Current knowledge among medical and non-medical students on the risk of thromboembolic complications of oral hormonal contraception

INTRODUCTION

Oral contraceptives are one of the most popular methods of preventing unintended pregnancy [1]. Between 2015 and 2019, 79.8% of women in the United States reported having used or currently using hormonal contraception in the form of oral tablets [2]. Two types of these preparations are available on the pharmaceutical market: progestogen-only pills and combined pills, which include an oestrogen component [3].
The use of oral hormonal contraception is associated with a number of side effects. The issues most commonly reported by women include mood changes, weight gain, headaches – including migraines, and persistent nausea [4, 5]. The most serious complication is the increased risk of venous thromboembolism (VTE), which is statistically most often recorded during the first year of contraceptive use [6]. The diagnosis of thrombosis is 2 to 3 times more frequent in individuals using oral hormonal contraceptives (OHC) containing oestrogen (≤ 35 µg ethinylestradiol [EE]) compared to those not undergoing this therapy [7]. The literature reports an increase in thrombotic episodes associated with the use of combined oral hormonal contraceptives in therapies containing oestrogens, including EE. Progestogen-only pills did not show a significant increase in the risk of cardiovascular diseases [8].
In Saudi Arabia, in 2022, an analysis of awareness and knowledge regarding VTE was conducted among non-students; however, obesity, hypertension, and physical inactivity were considered as additional risk factors, rather than the main subject of the study [9].
To date, no detailed scientific studies have been conducted among women in Poland regarding their awareness of VTE as a potential complication of oral hormonal contraception use. Our study may serve as a preliminary step towards expanding this issue on a larger scale in the future.
The aim of this study is to assess the knowledge of female and male students from a Polish university in the Świętokrzyskie voivodeship regarding the use of oral hormonal contraception and its possible complications.

MATERIAL AND METHODS

In May 2024, an online survey was conducted among students of medical (dietetics, pharmacy, physiotherapy, cosmetology, medicine, nursing, midwifery, emergency medical services, physical education, public health) and non-medical fields at Jan Kochanowski University in Kielce. The inclusion criterion for the analysed group was having current student status at JKU, which was verified through a statement from the respondent to ensure the confidentiality of the survey.
Official approval was obtained from the university authorities, including the Rector of Jan Kochanowski University in Kielce, for conducting research on the level of awareness among medical and non-medical students regarding the risks of thromboembolic complications associated with the use of oral contraceptives. The approval process included the submission of a detailed research plan and assurances of adherence to ethical standards, including the protection of participants’ personal data, which was a crucial element in securing permission to carry out the project.
Each respondent who provided a complete answer to the survey questions was included in the analysis. The survey research was conducted using a self-constructed questionnaire. The electronic surveys were sent to the students’ e-mail addresses for the first time, and then, if there was no response, a second time after 7 days. At every stage of the study, the principles of anonymity, respondent privacy protection, and the possibility to withdraw from the study at any moment were upheld.
For both male and female respondents, the common section of the survey was a demographic section containing sociodemographic data. Subsequently, the questions for the respondents differed depending on their gender. Women answered 20 closed-ended questions, either single-choice or multiple-choice, and 3 open-ended questions. Men, due to their non-use of OHP, answered 3 closed-ended questions and one open-ended question.
The first part of the original questionnaire for women focused on details related to hormonal contraceptives (OHC) – their prevalence of use, reasons for discontinuation, and the frequency of gynaecological check-ups. The second part included questions about symptoms, risk factors, and the respondents’ knowledge of VTE. Men were asked about their partner’s use of hormonal contraceptives, awareness of VTE symptoms and risks in women, as well as other alternative contraceptive methods.

STATISTICAL ANALYSIS

All statistical data obtained during the online survey study were digitised in a Microsoft Excel spreadsheet. STATISTICA version 13 by TIBCO was used for statistical analysis. Qualitative variables were presented by indicating the number (n) and percentage (%) of each response. Chi-square tests were used to compare the defined differences between groups. A significance level of p < 0.05 was considered statistically significant.

RESULTS

The study included a total of 558 students, 457 women (81.9%) and 101 men (18.1%). The mean age of the respondents was 25 years (SD = 4.5). The maximum and minimum age values were 32 and 18 years, respectively. Among the 457 women, 230 (50.3%) were studying a medical course, while 227 (49.7%) were enrolled in a non-medical course.
In the studied group of female students from all fields, 177 (38.7%) used oral hormonal contraception, 111 (24.5%) responded that they currently did not, but had used it in the past, while 150 (32.8%) claimed that they had never used this form of contraception. The main reason for discontinuing oral contraception was complications and contraindications to its use (56 [42.7%]), and the second most common reason was personal considerations (44 [36.3%]). Only 316 (69.1%) women were under regular care of gynaecological specialists, having check-ups once a year or more often, while 56 (12.3%) surveyed students had never had such a visit. The next question concerned whether tests were ordered before starting and during the use of OHC: 196 (62.7%) students before starting and 208 (68.8%) during contraception – did not receive a referral for medical check-ups. Before starting contraception, only 117 (37.3%) women received a referral for tests, and during therapy, such a referral was given to 94 (31.2%) women. The survey listed risk factors for thromboembolism. The most commonly reported by the women were smoking (105 [43.5%]), lack of physical activity (89 [36.8%]), family history of VTE (63 [23%]), and obesity (52 [21.5%]).
The survey included a question regarding knowledge about the symptoms of VTE. Among the women participating in the survey, 296 (65%) reported having such knowledge, while 161 (35%) were unable to recognise the symptoms. In response to the question concerning awareness of the risk of VTE, both genders provided answers. A total of 384 (84.2%) women and 82 (81.2%) men claimed to have knowledge and understanding of the most serious complication, VTE, during the use of oral hormonal contraception. The final question concerned their willingness to participate in additional classes containing – useful information about the impact of hormonal contraceptives (HC) and the risk of VTE associated with their use. As many as 381 respondents (84.4%) expressed interest, while only 76 (16.6%) indicated they would not want to participate in such training. Men were also included in the study group.
As many as 94% of surveyed women and 81% of surveyed men were aware of the side effects of using oral hormonal contraception (p = 0.001). Compared to men, women had a significantly higher awareness of the complications associated with the use of OCPs (oral contraceptive pills), which is why educating men about the side effects, symptoms, and impact of this contraceptive method is a crucial aspect. Awareness of side effects was influenced not only by gender, but also by whether students were enrolled in medical or non-medical studies. 97% of students studying medical fields and 92% of students studying non-medical fields were aware of the side effects (p = 0.013).
The next issue addressed in the survey concerned the most dangerous consequence of using OCPs, which is the increased risk of VTE occurrence. In this comparison, medical and non-medical students were evaluated. Respectively, 91% and 78% of students were aware of the occurrence of VTE. Knowledge about thromboembolic episodes was widespread among the respondents. However, medical students had a higher awareness of this condition as a complication of oral contraceptive use (p = 0.01). More knowledgeable individuals, i.e. 89% of medical students compared to 78% of the other group, were more willing to participate in additional classes on this topic (p = 0.001). The subsequent questions in the survey were directed at female participants. A very important issue for women was undergoing regular gynaecological check-ups. 92% of women using OCPs regularly attended medical appointments. In contrast, only 50% of women who did not use oral contraceptives underwent regular check-ups. Women using oral contraceptives attended gynaecological check-ups significantly more often than women who did not use this form of contraception (p = 0.0001). Females using OCPs were more aware of side effects (97% compared to 91% of non-users [p = 0.007]) and had greater awareness of thromboembolic complications (89% of users compared to 75% of non-users [p = 0.001]). The survey results suggest that women using OCPs more frequently attended gynaecological check-ups, had greater awareness of side effects, and were more aware of thromboembolic complications.

DISCUSSION

The use of oral contraceptives is one of the most popular methods of preventing pregnancy worldwide, and its effectiveness and health benefits are widely studied [10]. In the present study, 38.7% of female students across all disciplines used oral hormonal contraception. Oral contraceptives are associated with numerous benefits as well as potential health risks for women.
The benefits of using oral hormonal contraceptives (OHC) primarily include their high efficacy in preventing pregnancy, which, when used regularly, reaches up to 99.7% [11, 12]. Additionally, these methods contribute to the regulation of the menstrual cycle, alleviation of premenstrual syndrome (PMS) symptoms, and a reduction in the severity of menstrual pain (dysmenorrhoea) [13]. Furthermore, scientific research indicates a lowered risk of developing certain cancers, such as endometrial and ovarian cancer [14]. It is dangerous for pregnant women to have diabetes, which, if inadequately controlled, can lead to dangerous consequences including pre-eclampsia and spontaneous miscarriage. Therefore, the use of hormonal contraception can lead to delaying conception until optimal glycaemic control [15]. Pharmacotherapy in polycystic ovary syndrome is often based on the use of oral contraceptives in combination with spironolactone, pioglitazone, and metformin. Through the use of OCPs, women in the study had lower levels of ketotestosterone (11-KT) and testosterone than patients not using OCPs. Elevated levels of these hormones are one of the components of PCOS [16]. The authors of the presented studies emphasise the positive impact of hormonal contraception, which differs from the results of our study. However, it is also worth noting the beneficial aspects of this type of contraception.
Despite numerous benefits, the use of oral hormonal contraception (OHC) is associated with certain health complications. Primarily, attention should be paid to potential side effects, such as an increased risk of venous thrombosis, especially in women who smoke or suffer from other conditions predisposing them to the formation of blood clots [17, 18]. A clinical case of a patient who experienced renal vein thrombosis due to the use of this form of contraception along with cigarette smoking has been reported in Japan [19]. The first thrombotic episode documented in the literature occurred in 1961. It is a case of pulmonary embolism in a woman using OHC. A year later, an ischaemic stroke was reported in another patient. One can also find the occurrence of a myocardial infarction for the first time after hormone therapy. It is worth mentioning that OHCs were introduced to the commercial market in 1959. After just 2 years, serious side effects occurred [20]. However, the above examples did not contribute to the withdrawal of OHC from the market, and to this day they remain one of the more common contraceptive methods of choice.
In our own study, respondents demonstrated a high level of knowledge about the complications associated with the use of oral hormonal contraception: 384 women (84.2%) and 82 men (81.2%) claimed to have knowledge and understanding of the most serious side effects. Epidemiological studies have shown that the risk of thrombosis increases up to sixfold with OHC use, particularly during the first year of use [21]. In our study, 65% of female respondents were able to recognise the symptoms of thromboembolic disease.
The conducted study is the first attempt to assess and compare the knowledge about VTE as a complication of oral hormonal contraception among young individuals studying medical and non-medical disciplines at a higher education institution. It is also the first current study on this topic in Poland. In the conducted study, the focus was on the symptoms and risk factors of thromboembolic disease during the use of hormonal contraceptives (OHC).

THE LIMITATIONS OF THE STUDY

The main limitation of the study was that the survey was conducted solely among students of Jan Kochanowski University in Kielce. It would be beneficial to expand the studied population to include students from other universities. Conducting the survey among other social groups, such as non-students or women of varying ages, would also yield more comprehensive results. This would allow for an evaluation of students’ knowledge in comparison to the general population. Another factor that could influence the reliability of the survey is the possibility that students may choose responses they believe to be socially desirable rather than those reflecting their own knowledge. However, all survey questions were anonymous, which reduces the likelihood of this type of bias.
In the future, it would be reasonable to conduct a study among the general population in Poland to assess knowledge about VTE during the use of hormonal contraceptives, not only among students. It would also be worthwhile conducting more detailed research by asking more specific questions, such as how long after starting contraceptive use women experienced VTE symptoms, and in which group of women these symptoms occur most frequently. Additionally, it would be important to identify potential risk factors for VTE and compare individuals with these risk factors to those who experienced symptoms while using hormonal contraceptives.

CONCLUSIONS

The majority of women did not receive a referral from their physician for health check-ups prior to or during the use of oral hormonal contraception.
Medical students have a higher awareness of the risk of thromboembolic complications associated with the use of oral contraceptives compared to non-medical students.
Women using oral contraceptives (OCPs) had significantly greater awareness of side effects and thromboembolic complications compared to women who do not use this method. Moreover, women using OCPs attended gynaecological check-ups more frequently than non-users. As many as 84.4% of students expressed an interest in attending additional training on the effects of OCPs and the risk of VTE.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References