Dear Doctor, why is taking combined birth control pills unsafe for women with migraine auras?
DEAR DR. ROACH: I am a 47-year-old woman who has suffered from irregular periods for 22 years. I was prescribed combined birth control pills, which helped me control and regulate my periods well for 20 years.
At my annual check-up three years ago (at 44), I told my gynecologist that I had what sounded like a migraine aura, but no headaches. My gynecologist immediately stopped me from taking the combined birth control pills (after noting my age). I am not a candidate for an IUD because of a split uterus, so she suggested a hysterectomy, which I refused. She then prescribed me progesterone birth control pills. Since then, I have been taking three different types of progesterone pills, which have caused more problems than benefits, and my periods have not been regulated for two years.
My question is, apart from the above treatments, are there any other things I can do to control my period? I have had several tests, scans and a biopsy and all have shown no problems. At my age, is there any way I can go back on the combination pill until I reach menopause? I want to live a normal life rather than having to stay away from work and be locked up at home for days because of a heavy period. – JL
ANSWER: Your gynecologist is concerned that you may have a stroke. Women who suffer from migraine with aura have a much higher risk of stroke when taking estrogen. Published rates of this risk range from a 50% to 820% increase in risk. This is especially important for women over 45. The guidelines make it clear that the risk for women with aura to take combined oral contraceptives is unacceptable.
It is entirely possible to have a migraine aura without getting a headache (sometimes called a “migraine equivalent” or “acephalic migraine”). Almost everyone who suffers from migraine will get a painful migraine at some point. Although there is not much evidence to support this, I believe that the risk of stroke would also be increased for a woman with an aura but no headache who is taking oral contraceptives.
However, it has been my experience that the description of an aura is not always accurate. A migraine aura has both “positive” (bright lines, shapes, or objects) and “negative” (loss of vision). An aura usually develops slowly, over 5 minutes or more, and disappears completely within an hour. Neurologists are experts at taking the accurate medical history needed to diagnose an aura, and this diagnosis will be very important to you. If the neurologist thinks it is not an aura, you can return to your original treatment.
If this is not an option and you cannot use an IUD and do not want surgery, there is another option that I have read about but have never used: tranexamic acid, which is indicated for cyclical, heavy menstrual bleeding. You should ask your gynecologist if this is a possible therapy for you. This medication has several side effects and I do not prescribe it because it must be prescribed by an expert – that is, a gynecologist.
Dr. Roach regrets that he cannot respond to individual letters, but will include them in the column if possible. Readers can email questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.
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