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A Case of Chronic Calf Swelling. Rebecca, a forty year old housewife came into the office to see me about various complaints related to mood, poor quality sleep and weight gain. She had been on birth control pills for 2. BCPs had been very irregular. About two years ago after a long airplane flight, while shopping on vacation, she noticed her right calf was significantly larger than her left. Installing A New Guitar Saddle there. Shortly thereafter, she noticed an aching, heavy feeling in the enlarged calf,  When she returned home, she had ultrasound and CAT testing which was negative for acute deep venous thrombosis, and no treatment was offered. I explained to Rebecca her calf swelling and discomfort are symptoms of a healed clot formation in the deep vein that has resolved causing incompetent valves and chronic venous insufficiency. This is a complication of the birth control pills, the aftermath of an episode of deep venous thrombosis of the deep vein of the right calf vein. The blood clot has dissolved, and the vein has recanalized, explaining why the imaging tests showed normal findings. Estrogen Patch Canada' title='Estrogen Patch Canada' />As bad as this may be, it is actually a far better outcome than pulmonary embolus and stroke which may be caused by birth control pills, a far worse outcome. Oral BCPs Ninefold Increase in Stroke. One of the major adverse effects of oral birth control pills is the increased coagulation and blood clot formation which may cause DVT deep venous thrombosis, pulmonary embolus and stroke. Oral contraceptive use BCPs is associated with a ninefold increased risk of stroke cerebral infarction in women. Oral contraceptives BCPs alter platelet aggregation, enhance antithrombin III activity, decrease serum antithrombin levels, and increase the levels of certain coagulation factors, especially factor VII. Adverse Effect is a Reason to Discontinue BCPs. An adverse effect such as clot formation is certainly a good reason to discontinue birth control pills and switch to a more natural alternative,  Treatment with cyclic progesterone capsules on days 1. Good thyroid function is required for regular ovulatory cycles, and this is also evaluated and addressed. Transdermal Estrogen. You might ask, is there a safer way to take hormones, not associated with blood clot formation  The answer is yes. The  safer method of delivery is transdermal. In this method, the hormone comes in a skin cream or skin patch as a topical preparation applied to the skin. BMJ Study by Renoux. A well designed study  by Dr. Renoux in the 2. 01. BMJ compared oral and transdermal estrogen at both high and low dosage. Dr Renoux found no increased stroke with the low dose transdermal estrogen skin patches compared to non users. Photoinstrument 4.3 Crack. The oral estrogen pills at both low dose and high dose, as well as the the high dose transdermal estrogen patch were all associated with increased coagulation and stroke. Dr Speroff Speaks. As Dr Speroff points out in his editorial in Climacteric, the Renoux BMJ study is reassuring in that low dose topical estrogen was not associated with increased coagulation, clots and stroke. However, Dr. Speroff  advises caution with high dose topical estrogen preparations which showed similar tendency for increased coagulation as the oral estrogen pills. We still dont have these types of studies for commonly used topical hormone preparations containing combined hormone formulations such as Bi Est which is 2. Until then we will have to rely on the Renoux study. The Renoux study used topical patches as shown below Oral Estrogen Pills used in the BMJ Renoux Study Oral low dose products contained 0. Premarinor 2 mg of estradiol. Oral High dose products contained 0. Image/image.jpeg_gen/derivatives/landscape_620/image.jpeg' alt='Estrogen Patch Canada' title='Estrogen Patch Canada' />Transdermal Preparations. Transdermal low dose products contained 5. Transdermal High dose products contained 5. The low dose transdermal estrogen patch was not associated with increaed coagulation and stroke. The high dose patches and the oral pills, however, showed increased incidence of blood clots and stoke 1,2Inherited Thrombophilia A Contra Indication Against Use of Birth Control Pills. Some women have a genetic mutation which increases the risk for blood clots. This is called thrombophilia, and the two most common genetic mutations are the Leiden mutation of factor V and the G2. A mutation of prothrombin. Studies show that many of women suffering blood clots while on birth controls pills have an underlying genetic thrombophila, an inherited tendency to form clots, which places them at greater risk. Obviously, these women should avoid birth control pills and any other medications that cause blood clot formation. One might argue the case for routine screening for inherited thrombophila in all young women before starting oral birth control pills. In addition, women suffering from DVT or blood clot formation while on BCPs or any form of  HRT should have thrombophila screening testing. Dr Caprini from Northwestern reported on thrombophila screening in the 2. European Journal of Vascular Endovascualr Surgery4  Dr. Caprini screened 1. One quarter 2. 3 were positive for Factor V  Leiden FVL genetic mutation. Dr. Caprinis Thrombophilia Testing Panel included 4 Factor V Leiden FVL,Prothrombin 2. A mutation P2,methylene tetrahydrofolate reductase deficiency MTHFR,fasting serum homocysteine HC,lupus anticoagulant LA,anticardiolipin antibodies ACA,antithrombin deficiency AT,protein S deficiency PS, andprotein C deficiency PC. Cerebral Vein Thrombosis Associated with Inherited Thrombophilia. Dr. Ida Martinelli reported in the 1. NEJM on 4. 0 patients with idiopathic cerebral vein thrombosis. Patients were screened for inherited thrombophilia. Factor V mutation. Dr Martinelli advises against use of oral contraceptives in these patients. Articles with Related Interest This article is Part One. For Part Two Click Here. Author Jeffrey Dach MDLinks and References. Climacteric. 2. 01. Oct 1. 35 4. 29 3. Transdermal hormone therapy and the risk of stroke and venous thrombosis. Speroff L.   Obstetrics and Gynecology, Oregon Health Science University, Portland, Oregon, USA. Recent case control and cohort studies have indicated that the transdermal administration of postmenopausal estrogen therapy is not associated with an increased risk of cardiovascular complications, specifically stroke and venous thrombosis. These studies have prompted the clinical promotion of transdermal treatment as safer. There are reasons, however, to be cautious regarding postmenopausal transdermal hormone therapy, especially in regard to stroke. Previous reports linking postmenopausal estrogen therapy and the risk of stroke have not yielded consistent results, finding it difficult to adjust for all confounding factors, including compliance with treatment. Age of the population studies may be a critical issue. Notably, the risk of stroke with oral estrogen was not increased in the Womens Health Initiative when women with prior cardiovascular disease or those older than 6.