A coroner has issued a warning to women taking the contraceptive pill, and to doctors prescribing it, after two young women died 10 days apart in similar circumstances.
Both women had a previously unknown blood clotting condition, which is exacerbated when taking the pill, increasing the risk of developing deep vein thrombosis and pulmonary embolism by 35 times.
Georgia O’Neill, a 24-year-old make-up artist, was found dead on her bedroom floor in her shared flat in Mount Roskill, Auckland, by her flat mate in September 2021.
Earlier that day, O’Neill texted both her flatmate and her father saying she wasn’t feeling well, had a lot of pain in her lower back and running down her left leg. In her message to her flat mate, she said the pain made her want to throw up.
When she didn’t reply to her flat mate’s messages, she went to check on her and found her unresponsive, and paramedics pronounced her dead at the scene.
Coroner Ho has ruled the direct cause of death to be pulmonary thrombosis, but the post-mortem revealed that she also had a condition she did not know she had, which was exacerbated by the use of the oral contraceptive pill.
Prescription records show O’Neill had been taking the pill Ginet, a combined oral contraceptive pill from 2017 to 2019, and had recently started taking it again in July, the same year of her death.
Her previously unknown condition – Factor V Leiden mutation – affects blood clotting and women with the condition are 5 to 7 times more at risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE), according to clinical director of haematology and lead thrombosis clinician at Te Whatu Ora Waitematā, Dr Eileen Merriman.
Women with Factor V Leiden who are taking the pill have an approximately 35-fold increased risk of developing DVT or PE, compared with women without Factor V Leiden.
Women without the condition and otherwise ‘healthy’ taking the oral contraceptive pill have a three-to-fourfold increased risk of developing DVT or PE compared with women who do not take the pill.
Factor V Leiden is diagnosed by blood test. 2010 Royal College of Obstetricians and Gynaecologists guidelines do not recommend routine thrombophilia screening (testing for a person’s tendency to develop blood clots) prior to hormonal contraceptive use.
Coroner Ho, in his report on O’Neill’s death, referred to another New Zealand woman who died in September 2021, in similar circumstances.
Isabella Rangimohia Alexander, 17, died of pulmonary thromboembolism, with blood clots later found in her legs and lungs. Her death was ruled to also be caused by heterozygous Factor V Leiden mutation and exacerbated by recent commencement of the oral contraceptive pill.
Alexander had collapsed while on a walk with her father near her home in Muriwai on September 9, 2021.
The St Mary’s College Year 13 student was rushed to Auckland Hospital but died early the following morning.
Alexander had seen her GP on September 6, 2021 with new onset respiratory symptoms, but her GP had not considered pulmonary embolism as an explanation. An independent review concluded that the GP’s care was acceptable and that there were no indications pointing to this diagnosis at the time.
Coroner Ho has now given a warning regarding use of the combined oral contraceptive pill, which he said, if brought to public attention, could reduce the chances of the occurrence of other deaths in circumstances similar to the two women.
While use of the combined oral contraceptive pill increases the risk of developing deep vein thrombosis or pulmonary embolism in all women, the risk increases with family or personal history of blood clotting conditions – which women may not even be aware of.
Coroner Ho said that all women starting the combined oral contraceptive pill should be told that there is an increased risk of venous thromboembolism and advised to seek immediate medical attention if they develop symptoms of DVT or PE.
All prescribers of the combined oral contraceptive pill, and other hormone related medications, should ensure they take a comprehensive clinical history and inform patients about the risks of venous thromboembolism, the seriousness of the condition and the symptoms to look out for, he said.
In addition, medical practitioners need to be vigilant about the possibility of venous thromboembolism, even where a woman appears to have few risk factors.
Symptoms for deep vein thrombosis include leg pain or tenderness in the thigh or calf, leg swelling, skin that feels warm to the touch or with reddish discolouration and streaks.
For pulmonary embolism, symptoms include unexplained shortness of breath, rapid breathing, chest pain anywhere under the ribcage, fast heart rate, light headedness and passing out.
In the report, Dr Merriman emphasised that, in general, “the consequences of unintended pregnancy can present far greater damage to women than safe oral contraception. The risk of DVT and PE in pregnancy is sixtyfold higher than that from the combined oral contraceptive pill.”
There were also numerous benefits which women derive from being able to access a reliable and convenient method of birth control, she said.
The shattered family of Isabella Rangiamohia Alexander have already called for changes to the health care system regarding monitoring of the contraceptive pill.