Case-control study of oral contraceptives and risk of thromboembolic stroke: results from international study on oral contraceptives and health of young women

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Abstract
Objective: To determine the influence of oral contraceptives (particularly those containing modern progestins) on the risk for ischaemic stroke in women aged 16–44 years. Design: Matched case-control study. Setting: 16 centres in the United Kingdom, Germany, France, Switzerland, and Austria. Subjects: Cases were 220 women aged 16–44 who had an incident ischaemic stroke. Controls were 775 women (at least one hospital and one community control per case) unaffected by stroke who were matched with the corresponding case for 5 year age band and for hospital or community setting. Information on exposure and confounding variables were collected in a face to face interview. Main outcome measures: Odds ratios derived with stratified analyses and unconditional logistic regression to adjust for potential confounding. Results: Adjusted odds ratios (95% confidence intervals) for ischaemic stroke (unmatched analysis) were 4.4 (2.0 to 9.9), 3.4 (2.1 to 5.5), and 3.9 (2.3 to 6.6) for current use of first, second, and third generation oral contraceptives, respectively. The risk ratio for third versus second generation was 1.1 (0.7 to 2.0) and was similar in the United Kingdom and other European countries. The risk estimates were lower if blood pressure was checked before prescription. Conclusion: Although there is a small relative risk of occlusive stroke for women of reproductive age who currently use oral contraceptives, the attributable risk is very small because the incidence in this age range is very low. There is no difference between the risk of oral contraceptives of the third and second generation; only first generation oral contraceptives seem to be associated with a higher risk. This small increase in risk may be further reduced by efforts to control cardiovascular risk factors, particularly high blood pressure. This study shows a slightly increased relative risk of thromboembolic stroke in women currently using oral contraceptives compared with women not using them. The high dose oestrogen pills carry a higher risk than the low dose formulations, irrespective of the type of progestin The absolute risk of occlusive stroke for women who currently use modern oral contraceptives is very small—that is, the incidence in this age range is very low and not different between second and third generation oral contraceptives This small increase in risk can be controlled by avoiding prescription of oral contraceptives to women who have evidence of cardiovascular disease, in particular high blood pressure

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