Combined hormonal contraception: Is there an unacceptable health risk?

January 15, 2019 – The World Health Organization (WHO) classifies combined hormonal contraception as an unacceptable health risk in the presence of a known thrombogenic mutation but advises against routine thrombophilia genetic testing before initiating combined oral contraceptives (COC’s) on the grounds of high screening costs and low prevalence.

This is shocking to some degree and troublesome on the other hand. If the WHO and its medical experts find that  combined hormonal contraception as an unacceptable health risk in the presence of a known thrombogenic mutation, it has not to put that into perspective of financial interest, totally independent of screening cost or prevalence of the condition. WHO has to put that into perspective of possibly affected patients and the avoidance of any risks to them.

Given this scenario and from the perspective of patient-centered care, WHO has examined cost, prevalence, and other published arguments for and against thrombophilia screening before initiating COCs. their patient-centered review drew on relevant empirical evidence concerning the advantages and disadvantages of thrombophilia screening, while placing the discussion in the broader context of evolving attitudes toward genetic testing and a shifting policy landscape that provides many women direct access to COC’s and/or thrombophilia genetic testing.

Given variation in prior probabilities of thrombophilia, expected exposure to other risk factors for venous thromboembolism, attitudes towards risk, expected reactions to a positive test result, ability to pay, and concerns about genetic discrimination, WHO concluded that the current one-size-fits-most approach is not consistent with patient-centered care. Instead, WHO advocates for greater patient and provider education concerning the implications of thrombophilia genetic testing. Moreover, WHO recommends offering patients optional thrombophilia genetic testing before initiating COC’s.

While it is understandable that WHO may come to the conclusion lined out above, we at Thasso think that a much more advanced stance by the WHO on the issue would be appropriate for several reasons. First, the major genetic risk factors for thrombophilia are know. Second, if patients are going to suffer from VTE’s under COC’s, the health consequences for the affected individual are disastrous, possibly life long. Third, an argument about costs should be outdated; genetic testing is becoming a commodity, and a chip testing for the genetic risk factors of thrombophilia should be producible at very low cost. Lastly, in the light of the fact that COC’s are increasingly used to treat acne, particularly in young and very young girls even, WHO should promote the combination of prospective thrombophilia genetic testing before the use of COC’s for every individual.

The price of only one single young girl lost to life-long severe and life-threatening handicap is simply too high, given the fact that the means to prevent it are available. Cost cannot be an argument for not doing it, and if genetic discriminating (by health insurance companies, taking out insurance for life, or by prospective employers, for example) then one would have to work on these sources (seriously, with draconic penalties if discrimination should occur) in contrast to withholding risk minimization from patients. The latter would be plain unethical, irrespective of business opportunities .