because of repeated headaches. She denied history of fever, visual defects, confusion, weakness, numbness, head trauma, prior migraine or headaches and any thrombotic events. Past and family history was unremarkable. She did not have any addictions or allergies. Motor and sensory examinations were normal. Her thrombophilia screen, haemogram, liver function tests, kidney function tests, thyroid and lipid profile, APLA panel were normal. MR venography revealed an infarct in the sagittal sinus. A working diagnosis of Cerebral Department of Obstetrics & Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi-110095, India   Received: 02 December 2014 Accepted: 23 December 2014  *Correspondence: Dr. Anshuja Singla, E-mail: dranshuja@gmail.com Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT The incidence of venous thromboembolism with combined oral contraceptive is 20-30 per 1 lakh women years. Studies have shown that there is an increasing risk of VTE in current users and risk decreases with both time of use and decreasing estrogen dose. We report two cases in which both women had CVST triggered by combined oral contraceptive use. Before prescribing COCs, a complete personal and family history along with evaluation of risk factors for VTE and cardiovascular diseases is mandatory to ensure safe use of COCs.   Keywords: Combined oral contraceptive, Venous thromboembolism, Eastrogen DOI: 10.5455/2320-1770.ijrcog20150253  Singla A et al. Int J Reprod Contracept Obstet Gynecol. 2015 Feb;4(1):269-271 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                       Volume 4 · Issue 1    Page 270 Venous Sinus Thrombosis (CVST) due to COC was made. Neurology opinion was sought and low molecular weight heparin started. She had gradual improvement in symptoms and was discharged on warfarin. Alternative contraceptive advice was given. The women reported to us 2 months later with 7 weeks pregnancy. As she was not keen to continue the pregnancy and was on warfarin therapy, decision for termination of pregnancy was taken. Patient was discharged in a satisfactory condition and is on regular follow up with the neurology department till date. Case 2 28 year old parous female presented to OPD with severe acute onset continuous headache associated with vomiting. There were no complaints of visual disturbances, seizures, weakness of limbs, fever or altered sensorium or any similar episodes in the past. She gave history of abortion 5 months back following which she was diagnosed with an ovarian cyst and was started on LNG COC. Her general physical examination, motor, and sensory examinations were all normal. Her thrombophilia screen, hemogram, liver function tests, kidney function tests, thyroid and lipid profile, APLA workup were all within normal limits. Non contrast CT head showed thrombosis of right transverse, sigmoid & superior saggital sinuses. MR venography confirmed the findings. Since all investigations were normal, a diagnosis of CVST due to COC was made. Low molecular weight heparin was started .She had gradual improvement and was discharged on warfarin and is on regular follow up. MR venography done 3 months later showed resolution of thrombosis. DISCUSSION At present, no laboratory tests are available which can estimate the risk of developing VTE including Deep Venous Thrombosis (DVT), pulmonary embolism, thrombotic shock and CVST in asymptomatic COC users. The risk of VTE is 3-6 times more in users as compared to non-users.5 CVST, similar in etiology to DVT is rarer, though cases have been reported in literature. De Bruijn et al.6 and Martinelli et al.7 reported that compared to non-users, COC users have increased risk of CVST independent of pro thrombotic conditions. Jick SS8 reported 16 cases in 1 million users. Among them 5 cases were reported with desogestrel, 7 with norgestimate and 2 with LNG current users and 2 cases during the non-exposed times. Although non oral route delivers a lower systemic estrogen dose, a similar decrease in side effects has not been demonstrated. These views were endorsed by Sitruk-Ware et al.9 and Rad et al.10 Kolacki C11 and Dunne C et al.12 separately reported CVST in women using etonogestrel containing vaginal contraceptive ring.  A Danish cohort study4 concluded that compared to non-users of hormonal contraception, current users with LNG had 3 fold increased risk, those with desogestrel, gestodene and drosperinone had 6-7 fold increased risk of confirmed venous thrombosis. Our patient was a current LNG user. Therefore, before prescribing COC’s, a complete personal and family history along with evaluation of risk factors for VTE and cardiovascular diseases is mandatory to ensure safe use of COC’s. Caution must be exerted on over the counter sales of COC especially in low resource countries because nobody knows who can be a potential candidate to have thrombosis. Funding: No funding sources Conflict of interest: None declared Ethical approval: Not required  REFERENCES 1. Fruzzetti F, Perini D, Spirito N, Manca R. Oral contraceptive pill and thrombotic risk: epidemiological studies. Minerva Ginecol. 2012;64:539-49. 2. Vandenbroucke JP, Helmerhorst FM, Bloemenkamp KW, Rosendaal FR. Third-generation oral contraceptive and deep venous thrombosis: from epidemiologic controversy to new insight in coagulation. Am J Obstet Gynecol. 1997;177:887-91. 3. Walker AM. Newer oral contraceptives and the risk of venous thromboembolism. Contraception. 1998;57:169-81. 4. Lidegaard Ø, Nielsen LH, Skovlund CW, Skjeldestad FE, Løkkegaard E. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001-9. BMJ 2011;343:d6423. 5. WHO. Cardiovascular disease and steroid hormone contraception: report of a WHO scientific group. World Health Organ Tech Rep Ser. 1998;877:1-89. 6. de Bruijn SF, Stam J, Koopman MM, Vandenbroucke JP. Case-control study of risk of cerebral sinus thrombosis in oral contraceptive users and in (correction of who are) carriers of hereditary prothrombotic conditions. The Cerebral Venous Sinus Thrombosis Study Group. BMJ. 1998;316(7131):589-92. 7. Martinelli I, Sacchi E, Landi G, Taioli E, Duca F, Mannucci PM. High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene mutation and in users of oral contraceptives. N Engl J Med. 1998;338(25):1793-7. 8. Jick SS, Jick H. Cerebral venous sinus thrombosis in users of four hormonal contraceptives: levonorgestrel-containing oral contraceptives, norgestimate-containing oral contraceptives, desogestrel-containing oral contraceptives and the Singla A et al. Int J Reprod Contracept Obstet Gynecol. 2015 Feb;4(1):269-271 International Journal of Reproduction, Contraception, Obstetrics and Gynecology                                       Volume 4 · Issue 1    Page 271 contraceptive patch. Contraception. 2006;74(4):290-2. 9. Sitruk-Ware R, Plu-Bureau G, Menard J, Conard J, Kumar S, Thalabard JC, et al. Effects of oral and transvaginal ethinyl estradiol on hemostatic factors and hepatic proteins in a randomized, crossover study. J Clin Endocrinol Metab. 2007;92(6):2074-9. 10. Rad M, Kluft C, Ménard J, Burggraaf J, de Kam ML, Meijer P, et al. Comparative effects of a contraceptive vaginal ring delivering a nonandrogenic progestin and continuous ethinyl estradiol and a combined oral contraceptive containing levonorgestrel on hemostasis variables. Am J Obstet Gynecol. 2006;195(1):72-7. 11. Kolacki C, Rocco V. The combined vaginal contraceptive ring, nuvaring, and cerebral venous sinus thrombosis: a case report and review of the literature. J Emerg Med. 2012;42(4):413-6. 12. Dunne C, Malyuk D, Firoz T. Cerebral venous sinus thrombosis in a woman using the etonogestrel-ethinyl estradiol vaginal contraceptive ring: a case report. J Obstet Gynecol Can. 2010;32(3):270-3.      DOI: 10.5455/2320-1770.ijrcog20150253 Cite this article as: Singla A, Yadav G, Shree S. Combined oral contraceptives & cerebral venous sinus thrombosis: 2 cases and review. Int J Reprod Contracept Obstet Gynecol 2015;4:269-71. 

Combined oral contraceptives & cerebral venous sinus thrombosis: 2 cases and review

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Combined oral contraceptives & cerebral venous sinus thrombosis: 2 cases and review

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International Journal of Reproduction, Contraception, Obstetrics and Gynecology