Potential Cardiovascular Risks of Estrogens and Progestins
In this video, Anum Minhas, MD, MHS, discusses the potential cardiovascular risks of estrogens and progestins, the contraceptive recommendation for patients seeking to avoid pregnancy and have a high risk of thromboembolism, and gaps in the research on obesity, hypertension, diabetes, and contraception in women of childbearing years.
Additional Resources:
Lindley KJ, Bairey Merz CN, Davis MB, Madden T, Park K, Bello NA; American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group. Contraception and reproductive planning for women with cardiovascular disease: JACC focus seminar 5/5. J Am Coll Cardiol. 2021;77(14):1823-1834. doi:10.1016/j.jacc.2021.02.025
ACOG Practice Bulletin No. 206 Summary: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2019;133(2):396-399. doi:10.1097/AOG.0000000000003073
TRANSCRIPTION:
Anum Minhas, MD, MHS: Hi, everyone. This is Dr Anum Minhas and I'm a cardiologist at Johns Hopkins University with expertise in women's cardiovascular health.
C360: Why are women of childbearing years with obesity viewed as an at-risk population for increased cardiovascular disease?
Women with obesity are known to have an increased risk for cardiovascular disease, and this goes for men too, and people of all genders. So, obesity increases the risk of cardiovascular disease. Now, additionally, pregnancy itself can be a stress test for the heart, and pregnancy can potentially unmask pre-existing risk that is present in a patient, and then additionally potentially increase the risk for new conditions such as preeclampsia that are subsequently related to higher coronary artery disease, stroke, and heart failure later in life. So, women with obesity have an increase in developing adverse pregnancy outcomes such as preeclampsia, and gestational diabetes, which are subsequently linked to increased cardiovascular disease. And then obesity itself, independent of pregnancy, as we know, can increase the risk for cardiovascular disease.
C360: What are some potential cardiovascular risks of estrogens and progestins?
Yeah. So, there have been multiple studies now that have been done looking at the role that estrogen and progesterone play in cardiovascular risk. In general, younger women are protected from cardiovascular disease in part because of estrogen and progesterone which are naturally present in the body. However, in the setting of estrogen and progesterone that are introduced iatrogenically, for instance, with the use of contraceptives that might contain estrogen and progesterone, there are noted to be some increased risk markers, cardiovascular risk markers. So, for instance, blood pressure is known to be higher in patients who are receiving estrogen in some formulations. On the other hand, progestins can increase glucose tolerance. Estrogens are associated with an increase in coagulation factors, as are progestins. Vasomotion can be affected by estrogen and progestin. So, for instance, some studies show that estrogens are associated with an increase in COX-2 and, an increase in nitric oxide. On the other hand, progestins are associated with an increase in vasoconstriction and a decrease in nitric oxide. And then even some changes in the EKG can be noticed. So, some studies suggest that estrogens are associated with increased QT prolongation, while other studies show that progestins are associated with lower QT prolongation. So, all these things tell us that hormones can and do affect the cardiovascular system, and multiple changes can occur, multiple cardiovascular changes that can occurs among patients that are taking estrogen supplements or progesterone supplements, or of course using them as part of a contraception method.
C360: For what populations are oral estrogen-free progestin-only pills recommended or not recommended?
Yeah, so in general, oral progestin-only pills are recommended in patients who are seeking to avoid pregnancy but have a high risk of thromboembolism. So, for instance, in patients that have prior cardiovascular disease, such as peripartum cardiomyopathy, in patients that have had a prior DVT or a PE, or in patients that have ischemic heart disease, progestin-only contraception would be recommended as compared to combined contraception.
C360: What are the gaps in research on obesity, hypertension, diabetes, and contraception in women of childbearing years?
Yeah, so you know, as an epidemiologist and as a cardiologist, it is striking to me how quickly the prevalence of obesity, hypertension, and diabetes are rising in the United States as a country, particularly among younger individuals of reproductive age. So, with that, you know, naturally the question is how safe are different contraceptive methods for women that might have obesity, diabetes, hypertension? Among those cardiometabolic risk factors, we probably have the greatest data on women with hypertension, whereas not as much is known for women with obesity and diabetes in terms of the cardiovascular risk brought on by the different forms of contraception that are available. I think it's important for us to study what the potential cardiovascular risk would be for patients that have pre-existing, pre-pregnancy cardiometabolic risk factors, especially as we expect the prevalence of these risk factors to continue to increase at a population level.
C360: Is there anything else you would like to add?
I think as cardiologists and as researchers in general and clinicians, we are taking care of more and more patients who have pre-existing cardiovascular disease and more and more patients who have cardiovascular risk factors. We need to have good data on how to manage these patients and also good recommendations and guidelines on how to manage these patients. And I think this is an area of cardiology and an area of medicine that highlights the importance of multidisciplinary collaboration. So, for most patients with heart disease who are of reproductive age, I strongly recommend that they both follow with a cardiologist who has some expertise in managing such patients, but then also an obstetrician or a maternal-fetal medicine physician who has experience and comfort in managing patients with cardiovascular disease and cardiovascular risk factors who are pregnant or interested in pregnancy. I think with combined expertise, we can offer our patients the best strategies and the safest strategies, both for the pregnancy itself and then for their reproductive years in general.