Use of combined hormonal contraception and stroke: A case‐control study of the impact of migraine type and estrogen dose on ischemic stroke risk

Abstract

Objective To clarify how factors such as estrogen dose and migraine history (including migraine subtype) impact ischemic stroke risks associated with combined hormonal contraceptive (CHC) use. Background CHC use in those with migraine with aura has been restricted due to concerns about stroke risk. Methods We conducted a case‐control analysis of stroke risk associated with estrogen dose and migraine history among CHC users in a large tertiary care center. All women aged 18–55 who used a CHC between January 1, 2010, and December 31, 2019, were identified. Those with a stroke diagnosis were identified using ICD codes and confirmed via chart and imaging review. Details of personal and family medical history, stroke evaluation, ethinyl estradiol dosing (EE; ≥30 vs. <30 μg), and demographics were collected. From a random sample of 20,000 CHC users without stroke, a control cohort (n = 635) was identified and matched based on patient characteristics, medical and family histories, as well as stroke risk factors, to assess association between migraine diagnosis, migraine subtype, estrogen dose, and stroke. Results Of the 203,853 CHC users in our cohort, 127 had confirmed stroke (0.06%; CI 0.05%, 0.07%). In unadjusted analyses, a higher number of patients in the case cohort had a diagnosis of migraine (34/127, 26.8%) compared to controls (109/635, 17.2%; p = 0.011). Stroke risk was higher with ≥30‐μg EE doses compared to those using a <30‐μg dose (OR, 1.52; CI 1.02, 2.26; p = 0.040). Compared to no migraine, personal history of migraine increased the odds of stroke (OR, 2.00; CI 1.27, 3.17; p = 0.003). Compared to no migraine, stroke risk was not significantly increased in those with migraine with aura, but migraine without aura increased the risk (OR, 2.35; CI 1.32, 4.2; p = 0.004). Conclusions Overall stroke risk in our cohort of CHC users was low. When CHCs are used in those with migraine, formulations containing ≤30 μg EE are preferred. Shared decision‐making should include discussions about ischemic stroke risks in patients with migraine, even those without aura.

Women's health, hormonal balance, and personal autonomy

“…Additionally, HBC containing low doses of norgestrel or levonorgestrel (117) showed an increased RR for hemorrhagic stroke at 3.23 (95% CI: 1.24-8.41), and the RR for aneurysmal bleeding increased to 4.46 (95% CI: 1.58-12.53). Similar results were found in a study addressing the role of migraine, and the risk of cerebral stroke RR was 2.52 (115) in patients with and without aura, increased to 6.25 and 6.35, respectively (116), and was dose-related (122). Furthermore, the data suggest that the stroke RR in HBC users is affected by the presence and degree of other pathologies (115,123).…”

Paternalism in practice: How we create obstacles for sexual, reproductive, and menopausal healthcare despite our best intentions

“…For example, the use of estrogen-containing combined hormonal contraceptives (CHCs) in those who have migraines with aura is strongly discouraged because of a potential increased stroke risk (though absolute risks are low with the use of modern methods). 29 Certainly, for pregnancy prevention alone, if a progestin-only option is tolerated, that would be preferred. However, women may need (or prefer) CHCs to treat a medical condition, in which case the risk-benefi t ratio changes.…”

“…Not uncommonly, I will prescribe a method with a known contraindication, but only after a detailed discussion about pros and cons of different contraceptives-and after the patient verbalizes understanding and provides consent. 29,30 Two guiding principles of reproductive care As a consultant for the contraceptive and hormonal needs of our medically complex patients, I follow 2 guiding principles in managing patient care. First, the contraceptive that the patient prefers is the one she is most likely to use after she leaves my offi ce.…”

“…Fortunately, some guidelines do soften language to address necessary variations in practice (eg, newer migraine guidelines since the publication of the CDC eligibility criteria) and emphasize the importance of shared decision-making, as opposed to a universal recommendation to withhold CHCs in those with migraine with aura. 29,31 The contraceptive that the patient prefers is the one she is most likely to use, and whatever the risks of any contraceptive, the risks of an unintended pregnancy are always far greater…”