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HEART ATTACK AND THE PILL
There is also evidence that heart attack and strokes are commoner in women who are on the pill. The Royal College of General Practitioners confirmed this by the exacting method of following up a large number of women to compare the risk in pill-users and others. Overall, the risk of heart attack is doubled; but this statement needs to be qualified. First, the risk of heart attack in young women is very small indeed, so that a twofold increase is hardly a major hazard. Second, we are learning to recognize groups of women who are at particular risk. For example, those aged forty and over have a much greater increase in risk than do younger women; one estimate is that the increase is about ten times greater. This is probably an unacceptably high risk, and women in their forties should be very cautious about using the pill rather than alternative methods of contraception. Third, when a woman using the pill has some other risk factor the combined risk is strikingly increased. Cigarette smoking is the commonest source 0f enhanced risk, and Dr Ory has recently shown how great the combined hazard may be. On present evidence a woman who wishes to start using the pill may be wise to give up smoking first. Having high blood pressure or a high blood-cholesterol or triglyceride level are other probable sources of abnormally high risk in pill-users. The blood pressure should be checked before starting an oral contraceptive; at present this is not always done.
It is not clear what to advise in the case of a woman whose family is very prone to ischemic heart disease. As a minimum precaution her doctor is likely to check her blood pressure and her cholesterol and triglyceride, and to test her for diabetes. It may be prudent to use other family-planning methods. Newer forms of the pill contain much less of the hormone oestrogen than earlier preparations (20 instead of 50 micrograms). It is likely that the low-oestrogen pill is far safer; but it is still not clear whether they should be used by women from high-risk families. If they are, their use should be confined to women below the age of 35 years, who do not have other risk factors (particularly high cholesterol levels, high blood pressure or smoking).
In most women the pill causes a slight increase in blood pressure, and in triglyceride and cholesterol levels. But people vary widely in their response, and sometimes these measurements increase steeply. This is especially likely if they are somewhat high to start with. The pill can also make diabetes worse, or can bring out latent diabetes. All these factors may contribute to the risk of heart disease. In addition the pill appears to alter our thrombosis (‘clotting’) mechanisms. In most women who have a fatal heart attack while on the pill, Dr Spain has found thrombosis in a coronary artery. There is some evidence as to why this may be: the pill seems to decrease the amount of a protective substance in the blood called antithromin III.
Despite this list it is very important to remember that the increase in risk is small in women under the age of about forty years or so, except in those also at risk from other factors or, perhaps, those with a family history of heart disease.
*53/202/5*
