I went on Facebook yesterday evening and my head exploded.
Image from uproxx.com.
And no, it was not a stroke from birth control pills. Although, I will be the first to tell you that I am at increased risk of stroke because of them.
It was a related topic, though. The headline cited from CBC news on at least four of my NON-MEDICAL (please note) friends was “Yaz, Yasmin birth control pills suspected in 23 deaths” along with statements from the poster that they stopped taking their pill or were putting this warning out to protect their friends.
Image from litteratursiden.dk.
I had to read the article. As soon as I read the title, I told Patrick that this was totally because some crazy person or people decided to sue the drug company because they had a stroke or a pulmonary embolism (blood clot to the lungs). I was right.
It is actually a sad story, a young girl died from a massive PE while working out. I feel badly. It could be one of my friends. Now, her family decided to sue the drug company that produces this particular pill and are entering a class action suit with a bunch of other people and families who have had potential complications from the pill.
I am not belittling the consequences of a PE or stroke or even a DVT. The first two can kill you and all three can lead to requiring lifelong anticoagulation, which is in and of itself a risky treatment.
This article reports that Bayer, the producer of this particular OCP that contains a novel progestin (aka a different compound that mocks progesterone in the woman’s body) that is sometimes easier to tolerate has paid out millions in lawsuits in the U.S. It also reports the Health Canada findings of reported deaths and serious events due to these particular oral contraceptives as slightly higher than others.
Then, today, to top everything off, I see a CBC community blog reposting some of the comments and social media backlash from the report. Most of the article reiterates a few of the horror stories of people who did have clots and a few who are glad to have changed pills or want to change pills. Then, at the end, they acknowledge that some people pointed out that with any medication there are risks and benefits.
And this brings me to my discussion of the article.
Let’s start with some science.
Image from evolvefish.com.
I know, what does science have to do with this, our lives are at risk!?!
Seriously, science is key here.
Blood clots are normal things are bodies make all the time. Clotting is super complicated (and fascinating) and I am not going to get into the details. Sometimes, our bodies clot too much and that can lead to clots forming in places we don’t want them to… Like our brains or in our legs. And those clots in our legs can break off and get stuck in other places that are dangerous, like our lungs.
Image from bbc.co.uk.
A bunch of things put us at increased risk of clotting.
I checked out a few sources that quote clot risks for your average non-pregnant, non-OCP taking female from 1 to 4 in 10,000.
Some people have genetic alterations that put them at risk. There are certain proteins that, when present make you more at risk of forming clots at baseline. Just a crappy genetic hand. If you have a few relatives that have had “unprovoked clots,” then you might too.
There are other things that provoke clots… Stasis. Aka sitting around and doing nothing. Long distance travel, for instance. Sitting still for flights greater than 8-10 hours, for instance is quoted as a 0.5% risk for all ages not in a high risk category. Or following surgery or a long period of bedrest, average risk women are at anywhere from a 5-10 fold increased risk of blood clots. Some non-hormonal medications increase that risk. Obesity and smoking each have been quote to almost double the clot risk.
Now we move on to the hormonal stuff. I found this fabulous post here at The Blog Who Ate Manhattan if you are a visual sort of person.
Oral contraceptive pills and other hormonal birth control contain different quantities and formulations of hormone.
I will be the first to admit that studies offer varied accounts on the rates of side effects and clots are no different for this. Different studies have different reporting criteria and sometimes rates are grossly underestimated, although overestimation is also possible depending on the age and risk group assessed.
Image from nationalnursingreview.com.
Your traditional OCP pill (like a tricyclen or evra) have a 3-6 per 10,000 risk of clot. OCP with the novel progesterin like Yasmin have an anywhere from 3-9 in 10,000 risk of clot. The interesting piece with the OCPs is that clot risk is highest for the first year and then does drop a bit. The patch also has an increased clot risk of anywhere from 3-10 in 10,000. The ring increases risk too with a 3-8 per 10,000 risk. Progesterone-only contraceptives are some of the only ones that don’t have evidence for increasing clot risk with rates from 1-3 per 10,000.
But wait… Pregnancy is the highest risk of all hormonal risks. It increases the risk of clots up to 5 times. FIVE TIMES!
A lot of numbers, I know.
image from nl.123rf.com.
So, to sum it all up… Everyone is at risk for blood clots. Our risks increase based on the combination of risks we are at. For instance, women over 35, especially those who smoke are almost never offered combination OCP or patches because that would put them at a rather significant clot risk, especially if they decide to go on a long flight and not move.
And yes, numbers do suggest that people on OCP are at increased risk of clots. And that women who choose Yaz or the patch or the ring are at some increased risk of clot compared to others. But then again, pregnancy is much worse!
So, hmmm… Are there lawsuits against other hormonal contraceptive drug companies?
My research for this post shows that there are class action suits in the US against what looks like most drug companies who produce whatever hormonal contraceptive, but especially the higher risk ones… The Yasmin family, the patches and the vaginal rings.
But, I question this practice.
I also wonder why women don’t start suing their male partners for making them pregnant and increasing their clot risk. I shouldn’t. It probably has been done.
All medications have risks.
I have heard people tell me that they don’t want to put anything foreign into their bodies. But, even taking a supplement can be potentially toxic and even Tylenol has risk and adverse reactions. Sure, some things have significantly more risk. But, if you are worried about that, you weigh the risks and the benefits. Use some common sense.
Image from jantoo.com.
When I prescribe birth control (which is rare given I am an oncology resident), I like to have a discussion to assess for other clotting risks and regarding the risks and benefits of the medication as a whole. I was taught (and was under the impression) that physicians ask about things like smoking, high blood pressure, family history of clots and migraines with auras to work out the risks that could happen when on a hormonal contraceptive. I will be the first to acknowledge that we in medicine could do a better job at explaining risks and benefits of drugs, but I also need to point out how many drugs there are and how tight time is.
Clotting is a KNOWN risk of hormonal contraceptives. And therefore taking it, to me, acknowledges that increased risk. Just like you might also get nauseous, have spotting or gain weight. Just like people who take asprin may bleed or people who take antibiotics may have an allergic reaction. There are rare adverse events and there are common adverse events. You always discuss the common and the life-threatening rare. And you weigh the risks.
Clotting is also a known risk to being human. So, really, it is sometimes difficult to attribute every complication to the pill, even if a woman is taking it.
I will be my own example.
I have no clotting risk factors. But, I have migraines with aura. Having a migraine with aura puts me at double the risk of stroke than my normal counterparts (stroke risk in women 15-34 is somewhere between 2 and 3 per 10,000). Adding a combination hormonal contraceptive to the migraine pot increases that risk to anywhere from 11-23 per 10,000. Pregnancy will increase my stroke risk to similar or greater odds.
When I learned this, I opted to take a progesterone only contraceptive. It is a bit less effective and more use dependent, but it was worth it. Will I still get pregnant? Hopefully. Risk versus benefit. Baby>stroke risk. OCP (that potentially worsens the migraines anyway)<stroke risk.
If I were to take a combined OCP, I could have a stroke. I could also have a stroke without taking it. But, who can say for sure. It is just a probability.
The media likes to sensationalize things. And people freak out about stuff. And thus this makes great news.
I don’t like that the people of the media or society who freak out about crap like that is that they don’t think of the other reprecussions. I mean, sure they are making people aware of the risk and maybe stopping a few people from taking a fine medication and thus decreasing their clot risk slightly. But, they are also making people come off of a medication that works for them just because of heresay. Everyone gets side effects and now many will catastrophize them because of this. Some people will get worse side effects from a different pill. Some people will still get a clot. And many people could get pregnant because of their fear of the pill.
Does the cost of unwanted pregnancies that have risks of their own outweigh someone’s need for repayment, the media’s need for publicity or even a few complications (as terrible as that sounds)?
So, this whole news thing makes me crazy. Everyone is coming out of the woodwork with their problems and their cautions. These are KNOWN risks and KNOWN problems. They are much less than the issues that arise with pregnancy and those that arise in people with unwanted pregnancies.
Plus, it is fostering further mistrust in the medical system. I will be the first to acknowledge the system isn’t perfect and we make mistakes, but it is unfair to put such fear and paranoia into people.
Image from vitalia.pl.
If you want to make an informed decision read legitimate research, not news sites and private blogs (seriously, don’t take my word for it). Talk to your doctor and your pharmacist and weigh your options and your personal risk.
Sometimes bad stuff just happens even if every other risk factor is 0. And sometimes you can have a giant “hit me” sign on your chest and be fine. Such is life and biology and probability.
I wish people didn’t have to hurt, but I wish they wouldn’t inflict such wrath while trying to get “justice.”