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How to deal with the risk (small but lethal) of developing thrombosis because of the pill

RIO – It is increasingly common to find young women who have left the contraceptive pill behind. Created in 1960, the pill that represented a revolution in the life of this portion of the population – who for the first time had the chance to do family planning – today is viewed with caution by women. The main fear is thrombosis, that is, the formation of a thrombus inside a blood vessel or heart. In some cases, the condition may progress to its most serious complication, stroke. This side effect of the pill, already well documented in the medical literature, is very rare, but when it does, it has the potential to be lethal.

Contraception Guide:
Know the pros and cons of each method

The risk of a woman who does not take the contraceptive pill to develop thrombosis is 4 in 10,000, over the course of a year. If she takes the pill, that risk more than doubles to 10 in 10 thousand in a year, explains gynecologist Ilza Maria Urbano Monteiro of the Brazilian Federation of Gynecology and Obstetrics Associations (Febrasgo).

This rate of risk has already greatly decreased over the past few decades. The first pills had a hormone dosage up to 90% higher than the current ones, which generated more serious side effects in the 60's. So why did the wave of dropping the pill come just in the last few years?

– Today, you can choose. When the pill was created, there were no other options, such as the IUD or the diaphragm, "says Ilza, who is vice president of Febrasgo's National Contraceptive Commission. – With women's increasing empowerment, women have become more concerned with choosing how to take care of their own bodies, how they work, what options they have, and how to decide with their doctor what is safer for them. the case of each.

For mining company Carolina Jardim (read the full report at the end of the report), who had pulmonary embolism after thrombosis for less than a month – and had no other risk factor besides the contraceptive pill – the red alert came on. She complains about the lack of medical advice.

"Since I've always been healthy, I never imagined that could happen to me," she says. "All my life, no gynecologist I consulted with has informed me or warned me about the risks.

A similar case occurred with Ana Carolina Asch (the full report is also at the end of the text), who had thrombosis in 2015 and today has as a sequel the thickening of a vein in the leg.

"The truth is, I was very lucky. I could have died. I got the feeling that the pill is a roulette wheel: it's okay … until it's gone, "she says. "What scared me the most was the fact that a medicine had made me sick. And when I started complaining about thrombosis, the doctor said that I was "a very impressionable little girl." I even suffered misogyny.


Guidance for the doctors themselves

The gynecologist Ilza Maria Urbano Monteiro points out that, in order to better guide the doctors themselves and the population in general, Febrasgo launched the campaign
#Decide Together,
with an online page that gathers information on all existing contraceptive methods.

"What we can not do is demonize the pill because, for all the people it takes, the risk is quite small. During pregnancy, for example, the risk of thrombosis is three times higher than during pill use. But what is fundamental is that the woman is well informed, so that she can choose, under the doctor's guidance, the risk that is worth running – she points out.

Adriana Scavuzzi, a member of the Gynecology and Obstetrics Technical Chamber of the Federal Council of Medicine (CFM), explains that a thorough consultation is always necessary to choose a more appropriate form of contraception for each woman – and that this has to be done with the her participation. And not with a hurried prescription written in a few minutes.

"It's impossible to prescribe a contraceptive method for a woman in five minutes," the doctor says.

That's because there are some contraindications, and the doctor needs to evaluate that. The pill can not be taken, for example, by women who have had some thrombosis, who have a history of thrombosis or cardiovascular disease in the family among first-degree relatives, are smokers who are 35 years old or older, obese or hypertensive.

Not every pill creates a risk of thrombosis

The risk of thrombosis is associated with estrogen. It is primarily responsible for the increase in clotting factors, and therefore, the higher the dose of this hormone, the greater the risk of developing the disease. Therefore, only the combined estrogen and progesterone pills have any possibility of causing thrombosis.

There is a second set of pills made only of progesterone. These do not offer this risk. Adherence to this pill, however, is low because about 30% of women have minor bleeding. The trend is that with use, they decrease, but many leave the method early on account of the nuisance.

– The progesterone pill has a very good efficacy, similar to that of the combination. But it is not usually the first choice of women because it can generate these "menstrual leaks" and, in some cases, can also interfere with the libido – says Isabela Henriques Rosa, gynecologist of the Clisam team and the Hospital Santa Lucia.

Among non-hormonal methods of contraception – that is, they do not in any way interfere with the hormones and hence are far from causing thrombosis – are the copper IUD, the diaphragm, and the condom. In general, many women who rethink the use of the pill rely on them.

IUD is underused

About 30% of women between the ages of 20 and 39 in Brazil use contraceptive pills, according to Febrasgo. The IUD is used for less than 5% in this same age group. For experts, the latter method is underutilized.

– From the point of view of effectiveness (to avoid unwanted pregnancy), the IUD is much better (than the pill). In addition to eliminating risk of thrombosis – says gynecologist Ilza.

She explains that every pill can fail and cause unplanned pregnancies in three out of every 1,000 women over a year. But in practice, statistics show that 80 out of every 1,000 women get pregnant in a year, even taking the pill. This is because it is common for them to forget to take a day or to delay the time. On the other hand, the risk of failure of the IUD is three cases out of every thousand, both in theory and practice – because the device stays in the body for years, not depending on the patient's good use.

– So I usually say that the main problem of the pill is not thrombosis, but the failure, says Ilza.

For CFM gynecologist Adriana Scavuzzi, IUD use should be more stimulated, including among adolescents – those who have already begun sex life. She considers that there is a lack of information regarding contraceptives in general.

– If the woman migrates from the pill to the IUD, for example, that's okay. Because this is a secure device. My fear is about those who abandon the pill, afraid of thrombosis, and begin to use nothing or adopt methods without scientific proof, by idioms. It is rash and unjustifiable, "he says.

Genetic tests are not output

Many women have the following question: if there are medical tests to check if the patient has any genetic mutation that causes thrombophilia – a propensity to develop thrombosis – should not it be necessary for gynecologists to ask for this test before prescribing a pill?

The answer of the experts is no. They say it is unrealistic to ask for genetic research from all women seeking contraception. It is not a type of test carried out in the Unified Health System (SUS), it is not covered by health plans and it is expensive. What's more, even if the test is negative, there is no guarantee that the woman will not develop thrombosis.

"There are people who have no apparent risk factor, and the genetic tests also do not indicate anything. But still, the person develops the disease. It may be that the woman has some kind of mutation that medicine has not yet discovered and failed to track – says gynecologist Karina Tafner, a specialist in gynecological endocrinology and human reproduction by Santa Casa de Misericordia de São Paulo.

'Medicalization of sexuality'

According to experts, the relationship of women to the contraceptive pill has been changing over time, depending in general on the social demands of each time.

The first impetus for research that would result in the contraceptive pill in the early 1960s was not by scientists but by feminists. This is what explains an academic study of Collective Health done by the specialist Marina Nucci, in 2012, at the Institute of Social Medicine (IMS / Uerj).

"Margaret Sanger, a women's rights activist and pioneer of birth control in the United States, long sought scientists who could develop a simple and inexpensive method of contraception until she met biologist Gregory Pincus in 1951. Another woman who played a central role in the creation of the pill was Katherine Dexter McCornick, a friend of Sanger, who funded almost entirely the research project with its own resources, "said Marina, in her text.

In the study, the author discusses the idea of ​​"day-to-day drug" and "medicalization of sexuality" – and it is against this idea that many women today stand up. Since its inception, the contraceptive pill has been designed not to treat a disease but rather to be used routinely by healthy women.

"As a result of feminist claims, the pill has revolutionized not only women's lives, but society as a whole. However, it is a drug and, like all medicines, it poses risks to the health of its users," she continues.

She tells, among other things, how the biologist Gregory Pincus instituted that the "normal" would be a 28-day cycle; and that menstruation – although biologically unnecessary – should be imitated during the use of the pill, with an interval of one week, to make the product more acceptable.

Reports: 'I had thrombosis'

Read below two first-person reports of women who, even healthy and out of groups predisposed to thrombosis – were not hypertensive or smokers, for example – had the problem. The only risk factor was the combined contraceptive pill (estrogen and progesterone).

In both cases, thrombosis progressed to pulmonary embolism, an extremely severe complication.

Carolina Jardim, 33 years old, journalist

Carolina had central and peripheral pulmonary thromboembolism for less than a month:
Carolina had central and peripheral pulmonary thromboembolism for less than a month: "the lack of information and guidance could have cost my life" Foto: Personal archive

On the night of April 4 of this year, I was alone at home and I began to feel a lot of pain to breathe. Each time he pulled the air, he felt a strong pressure in the upper abdomen. My body fainted, I sweated cold and I came to see everything black. It was the first time I actually thought I might die.

At that moment my husband called me and said he was hurrying to get me to the hospital immediately. He had just taken my CT scan the day before, and the examination showed a spot on the lung, indicating the possibility of pulmonary infarction.

I had a central and peripheral pulmonary thromboembolism that obstructed the right pulmonary artery. Disruption of blood flow led to an infarct of a segment of the lung. I was hospitalized for seven days with injectable anticoagulant treatment and now I have to keep oral anticoagulation for up to six months.

"The moment I learned that the main suspect of my pulmonary embolism fell on the pill, I was overwhelmed by a mixture of feelings: sadness, fear, indignation and even guilt for not having taken action before."

Carolina Garden

about his diagnosis of thrombosis

Since there is no other apparent risk factor, the main suspect is contraceptive pill use. All of the doctors who treated me at the hospital reported that they recently followed or heard similar cases from other women in my age group.

I am 33 years old and had been taking the pill since I was 17. I had already begun to question the use of the pill and its effects on the woman's body and I was uncomfortable with the idea of ​​taking a hormone pump. I had also read about cases of women who had thrombosis, pulmonary embolism and other diseases due to hormonal contraceptive use.

All this made me think about replacing the pill with an IUD, but I did not take the idea further. As I have always been healthy, I did not imagine that this could happen to me. One of the biggest mistakes of the human being – and mine too – is always to believe that it will never happen to him.

Throughout my life, no gynecologist with whom I consulted informed or warned me about the risks.

The moment I learned that the main suspicion of my pulmonary embolism was on the pill, I was overwhelmed by a mixture of feelings: sadness, fear, indignation and even guilt for not having taken action before. I kept thinking about the myriad of uninformed women who can still go through what I went through.

Lack of information and guidance could have cost my life. With quick service and support from a network of people who have been at my side the whole time, I managed to recover well and without sequels. May my case serve as an example to save lives and the health of other women.

Ana Carolina Asch, 34 years old, designer

Ana Carolina had thrombosis in 2015, at age 29:
Ana Carolina had thrombosis in 2015, at age 29: "My leg was warmer and swollier than normal, reddish and with a doughy texture – like wet sand."

I had been on a combination pill since I was 14, before I even started my sex life. I have heard from my doctor the usual propaganda: help with pimples, with cramps, regulate the cycle. My gynecologist never asked if I had a family history of thrombosis. Luckily, I had not. I was not part of any risk group, I always had a stable weight, never smoked, had an active life. And I've never felt any side effects from the pill, like headaches, mood swings, malaise, nothing. My flow was light, I had no colic and I never wondered if the pill could do me harm.

Until, in September of 2015, when I was 29, I had superficial surgery to treat mild varicose veins. After any surgery, there is a risk of thrombosis because clots develop as part of healing. This is normal. But thrombosis only happens if you have some risk factor, such as smoking, overweight, genetic tendency. Then if you do not take precautions, the clots can accumulate and form a thrombus. I followed the doctor's instructions to prevent the formation of thrombosis in healthy people: I moved normally, did not let my legs rest. It should be enough. Each postoperative day, I should be better, with less discomfort in my legs. But I just got worse. I questioned the angiologist who accompanied me, but he just said that I was exaggerating and it should be some muscle pain. He said I was a "very impressionable little girl." On top of that, I suffered misogyny.

Meanwhile, my leg was warmer and more swollen than normal, reddish and with a doughy texture – like wet sand. I tightened it, and the skin did not return to the place immediately. I then sought an orthopedist, since my angiologist argued that the cause of my pain was a muscle problem. Arriving at this new doctor, he dismissed any muscular causes, sent me to the Pro-Cardiac Hospital, and there, it took only a Doppler echocardiogram, a simple ultrasound exam, to diagnose thrombosis. I was with the popliteal vein, the main vein behind the knee, completely clogged. The result of the test read: no flow. I was immediately hospitalized.

"I got the feeling that the pill is a roulette wheel: it's okay … until it's gone. I even took the genetic tests to see if I had any hereditary propensities. But it turned negative. What scared me was that a medicine made me sick. "

Ana Carolina Asch

about your thrombosis

The treatment was simple: injections of anticoagulants into the body would gradually break down the thrombus. The danger was that he would move and stop at some other vital area of ​​my body, which is called an embolism. And that's exactly what happened shortly after: I had a mild breathlessness and tests detected a pulmonary embolism. Each time my heart beat, it pushed the clots from my leg into my lungs. Each time my heart beat, I was closer to death. I was quite frightened by the fragility of life, as in a second everything could change.

I had to undergo surgery to put a filter in my vena cava to hold the clots before they reached the lung. I keep this filter in a pot on my shelf to remind me. In total I spent almost a month in the hospital: a week at the Intensive Care Center (ICU) after surgery, then in the semi-intensive, and finally I went to a room. I could not get up, not to go to the bathroom or shower, but I did not feel pain and I was happy to be alive. My perspective has changed. After that I had to take anticoagulants for a year and today I have as only side effect the thickening of the walls of the veins of the right leg. I need to do regular exercises to help the leg not swell and on hot days I use compression stockings. I just need to take anticoagulants when I get on the plane, as well as not let my legs stay down for more than four hours. Other than that, I lead a normal life, I went back to dancing and doing everything I like.

The truth is that I was very lucky. I got the feeling that the pill is a roulette wheel: it's okay … until it's gone. I got to do the genetic tests to find out if I had any thrombophilia, a hereditary propensity to develop thrombosis. The result was negative. What scared me a lot was that a medicine made me sick. The pill sickened a healthy body. Every drug has side effects, but those effects in the case of the pill are very serious and unpredictable, so much so that for much less the male pill has not been approved. It can not be recommended as the safest way for us to prevent an unwanted pregnancy. The gynecologist who always accompanied me was to visit me at the CTI, and told me that we could try a "less thrombotic" method. I do not want to have "less thrombosis" next time!

I changed my gynecologist and started using the copper IUD, which does not mess with our hormones. At first I had more cramps, more pimples … but today I deal with it very well. I learned more about my cycle and used it to my advantage, taking advantage of the extra energy of the follicular phase (before ovulation) or picking myself up and stopping to listen to me in the luteal phase (before menstruation, the dreaded PMS). The menstrual cycle need not be repaired, repressed, artificially regulated. His variations can help us to understand what is happening to us and in our life, each stage of it has something to teach us. The position of some doctors to minimize what women feel is more than a misogynist attitude, it is a murderous attitude.

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