Risky Business

Knowing blood-clot symptoms can save the life of unlikely victims: young, healthy athletes on birth control.

By Brigid Mander

When 25-year-old endurance mountain bike racer Carmen Messina went to the doctor in June of 2010 with complaints of breathing difficulties, she was diagnosed with seasonal allergies and exercise-induced asthma. Skeptically, she walked out the door with an inhaler, something she’d never needed before.

A week before, at the end of the first bike race of the season, Messina felt great. She stood on the podium after an 8-hour cross-country endurance event—the first she had planned for the summer—and confidently anticipated a successful season before heading home to Jackson, Wyoming, to continue training.

While in the doctor’s office, she wondered aloud whether her breathing issue could possibly be a side effect of Seasonique, a birth control pill she had been on for three weeks, and the only variable Messina could think of in her routine. “I remember the doctor saying that I didn’t fit the risk profile at all. So I pushed through the pain the next couple of days, thinking it was just inflammation from pollen, and went on one really hard ride … which turned out to be a bad idea.”

The morning after that tough workout she awoke coughing up blood. Messina immediately called another doctor who ordered a CAT scan, which revealed two large clots and a plethora of tiny, more dangerous ones in her lungs.

The typical risk factors for blood clots affecting women on birth control are fairly well-known: blood pressure greater than 140/90, obesity, smoking over the age of 35, and inherited tendencies to clotting (i.e., family members with clots or strokes suffered before the age of 50).

However, experts in ultrarunning and endurance racing are warning, with increasing frequency, that there may be increased risks of blood clotting that are specific to pro and endurance athletes. The long periods of physical stress, coupled with dehydration and prolonged post-race inactivity (when athletes are traveling) can contribute to clotting. For female athletes on certain types of birth control, these factors increase the blood-clot potential even more.

Several days after her initial misdiagnosis, Messina quit a training ride due to leg cramps. She loaded up on electrolytes and water, assuming that she must still be recovering from the stress of the race. But by the time of her CAT scan a few days later, she was so consumed by her breathing difficulties that she had forgotten all about the cramps, which were a definite warning sign.

The symptoms of blood clots are the same whether an individual is in a well-known risk category or not, and include one or more of the following: eye problems such as lost or blurred vision, slurred speech, severe headaches (signs that the clot has traveled to the brain), severe abdominal pain, chest pain, shortness of breath, tenderness in the calf or thigh, or—as Messina experienced—severe leg cramps.

In general, within the female population taking birth control, the risk of clotting while on oral contraceptives is 1 in 3,500, according to studies by the World Health Organization. That risk is elevated due to birth control pills’ employment of estrogen. In conjunction with progesterone, estrogen is used to mimic pregnancy and tricks a woman’s reproductive and hormone-control systems to prevent pregnancy from actually occurring. Estrogen is a useful side effect to protect a mother’s blood supply during and after pregnancy and childbirth, when life-threatening blood loss is a risk. But estrogen in oral contraceptives raises the risk of clots in otherwise healthy women whose blood supply isn’t a life-threatening concern.

Third- and fourth-generation contraceptives (the most newly released) contain new formulations of progesterone to maximize beneficial side effects of oral contraceptives, including clear skin and reduced symptoms of premenstrual syndrome. But for unknown reasons, the progesterones in these new pills are suspected to increase the risk of blood clots one-and-a-half times more than other pills, according to Christina Moran, a nurse practitioner of family health and gynecology at a clinic in Jackson, Wyoming.

Ultra-runner and Ironman athlete Robyn Dunn discovered that she’d developed blood clots shortly after starting on Yaz, a relatively new birth control pill that is one of the most widely prescribed. During a 50K race, she had difficulty breathing and had to drop out of the event—a first for her. “I remember that I was out of breath on a tapering [short] run a couple of days before the race,” says Dunn, “but I never would have thought that symptom was due to clots.” Like Messina, she didn’t connect the dots between her early symptoms and her race-day breathing problems. And because she also didn’t fit the high-risk profile for blood clots, she was initially misdiagnosed and placed on anti-inflammatories for her lungs. Five days after the race, she went back to the emergency room with new chest and back pain, and doctors found bilateral pulmonary embolisms.

Messina and Dunn were lucky to have made full recoveries—thanks to their diligence in seeking further treatment when their symptoms persisted. The sooner clots are identified and treated, the less damage they can do. This means that awareness of blood-clot symptoms, birth control’s active ingredients, and risk factors for clotting can lead to quicker diagnoses and easier recovery from potentially deadly clotting scenarios, such as deep-vein thrombosis or pulmonary embolism. Especially at risk are women with thrombophilias—abnormal blood-clotting disorders that are hereditary conditions.

Messina, who eventually tested positive for Factor V Leiden—the most common hereditary clotting-gene mutation—should not have been on oral contraceptives at all. “I didn’t like the pill I was on, so the nurse in the office just gave me a free a sample of another pill and said, ‘Try this and see if you like it,’” she recalls, stressing that pre-prescription testing and screening questions should be a higher priority for physicians and nurses.

In Messina’s case, her hidden genetic susceptibility only surfaced when she tried oral contraceptives, even though the pill she was on is one of the lowest-dose estrogen pills on the market. Messina’s doctors saw her active lifestyle and put her in a non–risk-associated category, when in fact her intensive training schedule, race-pace efforts, and her hidden genetic mutation actually made her a high-clotting-risk patient.

The lesson she learned from the experience is that young, active women have the responsibility of creating awareness in their doctors and pushing for recognition of clotting symptoms that their doctors aren’t looking for. “If a woman feels she might be at risk for blood clots, either because of lifestyle, family history, or maybe just not wanting to deal with the risk,” says Moran, who treats dozens of elite-level athletes at her clinic, “she should know there are plenty of contraceptives that do not use estrogen—patients just need to tell their health-care provider they want to discuss other options.”

After recovering from her embolism, Dunn also suggests not to be drawn in by slick advertising campaigns, and to ask serious questions about which method of birth control is right for each individual. “Television ads for these pills show cool, hip women having a good time. They aren’t great at portraying how dangerous these medications can be,” she says. “I want the medical community to raise physician awareness, and I want to take what happened to me and help others.” n

The genetic disorder, Factor V Leiden, increases deep-vein thrombosis and pulmonary embolism risk in women who take oral contraceptives by 35 fold.

Some people with Factor V Leiden never develop clots, but experience another symptom: unexplained pregnancy loss in the second or third trimester.

A Pill for Him?

Is carrying a 28-pill packet putting an unwanted burden in your pack? You may soon have a chance to shift the weight.

For 50 years, the pill has given women control over their reproductive health and liberated us from unwanted pregnancies. But the novelty of liberation has faded, and some women want to avoid side-effects and blood-clotting potential, while others want to escape the grind of taking—and remembering—a daily pill. What’s a girl to do? For some of us, the answer could be: Go ultralight and pass the birth-control scrip to the man in your life.

Recent studies suggest male hormonal contraceptives (MHC) could be on the market as soon as 2013 and the most promising methods are man-friendly and low-maintenance: quarterly injections or once-yearly under-skin implants. Studies suggest that the active-ingredient hormones—mainly testosterone and progesterones—shut off sperm production with few side effects and that men would welcome the opportunity to have a little more control of their own when it comes to reproductive rights. It’s a win-win, so what’s the hold-up?

According to Dr. Christina Wang, head of the MHC clinical trials at Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute, it’s a funding issue. “We know it works,” she says. “We just need support to make sure it gets to the market so people can use it.”