Oral contraceptives and the risk of subarachnoid hemorrhage: a meta-analysis.
OBJECTIVE
The objective of this study is to estimate the risk of subarachnoid hemorrhage produced by oral contraceptive use.


METHODS
Studies published since 1960 were identified using MEDLINE, Cumulated Index Medicus, Dissertation Abstracts On-line, and bibliographies of pertinent articles. Two independent reviewers screened published cohort and case-control studies that evaluated the risk of subarachnoid hemorrhage associated with oral contraceptives. Eleven of 21 pertinent studies met predefined quality criteria for inclusion in the meta-analysis. Relative risk (RR) estimations evaluating subarachnoid hemorrhage risk in oral contraceptive users compared with nonusers were extracted from each study by two independent reviewers. Study heterogeneity was assessed by design type, outcome measure (mortality versus incidence), exposure measure (current versus ever use), prevailing estrogen dose used, and control for smoking and hypertension.


RESULTS
The overall summary RR of subarachnoid hemorrhage due to oral contraceptive use was 1.42 (95% CI, 1.12 to 1.80; p = 0.004). When the two study results failing to control for smoking were excluded from the analysis, a slightly greater effect was seen, with an RR of 1.55 (95% CI, 1.26 to 1.91; p < 0.0001). In the six studies controlling for smoking and hypertension the RR was 1.49 (95% CI, 1.20 to 1.85; p = 0.0003). High-estrogen oral contraceptives appeared to impart a greater risk than low-dose preparations in studies controlling for smoking, but the difference was not significant (high-dose RR, 1.94; 95% CI, 1.06 to 3.56; low-dose RR, 1.51; 95% CI, 1.18 to 1.92).


CONCLUSIONS
This meta-analysis of observational studies suggests that oral contraceptive use produces a small increase in the risk of subarachnoid hemorrhage.
Department of Neurology, University of California, San Francisco 94143-0114, USA.
S C
SC
Johnston
J M
JM
Colford
D R
DR
Gress
D016022:Case-Control Studies; D015331:Cohort Studies; D003276:Contraceptives, Oral / Q000009:adverse effects*; D006801:Humans; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000139:chemically induced*; D016896:Treatment Outcome
D003276:Contraceptives, Oral