Oral contraceptives and postoperative venous thrombosis [letter]

I would like to comment on the article by DeStefano and associates (Am. J. Obstet. Gynecol. 143:227 1982). Rather than incriminating the oral contraceptive (OC) for this unfortunate accident had this happened in my dept. I would charge the surgeon for the untimely procedure of tubal ligation in a lady of 24 and for an inappropriate technique of a 41-minute laparotomy instead of a simple 3-minute tubal ring or clip laparoscopy. However a culture difference such as this is not the focal point of either this letter or the authors themselves. I would like to point out 2 aspects of the matter. 1st we now know not only that estrogen plays a part in cardiovascular accidents but also that the progestogens seem to be the new villain with findings of decreased high-density lipoproteins hyperinsulinism and insulin resistance possibly raising the cardiovascular risk factors. With this in mind an ideal OC not only would be a low estrogen one but also would be combined with a progestogen with fewer metabolic effects such as norethindrone in the lowest possible dosage. 2nd I do not think that a 1-month abstinence from the OC would prevent postoperative thromboembolic phenomena. Our experience has been that effects of the OC may be prolonged after discontinuation of use for up to 6 months and beyond. Even after its discontinuation the rise of cardiovascular accidents may continue. To give some protection against postoperative cardiovascular complications I would think a discontinuation of OC use for 3-6 months would be in order. The protection against pregnancy during this lapse of time would be another matter. (full text)