Download Choosing the Best Contraceptive Method for the Adult With

Choosing the Best Contraceptive
Method for the Adult With Congenital
Heart Disease
Candice K. Silversides, MD, MS, FRCPC, Mathew Sermer, MD, FRCPC,
and Samuel C. Siu, MD, MS, FRCPC
Corresponding author
Candice K. Silversides, MD, MS, FRCPC
University of Toronto Pregnancy and Heart Disease Research
Program, Toronto General Hospital, 585 University Avenue, 5N521 North Wing, Toronto, Ontario M5G 2N2, Canada.
E-mail: [email protected]
Current Cardiology Reports 2009, 11:298–305
Current Medicine Group LLC ISSN 1523-3782
Copyright © 2009 by Current Medicine Group LLC
As women with congenital heart disease (CHD)
approach childbearing age, issues such as pregnancy
and contraception need to be addressed. Women
with CHD represent a heterogeneous population.
While some have simple cardiac lesions and thus
have contraceptive risks that are no different from
those of the general population, others have complex,
multisystem disease such that incorrect contraception advice can be associated with serious health
consequences. Choosing a contraceptive requires
consideration of the risk of pregnancy; the available
contraception options; their risks, failure rates, and
benefits; and the preferences of the woman. This
review focuses on contraceptive selection in women
with CHD.
Introduction
As the population of women with congenital heart disease (CHD) reaching childbearing age continues to grow,
issues such as pregnancy and contraception need to be
addressed. The current American College of Cardiology/
American Heart Association guidelines for the management of adults with CHD suggest that “it is the duty of
the adult CHD specialist to provide or otherwise make
available informed advice on contraception, including
discussion of risk” [1].
Women with CHD represent a heterogeneous population. While some women have simple cardiac lesions,
making their pregnancy and contraceptive risks no
different from those of the general population, others
have complex, multisystem disease. For them, incorrect
pregnancy or contraception advice can result in serious
health risks. In this group of women, choice of contraception requires consideration of the following:
•
Pregnancy risk
•
Available contraception options and their risks
and benefi ts
•
Failure rates and understanding the consequences
of an unplanned pregnancy
• Preferences of the woman
For women with CHD, these issues can be complex,
and input may be needed from a cardiologist who has
expertise in CHD and from a gynecologist or obstetrician. In regard to the risks of pregnancy, cardiologists
are best suited to assess maternal cardiac risks, address
cardiac medication use during pregnancy, and provide
information about long-term prognosis when appropriate. Women must be educated about these risks to
determine if and when they wish to become pregnant.
Risk stratification during pregnancy integrates global
and lesion-specific risks and is discussed elsewhere
[2–5]. In addition, understanding the risk of pregnancy
is important to determine the type of contraception
required. For example, in women with prohibitively
high pregnancy risks (eg, those with Eisenmenger’s
syndrome), permanent forms of contraception may be
required. In women at high risk for complications (eg,
women with mechanical valves, Fontan circulation, or
significant systemic ventricular dysfunction), failure
rates are an important consideration [6]. Beyond pregnancy risk assessment, cardiologists are responsible for
educating women about safe conceptive options as they
relate to their cardiac condition. Complicating matters
is our current lack of contraceptive efficacy and safety
data in women with CHD. All recommendations are
extrapolated from studies in women without CHD, thus
highlighting the need for careful individualized assessment. This review focuses on contraceptive selection in
women with CHD.
Choosing the Best Contraceptive Method for the Adult With CHD
Contraceptive Options
Contraceptive options include the following:
•
Combined hormonal contraceptives (COCs;
estrogen/progestin formulations)
•
Progestin-only formulations
•
Intrauterine devices (IUDs)
•
Barrier methods
•
Sterilization/permanent forms of contraception
Many women use different forms of contraception during their reproductive years. In a survey from our center,
women with CHD reported use of multiple methods of
contraception, most commonly condoms, COCs, progestin
injections, and rhythm or natural methods. Five percent
had undergone a tubal ligation [7•]. Each method has associated benefits and risks that are discussed in detail below.
Combined hormonal contraceptives
COCs containing estrogens and progestins (synthetic
forms of progesterone) inhibit ovulation primarily by suppressing the hypothalamic gonadotropin-releasing factor.
COCs vary in the type of progestin and concentrations
of estrogen/progestin used. Significant modifications have
been made since their introduction; consequently, they are
referred to as first-, second-, third-, and fourth-generation
COCs. Over time, there have been decreases in the dose of
estrogen and changes in the types of progestins used. The
current term low-dose COC refers to formulations with
35 μg or less of ethinylestradiol. The most commonly used
delivery mode is oral, but other preparations are available
and include transdermal patches (ORTHO EVRA; Ortho
Women’s Health & Urology, Raritan, NJ) and vaginal
rings (NuvaRing; Schering-Plough, Kenilworth, NJ). Nonoral routes are used for 21 days and then removed for 7
days. Failure rates vary from 3% to 8% during the fi rst
year of use [6]. Estrogens and progestins can interfere with
drug metabolism, and warfarin levels can be affected.
Therefore, monitoring of International Normalized Ratio
is important, particularly when initiating use of COCs.
Estrogen and progestins have several adverse cardiac
effects. The most clinically important is that of estrogen, which alters the coagulation profile and results in
increased rates of thromboembolic complications. Clinical
studies have shown an increased risk of venous thromboembolism in current users compared with nonusers [8,9].
The actual risk of venous thromboembolism from pregnancy itself is much higher. Complications are reported
to be highest within the fi rst 6 months of use. The higher
doses of estrogen in fi rst-generation COCs were associated
with higher rates of thromboembolic disease. Second- and
third-generation formulations have been associated with
less thromboembolic risk [10,11]. The thromboembolic
risks of the newer formulations of COCs and nonoral
formulations are not known. COCs have been shown
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to have a negative impact on the lipid profile (reduction
in high-density lipoproteins and increase in low-density
lipoproteins/triglycerides) [12] and glucose metabolism
[13]. Use of COCs is associated with an increase in blood
pressure [14,15]. The risks of arterial thrombotic complications are increased in women taking COCs who have
additional vascular risk factors, such as hypertension,
diabetes, obesity, smoking, or migraine headaches [16,17].
However, this association between coronary artery events
and use of second- and third-generation COCs has not
been demonstrated consistently [18,19]. Finally, some data
suggest that estrogen may modify the potassium channel,
but the clinical significance of this fi nding is unknown.
Because of the potential adverse effects of COCs, the
World Health Organization (WHO) and American College of Obstetrics and Gynecology (ACOG) have published
general guidelines for the use of low-dose COCs (Table 1)
[20,21,22••]. Although they are not specific to women
with CHD, these guidelines need to be incorporated into
decision making for all women. For instance, COCs are
contraindicated in women older than 35 years of age who
smoke. Other examples that may pertain to women with
CHD include contraindications to COCs in women with
migraines and focal neurologic symptoms (migraines with
aura). Migraines may be more common in some forms of
CHD (ie, women with coarctation of the aorta), and this
recommendation is important to address [23]. COCs are
also contraindicated in women with severe (decompensated)
cirrhosis or benign or malignant liver tumors. This may be
relevant for women with CHD who have liver disease from
a blood transfusion during previous cardiac surgery or in
those with a Fontan circulation [24].
There is limited literature addressing contraceptive
selection in women with CHD [1,25–27,28••]. The most
detailed consensus statement comes from a British working
group that developed guidelines for contraceptive use in
women with heart disease using the WHO format (Table 2)
[27]. These recommendations are discussed below. For
women with CHD, the thrombotic risk posed by COCs
is the main contraindication to their use. Cardiac lesions
classified as WHO class 4 (COC method not to be used)
included conditions with increased thrombotic or embolic
risks. Lesions with increased thrombotic risks (WHO class
4) include older-style mechanical valves (Starr Edwards,
Björk-Shiley), which have higher rates of valve thrombosis; pulmonary hypertension of any cause, which can be
associated with pulmonary artery thrombus/pulmonary
embolism [29]; and dilated cardiomyopathy and left
ventricular dysfunction from any cause (left ventricular
ejection fraction < 30%). Women with Fontan operations
(particularly the older right atrial to pulmonary artery
Fontan operation) are at high risk for atrial thrombus and
pulmonary emboli [30] even when they are not exposed
to COCs, and some centers advocate prophylactic anticoagulation in all of them. Both the British working group
and the American College of Cardiology/American Heart
Association adult CHD guidelines have made similar
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Table 1. Recommendations of the American College of Obstetrics and Gynecology for the use of hormonal
contraception in women with coexisting medical conditions
Recommendations
Level of evidence
COCs are not recommended for women with a documented history of unexplained venous thromboembolism or venous embolism associated with pregnancy or exogenous estrogen use, unless they are
taking anticoagulants.
A*
COCs should be prescribed with caution, if ever, to women older than age 35 y who are smokers.
A*
Levonorgestrel IUS is appropriate for women with diabetes without retinopathy, nephropathy, or other
vascular complications.
A*
Women with well-controlled and monitored hypertension who are aged 35 y or younger are appropriate
candidates for a trial of combination contraceptives, provided they are otherwise healthy, show no
evidence of end-organ vascular disease, and do not smoke.
B†
Use of COCs by women with diabetes should be limited to those who do not smoke, are younger than
age 35 y, and are otherwise healthy with no evidence of hypertension, nephropathy, retinopathy, or
other vascular disease.
B†
Use of COCs may be considered in women with migraine headaches if they do not have focal
neurologic signs, do not smoke, are otherwise healthy, and are younger than age 35 y. Although
cerebrovascular events rarely occur in women with migraines who use COCs, the impact of a stroke
is so devastating that clinicians should consider the use of a progestin-only, intrauterine, or barrier
contraceptive in this setting.
B†
COCs should be used with caution in women older than age 35 y who are obese.
B†
If COC are continued before major surgery, heparin prophylaxis should be considered.
B†
Women with controlled dyslipidemia can use low-dose COCs. If the low-density lipoprotein level is
> 160 mg/dL, triglyceride level is > 250 mg/dL, or multiple additional risk factors for coronary artery
disease are present, alternative contraception should be considered.
C‡
Progestin-only contraceptives may be appropriate for women with coronary artery disease, congestive
heart failure, or cerebrovascular disease.
C‡
*Recommendations and conclusions based on good and consistent scientific evidence.
†
Recommendations and conclusions based on limited or inconsistent scientific evidence.
‡
Recommendations and conclusions based primarily on consensus and expert opinion.
COC—combined hormonal contraceptive; IUS—intrauterine system.
(Adapted from American College of Obstetrics and Gynecology Committee on Practice Bulletins-Gynecology [22••].)
recommendations to avoid COCs in women with cyanosis
related to intracardiac shunts or after Fontan operations
(WHO class 4 and class 3, respectively) [1]. With underlying arterial disease, there is a risk for adverse events.
Therefore, COCs should not be used in women with
ischemic heart disease or previous arteritis involving the
coronary arteries (ie, Kawasaki disease). Because of the
risk of paradoxical emboli in women with intracardiac
shunts or pulmonary arteriovenous malformations, COCs
were classified as WHO class 4. Intracardiac shunts, both
right to left and left to right (which have the possibility of
reversing shunts transiently), were considered contraindications to using COCs. However, an exception was made
in the case of intracardiac shunting as a result of a patent
foramen ovale, a normal variant in approximately 20% of
the population.
Some of the WHO class 4 recommendations from
the British working group may not be universally
accepted. For instance, the consensus from the British
working group was that even when treated with warfarin, women with older-style mechanical valves and
Fontan circulation should not use COCs. This opinion
is not supported by data, and the risk of thrombosis
in women who are adequately anticoagulated is not
known. Therefore, physician practice may vary when it
comes to using COCs in women treated with warfarin.
Another example in which physician practice may vary
relates to COC use in women with dilated left atrial
dimensions greater than 4 cm (WHO class 4, according
to recommendations). As no data support this recommendation and many women with CHD will have left
atrial enlargement, this type of recommendation needs
to be tailored to the individual.
WHO class 3 (caution in use) cardiac lesions include
newer-generation mechanical heart valves such as bileaflet
valves, atrial fibrillation or flutter, prior thromboembolic
event and currently on warfarin (ACOG guidelines suggest that COCs are contraindicated in women with prior
thromboembolic events), repaired coarctation with aneurysm and/or hypertension, and Marfan’s syndrome with
unoperated aortic dilation (Table 2).
Although there are many potential adverse effects
of COCs, there are also benefits beyond contraception,
specifically protection against endometrial and ovarian
cancer, reduced risk of benign breast cyst, reduced risk
of iron-deficiency anemia, and treatment of acne. These
benefits can be important for some women and need to be
factored into decision making.
Tissue prosthetic valve lacking any of the Atrial septal defect with left-to-right
Dilated left atrium > 4 cm
features noted in WHO class 3 or class
shunt that may reverse with physiologic
4 columns
stress (eg, Valsalva maneuver)
Mild pulmonary stenosis
Pulmonary arteriovenous malformation
*Condition with no restriction on use of the contraceptive method.
†
Condition in which the advantages of the method generally outweigh the theoretical or proven risks.
‡
Condition in which the theoretical or proven risks usually outweigh the advantages of using the method.
§
Condition that represents an unacceptable health risk if the contraceptive method is used.
LVEF—left ventricular ejection fraction; WHO—World Health Organization.
(From Thorne et al. [27]; with permission.)
Prior left ventricular dysfunction, any cause
(eg, dilated cardiomyopathy [LVEF < 30%])
Uncomplicated Marfan’s syndrome
Coronary arteritis (eg, Kawasaki disease
with coronary involvement)
Coronary artery disease
Past thromboembolic event (venous or
arterial) while not taking warfarin
Past cardiomyopathy fully recovered,
including peripartum cardiomyopathy
Previous thromboembolism
Hypertrophic cardiomyopathy lacking any
WHO class 3 or class 4 features
Fontan heart even while taking warfarin
Cyanotic heart disease even while taking warfarin
Repaired coarctation with aneurysm
and/or hypertension
Bileaflet mechanical valves in the mitral Björk-Shiley or Starr Edwards valves even
or aortic position while taking warfarin while taking warfarin
Simple congenital lesions successfully
Small left-to-right shunts not reversible with Marfan’s syndrome with aortic dilation,
repaired in childhood and with no
physiologic maneuvers (eg, small ventricular unoperated
sequelae (atrial or ventricular septal
septal defect, small patent ductus arteriosus)
defect, patent ductus arteriosus, or total
anomalous pulmonary venous drainage)
Repaired coarctation with no hyperten- Surgically corrected congenital heart
sion or aneurysm
disease lacking any of the features noted
in WHO class 3 or class 4 columns
Uncomplicated mild native mitral and
aortic valve disease
Bicuspid aortic valve with normal
function
Atrial fibrillation or flutter if
not anticoagulated
Most arrhythmias, other than atrial fibrillation Atrial fibrillation or flutter while
or flutter
taking warfarin
WHO class 4 (do not use)§
Mitral valve prolapse with trivial mitral
regurgitation
WHO class 3 (caution in use)‡
WHO class 2 (broadly usable)†
WHO class 1 (always usable)*
Table 2. Recommendations for the use of combined hormonal contraceptives (combined oral contraceptives, transdermal patches, and vaginal rings)
in women with cardiac disease
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Progestin-only contraception
Intrauterine devices
Oral progestin-only contraceptives (“mini-pills”) act on
the cervical mucus to decrease sperm penetration; the
injectable form also inhibits ovulation. Norethindrone
and norgestrel are the most common progestins (synthetic form of progesterone) used in the oral preparations.
Other methods of delivery of progestin-only contraception include intramuscular (depot medroxyprogesterone
acetate [Depo-Provera; Pfi zer, New York, NY]), subcutaneous (medroxyprogesterone acetate [Depo-SubQ
Provera; Pfi zer, New York, NY]), subdermal implants
(etonogestrel [Implanon; Schering-Plough, Kenilworth,
NJ]), and levonorgestrel-impregnated intrauterine systems
(Mirena; Bayer, Leverkusen, Germany).
Because there is no associated increased risk of arterial
or venous thrombotic events, progestin-only forms of
contraception are often suitable for women with CHD
[31–33]. They also have less effect on blood pressure compared with COCs and can be used by smokers. One of
the major limitations of the oral preparations is their relatively high failure rates (5% to 10%) within the fi rst year
of use; pills also must be taken at the same time each day
[6]. The high failure rates limit their use in women at high
risk for pregnancy-related complications. Women with
Eisenmenger’s syndrome, significant pulmonary arterial
hypertension, Marfan’s syndrome with dilated aorta,
significant cardiomyopathy, or severe symptomatic aortic
stenosis should not use oral progestin-only contraception.
Injectable and implantable forms are much longer lasting;
depot medroxyprogesterone acetate injections are administered every 3 months, and etonogestrel implants every 3
years. Failure rates are much lower with the injectable and
implantable forms of progestin-only contraception and
therefore are suitable for women at high risk for adverse
pregnancy outcomes.
The most common side effect is irregular uterine
bleeding, which results in high discontinuation rates.
With depot medroxyprogesterone acetate or subdermal
etonogestrel implants, women may become amenorrheic over time, but early irregular bleeding remains
unacceptable to many. Progestin use can result in fluid
retention, which must be considered in some women
with clinical heart failure or other conditions adversely
affected by volume retention. Although intramuscular
injections can result in hematomas in women taking
anticoagulants, ACOG guidelines still recommend
depot medroxyprogesterone acetate as an appropriate option for this population [22••]. Like the COCs,
progestin-only contraception can affect warfarin levels. Although there have been concerns about the use
of depot medroxyprogesterone acetate and osteoporosis, the most recent recommendations suggest that in
healthy young women and adolescents, the advantages
of depot medroxyprogesterone acetate likely outweigh
the potential risk of future osteoporosis [22••]. Subdermal etonogestrel implants are considered to be as
effective as sterilization.
IUDs are inserted into the uterus and prevent fertilization; impede the ability of the sperm to fertilize the
ova; and, if fertilization occurs, prevent implantation.
There are two commonly used IUDs: the copper IUD
and the progestogen-releasing IUD (Mirena). The progestogen-releasing IUD also acts on the cervical mucus
to prevent fertilization. IUDs are very effective forms of
contraception (failure rates of 0.1% [progestogen-releasing IUD] and 0.8% [copper IUD] during the fi rst year of
use). Once inserted, they are effective for many years.
The IUDs’ popularity in the United States decreased
because of earlier reports of an association with pelvic
infections. For women at low risk for sexually transmitted disease, the risk of infection is low, but exposure to
sexually transmitted disease is an important factor when
considering this form of contraception [34]. There is a
risk of infection with IUD insertion that can be eliminated with cautious aseptic technique and antibiotic
prophylaxis in high-risk women. The most common
side effects after insertion are uterine bleeding, which is
reported to be less with the progestogen-releasing IUD.
In some instances, expulsion of the IUD can occur. For
women with pulmonary hypertension or Fontan circulation, the profound and difficult-to-treat vagal reaction
(bradycardia and hypotension) that can occur with
device placement makes this form of contraception contraindicated. Otherwise, IUDs are considered a safe and
effective alternative in women with CHD.
Barrier and chemical forms of contraception
Barrier methods of contraception include the male and
female condoms, diaphragms, and cervical caps. Spermicides typically contain the surfactant nonoxynol-9 and
come in the form of foams, gels, creams, and suppositories.
To provide adequate contraception, it is recommended
that spermicides be used in combination with barrier
methods of contraception. The male latex condom, the
most common barrier method, protects against pregnancy
and sexually transmitted disease. There are no maternal
risks for women with CHD who use barrier methods.
However, with typical use, unintended pregnancy within
the fi rst year of use occurs in 15% to 32% of women
(Table 1). Because of the high failure rates, women at high
risk of adverse pregnancy outcomes (discussed previously)
should not use this form of contraception.
Permanent forms of contraception
Sterilization options include vasectomy for the male
partner, tubal ligation, and insertion of intratubal
stents (Essure). Because of the decreased life span of
women with complex CHD and the possibility that men
may outlive their spouses and want to father children
with a new spouse, couples may not wish to proceed
with vasectomy. Tubal ligation and intratubal stents are
intended to be permanent. Because of the psychological impact, women should be counseled carefully and
Choosing the Best Contraceptive Method for the Adult With CHD
educated about the effective alternative options. In
some cases, sterilization may be considered if the risk
of pregnancy is prohibitive and other options are not
acceptable to the women. Tubal ligation has reported
failures of 1 in 200 in some series, but others suggest
that the failure rates are much lower. Failure rates vary
according to the method of surgical approach, the clinical features of the woman, and the experience of the
gynecologist [35,36]. Procedures, such as tubal ligation,
are associated with increased risks in some women with
CHD. General anesthetics, increases in intra-abdominal pressure from abdominal insuffl ation with carbon
dioxide, and instrumentation of the cervix resulting
in a vasovagal response can be dangerous in patients
with Fontan circulation or Eisenmenger’s physiology.
There is also a risk of paradoxical emboli from carbon
dioxide gas in women with right-to-left shunts. In these
patients, laparoscopic complications can be avoided by
performing a tubal ligation via a mini laparotomy. Nevertheless, because of the risks, these procedures should
be performed by obstetricians or gynecologists with
expertise in treating women with CHD. Preliminary
data suggest that intratubal stent (Essure) insertion
with local anesthesia may be a safer alternative for
women with complex forms of CHD [37,38]. As with
laparoscopic procedures, these procedures should only
be performed at centers with expertise in treating CHD
in high-risk women.
Specific Recommendations for High-risk
Cardiac Lesions
Eisenmenger’s syndrome
Because of the high risk of pregnancy, women with Eisenmenger’s syndrome should be counseled about the option
of permanent contraception [39,40]. However, sterilization procedures are associated with maternal risks,
including mortality, and should only be performed at
centers with expertise in treating CHD. Mini-laparotomy
or intratubal stents may be safer options in this population of women. COCs should not be used due to the risk
of thromboembolism. Other safe and effective choices
include intramuscular, subcutaneous, and subdermal
forms of progesterone-only contraception and IUDs.
Mechanical prosthetic heart valves
Women with mechanical valves are at high risk for thrombotic complications; therefore, COCs should not be used
in those who are not receiving adequate anticoagulation.
No data are available on the safety of COCs in women
treated with warfarin. Thus, some specialists are comfortable recommending COCs in women appropriately
anticoagulated with warfarin. All women treated with
anticoagulation must receive preconception counseling
about the risks and benefits of various anticoagulation
regimens. Progesterone-only forms of contraception,
IUDs, and barrier methods are other alternatives.
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Fontan circulation
COCs are not recommended for women who have had a
Fontan operation because of the associated risk of right atrial
thrombus and/or pulmonary embolus and the potentially
disastrous effects of thromboemboli on the Fontan circulation. Because IUD insertion can result in a serious vagal
response, it is not recommended in this group of women.
Progesterone-only contraception is ideal. Barrier methods
can be used, but failure rates need to be considered.
Severe systemic ventricular dysfunction
Maternal complication rates are high, and in many cases,
pregnancy is contraindicated; therefore, barrier methods
are not suggested. Because of the potential for thrombus
formation, COCs also are not recommended in women
who are not being treated with anticoagulation. The recommendation to use COCs in women taking appropriate
anticoagulation may vary according to the treating physician. Progesterone-only forms of contraception and IUDs
are appropriate options.
Emergency Forms of Contraception
In the United States, emergency oral contraception (“morning-after” pill) contains the progestin levonorgestrel.
Combined forms (ethinyl estradiol and levonorgestrel) are
available in other countries. Pills must be taken within
72 hours of intercourse. The predominant side effects
are nausea and vomiting, but there is no risk of venous
thromboembolism [22••]. In almost all instances, there
are no contraindications to emergency contraception use in
women with CHD; however, caution is recommended in
women with current deep venous thrombosis or ischemic
heart disease. The reported failure rate is less than 1%.
As with other hormonal contraceptives, warfarin metabolism can be affected, and International Normalized Ratio
should be monitored.
Contraception Counseling
Discussions pertaining to contraception options should
begin early and may need to be reassessed as women age
or if there are changes in maternal health. A recent study
demonstrated that many young women with CHD do not
use adequate methods of birth control [41]. Furthermore,
several studies have shown that counseling is often done
poorly or not at all [7•,42,43]. In a survey of women with
CHD in our clinic, we found that only half recalled receiving specific information from a nurse or physician about
birth control. Of the 31 women with contraindications to
COC use in that series, 45% had used this method of birth
control [7•]. In this regard, there is room for improvement.
Models include formal contraception counseling programs
in the CHD clinic [44], collaborative CHD and contraception clinics [43], and patient educational materials (eg,
patient education conferences, websites, or educational
pamphlets in CHD clinics).
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Conclusions
Contraception counseling is an important aspect of care
for women with CHD. It requires understanding of the
risks of pregnancy and contraception efficacy and safety.
Unfortunately, in many instances, contraception counseling is being done inadequately. As a consequence, some
women are exposed to unnecessary risks. Improvements
in patient and physician education are necessary. Efficacy
and safety studies are not specifically available for women
with CHD, and recommendations are based on extrapolations from studies of women without heart disease. In
many cases, this extrapolation is adequate, but additional
studies are still needed to help us better understand the
risk in this unique population.
Disclosure
No potential confl icts of interest relevant to this article
were reported.
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