How to choose the right contraception?
Focus on venous thrombo-embolic risk

Pr Geneviève Plu-Bureau, Dr Brigitte Raccah-Tebeka, Dr Brigitte Letombe and Dr Isabelle Héron, our gynecological ambassadors for Agir pour le Coeur des Femmes, have drawn up a practical fact sheet on the main methods of contraception. The aim of this sheet is to alert the reader to the contraindications of certain types of contraception, to anticipate by identifying contraindications to prescriptions, and to act by adapting contraception to the woman's clinical history, personal and family history, tolerance and satisfaction with contraception. They focus on the risk of venous thromboembolic disease (VTE) in certain women using combined hormonal contraception (COP) (contraception containing an estrogen and a progestin, also known as estroprogestogen contraception).

Hormones, and in particular hormonal contraception, have enabled major advances in women's lives, but their use requires knowledge of their potential risks, in order to propose therapeutic strategies tailored to each woman's individual risk profile. Before each prescription, it is necessary to collect all vascular risk factors, as this risk constitutes one of the main contraindications to the use of estrogens.
Veinous thromboembolic diseases (VTEE) include deep vein thrombosis (lower limbs, upper limbs, brain, portal system, neck vessels...) and pulmonary embolism. These are rare diseases whose incidence increases with age, and is around 1 to 3/1000 in Western countries of all ages. In the context of young women, the incidence is 10 times lower (1 to 2 per 10,000 women who do not use COP). It is now clearly established that COP increases the risk of VTE by a factor of 3 to 6 compared with non-users. The risk increases with age and with a "starter" effect: this risk is clearly greater in the first year of use. It decreases in subsequent years of use, but remains significantly higher than for non-users. It also depends on the dose of estrogen and the type of progestin in the contraceptive combination. The presence of congenital biological thrombophilia increases the risk of VTE by a factor of 30. Family history, especially in the first degree (mother, father, brother or sister) or a high number of affected relatives of any degree, is a major risk factor for VTE.
Progestin-only contraception is particularly indicated for women with a contraindication to COPs. Progestin-only contraception, whether oral, implant or intrauterine device, does not alter coagulation parameters. However, their use is limited by the frequent occurrence of random bleeding.
Prescriptions should be adjusted to take account of any side-effects during renewal consultations. COP is formally contraindicated in women at high vascular risk whatever the route of administration and whatever the type of combined estrogen or progestin used.
Progestin-only contraception, with the exception of injectable medroxyprogesterone acetate, is not associated with an increase in venous risk. It therefore offers an interesting alternative in clinical situations where COCs are contraindicated.

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How to choose the right contraception?
Focus on venous thrombo-embolic risk