Contraceptive choices for females with congenital heart disease
Introduction
Family planning is an important part of any young woman's life. The impressive long-term survival now expected for women with congenital heart disease makes family planning options an integral part of their ongoing care. Planning one's future, including education, career, and procreation is essential for successful transition to adulthood. For generations, women have enjoyed increasing autonomy in all social aspects of their lives; perhaps most importantly those of their own sexuality. From choosing whether to have children or not, to enjoying sexual experiences without the fear of unwanted pregnancies, young women entering the 21st century are fortunate to have many safe contraceptive options. For those with congenital heart disease, these options need to be carefully evaluated and discussed openly, so that misconceptions are not perpetuated.
Published information about contraception in women with congenital heart disease is scarce and relies heavily on literature about the overall cardiovascular risks of different types of contraception [1], [2], [3]. There are no prospective data published about the relative risk of different forms of contraception specific to congenital heart disease, and many of the current recommendations are based on anecdote and commonsense. The complexity of congenital cardiac diagnoses, surgeries, and hemodynamics requires individual consideration of risk entities.
Section snippets
Hormonal contraception
Hormonal contraception is highly effective and safe for the majority of women with congenital heart disease. For the most compliant patients, failure rates vary between 1 and 3%, depending on the preparation used [4], [5], [6], [7]. The three main preparations include: the combined hormonal method in pill form, transdermal form, injectable form, or vaginal ring (containing varying doses of estrogen and progestin); the progestin-only pill; and the implantable or injectable forms of progestin.
Risk stratification
For the purpose of this review, thrombotic risk substrates are divided into three groups: low, moderate and high. Risks are primarily applied to thromboembolic potential, and, therefore relate specifically to hormonal contraception. For patients on anticoagulants (coumadin or aspirin), it can be argued that contraceptive thromboembolic risk is reduced. However, compliance and anticoagulation stability are major variables that influence risk. Multi-center trials are needed to determine whether a
Contraceptive counseling
Perhaps the most difficult and sensitive area of discussion between a pediatric cardiologist and their adolescent patient, is that of sexual activity and contraception [39]. Discussions need to be started early in adolescence, in order to avoid frequent misconceptions based on lack of information, or frankly wrong information. Initially, these discussions with the adolescent can include the parent and be addressed as ‘general information that is important for all young people with your type of
Conclusions
Young women with congenital heart disease currently have many options available for pregnancy prevention. The burden rests on the cardiologist to properly counsel female patients, and to collaborate with gynecologists so that this advice can be acted upon. Individual patient assessment and a basic understanding of the efficacy and risks of different contraceptive measures can assist the cardiologist in making safe decisions.
A combined oral contraceptive with the lowest dose of estrogen is the
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2010, Paediatric CardiologyManagement of Congenital Heart Disease in Pregnancy
2009, Paediatric CardiologyManagement of Pregnancy and Contraception in Congenital Heart Disease
2008, Congenital Heart Disease in AdultsContraception for women with heart disease: An update
2017, Minerva GinecologicaReproductive Health and Women with Congenital Heart Disease: A Practice Update
2016, Journal of Perinatal and Neonatal Nursing