Contraceptive use, both oral and parenteral, is associated with increased arterial stiffness in young healthy women

Contraceptive use, both oral and parenteral, is associated with increased arterial stiffness in young healthy women | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Contraceptive use, both oral and parenteral, is associated with increased arterial stiffness in young healthy women Paul Pettersson-Pablo, Torbjörn K Nilsson, Anita Hurtig-Wennlöf This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5018497/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Mar, 2025 Read the published version in Endocrine → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: Previous studies on the impact on arterial health of contraceptive use, or across the menstrual phases, have yielded differing results. Furthermore, there is little research on the differences based on the delivery method of the contraceptive, oral vs parenteral contraceptives. In this study, we examine arterial health using three different clinical physiological measures of arterial function and structure in contraceptive users and non-users. Methods: Young, healthy, non-smoking, women, between 18.0-25.9 years of age were enrolled in the study (n = 577). Menstrual phase and contraceptive use and type were assessed by questionnaire. Arterial stiffness was measured using pulse-wave velocity (PWV) and augmentation index (AIx). Arterial thickness was measured using carotid-intima media thickness (cIMT). Venous blood samples were analysed for various biomarkers, which were used in multivariate regressions to adjust for the effects of contraceptive use on the vascular measures. Results: Contraceptive users had a significantly higher PWV than non-users. The menstrual phase did not significantly impact PWV. The type of contraceptive, oral or parenteral, did not impact PWV. AIx and cIMT did not differ between any studied groups. Systolic blood pressure, Body Mass Index, serum lipids, C-reactive protein, and sex hormone binding globulin concentrations were higher in the contraceptive using group, but in multivariable models, adjusting for age, these biomarkers had only limited impact on the positive association between contraceptive use and PWV. Conclusion: Contraceptive users have higher PWV than non-users already in young healthy women. Young female adults Pulse-wave velocity Endocrine hypertension PWV Menstrual phase Contraceptive Arterial stiffness cIMT Cardiovascular risk factors Figures Figure 1 Introduction An increased arterial stiffness is associated with an increased cardiovascular risk and predicts cardiovascular events independently of established cardiometabolic risk factors blood pressure and hyperlipidemia [ 1 ]. Men display higher pulse-wave velocity, PWV, considered as the gold standard of arterial stiffness measurements, than women, and have a higher risk of cardiovascular disease (CVD), but this changes after menopause, after which women experience an increasing risk, with the odds ratio of women to men approaching equality for the risk of cardiovascular disease [ 2 ]. Hormonal factors are thought to be involved but studies on the effect of hormonal replacement therapy (HRT) on post-menopausal women have been contradictive, with some studies reporting beneficial effects and others detrimental effects on measures of arterial stiffness [ 3 – 6 ]. In premenopausal women, studies on the relationship between the menstrual phases and arterial stiffness have also yielded conflicting results, with some studies reporting an increased stiffness and others a decreased arterial stiffness [ 7 – 10 ]. Contraceptives are delivered as oral contraceptive pills (OCP) or as parenteral contraceptives (PCP), the latter available in preparations such as subdermal, spiral, or vaginal. We identified only five studies that have investigated the effect of the use of oral contraceptives on blood pressure and arterial stiffness, whose results were discordant much like those of HRT in postmenopausal women. Hickson et al., in 2011 [ 11 ], and Yu et al., in 2014 [ 12 ] observed higher PWV in the OCP group, while Priest et al., in 2018 [ 13 ] and Enea et al., in 2021 [ 14 ] observed no differences between the groups. However, Enea et al. observed higher central BP’s and AIx (augmentation index) in the OCP group. In Sweden, the use of OCP is prevalent, as shown in a 1997 study where 93% of the women reported having used OCP [ 15 ], but a study published in 2016 reported trends towards increasing prevalences of PCP contraceptive use [ 16 ]. In this study, we examined measures of vascular structure and function by analysing PWV, AIx, and cIMT in users of OCP and PCP as well as across the menstrual phases of the non-users of contraceptives, in a large cohort of young, healthy non-smoking women. Subjects and methods Study population The cross-sectional Lifestyle, Biomarkers and Atherosclerosis study (LBA) population are young, healthy adults (ages 18 to 25.9). The LBA study recruitment was done through community advertising and has been previously described in detail [ 17 ]. During two subsequent visits to the Örebro University physiology laboratory, the subjects underwent arterial stiffness examinations and filled out a questionnaire on their general health status, use of contraceptives or other medication and the date of the first day of their last menstruation. Women between 18 and 26 years of age, with a self-assessed good health, either using contraceptives or having had a menstruation within the last 35 days were included in the study. Smokers and subjects suffering from chronic disease were excluded. For subgroup comparison, the contraceptive users were grouped into users of OCP, vaginal contraceptives, intrauterine contraceptives, transdermal and subcutaneous contraceptives, and alternatively into users of estrogen containing contraceptives vs. all non-estrogen users (which includes users of gestagen CP). The date of onset of menstruation was used to assess the menstrual phase, with early follicular phase (EF) corresponding to day 1–8, late follicular phase (LF) day 9–15, early luteal phase (EL) day 16–23 and late luteal phase (LL) day 24 and − 1. The study was approved by the Regional Ethics Review Board, Uppsala, ref 2014/224. Arterial stiffness and cIMT measurements For PWV, carotid and femoral pulse waves were recorded with applanation tonometry with simultaneously electrocardiography (ECG) recording to get the pulse transit time. For AIx, radial artery tonometry was performed at the subject’s right wrist and the aortic pressure waveform was derived from the radial waveform by a validated transfer function. An average of AIx_HR75, standardized to a heart rate of 75, was derived. cIMT was measured using a high-resolution ultrasound B-mode system, (GE Healthcare, Vivid E9, Chicago, Illinois, US) with a 12 MHz linear array transducer. An average of three measurements was reported for each subject. Details on the methodology has been previously described [ 17 ]. Laboratory investigations Samples were collected after an overnight fast into sodium citrate fluoride vacutainer tubes for glucose analysis and serum and plasma vacutainer tubes for the rest of the analyses (BD Vacutainer; BD AB, Stockholm, Sweden). HsCRP was analyzed on a Siemens ADVIA 1800 Chemistry instrument with a CV of 5% at 0.74 mg/L with the Siemens High Sensitivity CRP Assay (ADVIA 1800 Chemistry System; Upplands Väsby, Sweden). Total cholesterol (CHOL), Triglycerides (TG), high-density lipoprotein (HDL) and glucose were assayed colorimetrically with Vitros MicroSlide technology (5.1TM FS; Clinical Chemistry Instruments, Raritan, NJ, USA). Direct low-density lipoprotein (direct LDL) was assayed by a two-step colorimetric assay with Vitros MicroWell technology. CHOL (3% CV at 3.9 mmol/L), TG (CV of 4% at 1.3 g/L), HDL (6% CV at 1.0 mmol/L), LDL (5% CV at 2.4 mmol/L) and glucose (4% CV at 4.6 mmol/L) were analyzed on a Vitros 5.1 system (Vitros 5.1TM FS, Clinical Chemistry Instruments, Raritan, NJ, USA). Sex hormone binding globulin (SHBG) was measured on a Roche Cobas system (Roche Diagnostics, Basel, Switzerland). Statistical analysis Statistical analyses were performed with statistical software SPSS version 22 (IBM, Armonk, NY, USA). Continuous data in the study population is shown as mean and standard deviation (SD) for normally distributed variables. Normal distribution was appraised by assessment of the size of the SD in comparison with the mean, as well as graphically displayed in a histogram and visually evaluated. Univariate and multivariate linear regression were used to statistically analyze the association between PWV, AIx and contraceptive use. Comparison of group means was done with ANOVA. Results Table 1 shows the distribution of OCP and PCP in the population. The number of OCP users are higher than PCP. Only one individual used a transdermal contraceptive. Employing variance analysis with ANOVA for subgroup comparison, we found no difference between the PWV, cIMT, or AIx measurements based on their hormonal delivery system. There were no age or BMI differences between the OCP and PCP groups. SHBG was markedly higher in the vaginal contraceptive group compared to other contraceptive types. Significantly higher SHBG was also observed in the oral contraceptive group compared to the non-using group and the other types, except the vaginal group (Table 1). SHBG was also higher in the estrogen using group compared to non-estrogen users (Table 2) and in the whole contraceptive using group vs non-using (Table 3). Population characteristics are shown in Tables 2 and 3. The contraceptive users of the study population measured higher vs. non-users on some of the CVD risk variables in this study: SBP, LDL-CH, TG, non-HDL-CH and CRP. The contraceptive group also had higher SHBG and PWV measurements. Table 3 shows the values in contraceptive users, grouped into users of estrogen-containing contraceptives vs. all non-users of estrogen contraceptives (i.e., including users of gestagen containing contraceptives). The EU group had significantly higher SBP, LDL-CH and non-HDL-CH, triglycerides, CRP, and PWV but no difference in BMI, HDL-CH, fasting serum insulin, AIx or cIMT. There was variation in mean PWV measurements in the different menstrual phases, with a tendency towards the lowest mean in late luteal phase, but the differences were not statistically significant (Figure 1). In multivariable linear regression, contraceptive use vs. non-use was positively associated with PWV, in three models (Table 4), and remained significant with adjustment for BMI, age, SBP and SHBG. The inclusion of BMI and systolic blood pressure has the greatest effect on the R 2 and the β coefficient of the association between PWV and use of contraceptives, with adjustment for SHBG having a slightly lesser impact. Similar results were obtained by testing the same linear models but comparing EU vs NEU (Table 5). Discussion In this study we found a significant association between use of hormonal contraceptives and PWV as a marker of arterial stiffness, but not with AIx or cIMT. This association remained significant after adjustment for established cardiometabolic risk factors BMI, age, blood pressure and SHBG. SHBG, included here as a marker of androgenicity, was strongly dependent on contrapeptive use and contrapeptive modes of administration (Table 1 ), but had only a limited impact on the association between PWV and contraceptive use (Tables 4 and 5 ). Furthermore, we found no statistically significant difference in PWV and AIx between OCP and PCP groups (Table 1 ), or when comparing the menstrual phases of non-users of contraceptives (Fig. 1 ). With respect to OCP and arterial stiffness, our findings concord with those of Hickson et al [ 11 ] and Yu et el [ 12 ], who found an increased arterial stiffness in their OCP groups. Furthermore, like them, we found no significant association between menstrual phase and arterial stiffness, although our cross-sectional study design is not optimal for assessing this particular factor. Our results with respect to PWV differ from those of Priest 2018 [ 18 ] and Enea 2021 [ 14 ]. Moreover, further contrasting with our findings, Enea et al. found an increased AIx in the OCP group that they stated was difficult to explain in light of the non-significance of PWV in their study. The lack of concordance between PWV and AIx in both our material and that of Enea, is a sign that, while both measurements aim at addressing “arterial stiffness”, they in fact probably correspond to slightly different properties, at different scales, in different parts of the arterial tree [ 19 , 20 ]. Our study is the first, to our knowledge, to measure arterial stiffness in a PCP group. There was a tendency towards higher PWV in the subcutaneous and vaginal groups (Table 1 ). While PCP bypass first pass metabolism in the liver, permitting lower dosages than what is typically found in OCPs, pharmacokinetic studies have observed increased plasma concentrations of estrogen in PCP compared to OCP [ 21 ]. OCP intake may also be less consistent, with OCP users displaying a lower compliance than parenteral methods [ 22 ]. Furthermore, PCPs have been found to confer a greater risk of thromboembolism than OCP [ 23 ]. The nature of the differences in CVD risk between OCP and PCP is unknown. Ethinyl-estradiol likely plays a role, being found in OCPs, but typically not as often in PCP, while both contain progestins. At the same time, both estrogens and progestins have been implicated in hypertension, by means of the activation of the renin-angiotensin-aldosterone system (RAAS), altered endothelial function, and oxidative stress [ 24 , 25 ]. The contraceptive using group in our material indeed had a significantly higher blood pressure than non-users (Table 2). In this population of young, healthy women, the contraceptive using group, both OCP and PCP, showed increased CVD risk markers, such as a higher lipids and CRP concentration, which concord with the findings of a previous study [ 26 ]. The CRP induction caused by orally delivered estrogen has been attributed to the hepatic first-pass effect, not reflecting an increase in systemic inflammation typically associated with an increasing CRP. Nonetheless, our results raise concerns regarding the safety of OCP with respect to arterial health. CRP correlates with endothelial dysfunction [ 27 ] and shows a proinflammatory effect on in vitro endothelium [ 28 ], which may be parts of the explanation, but its inclusion in multivariable models (Table 4 ) showed a limited effect on the relationship between contraceptive use and PWV, implying that CRP is only a minor part of the mechanism. Although the results of ours and previous studies on arterial properties in young women are conflicting, studies on hormone replacement therapy, HRT, in postmenopausal women describing beneficial effects on arterial stiffness are more plentiful [ 2 , 29 ]. Various mechanisms have been proposed, such as endothelin mediated effects on endothelial cells, and a downstream effect towards a more beneficial lipid profile. In a study with a longer follow up time, post-hoc analyses showed an initially detrimental effect of HRT, with the intervention group having more CVD events. After year 3, the inverse was seen, with fewer episodes in the HRT group. It was speculated that an initial estrogen induced prothrombotic effect was over time outweighed by the benefits of lipid profile changes on the evolution of underlying atherosclerosis [ 30 ]. However, in our population of young women, the contraceptive group showed higher values for several of the established CVD risk variables, including lipids. Our study is limited in its cross-sectional design, from which it is not possible to ascertain the order of the alterations in the variables examined. It may also not be fully representative of the young female population at large due to the recruitment mode. Future studies are warranted with a longitudinal design, examining the impact of OCP and PCP on stiffness and CVD risk markers on follow-up. The strengths of this study are that all subjects were young healthy non-smokers free of any chronic disorders, and its large population size, in a field of research where previous studies have typically studied small samples ( n < 100). This provided us with a higher power to detect even minor differences in the studied variables. There were statistically significant differences in SHBG between OCP, PCP, and the non-contraceptive using groups (Table 1 ), which are indicative of differences in androgenicity that may also play an important role in CVD risk, nonetheless the small impact it had as an adjustment variable on our multivariable examinations on the effect of contraceptives on stiffness (Tables 4 and 5 ) suggests that the relationship cannot be attributed to altered androgenicity profiles only. In conclusion, contraceptive using women exhibited an increased arterial stiffness compared to non-users measured as PWV. Despite significant differences in serum CVD risk biomarkers between NEU or NCU and EU or CU, the inclusion of these biomarkers in adjusted models only moderately affected the association between PWV and contraceptive use, suggesting that contraceptives exert direct actions on the arterial wall by as of yet unidentified additional factors. Abbreviations PWV Pulse-wave velocity IMT Intima media thickness CH OCP,Oral contraceptive pills Total cholesterol TG Triglycerides HDL-CH high-density lipoprotein cholesterol LDL-CH low-density lipoprotein cholesterol CVD Cardiovascular disease BMI Body mass index. Declarations Acknowledgements This work was supported by AFA Insurance [grant 130275]; Region Örebro County’s Research Committee, Örebro, Sweden [OLL-780061]; and Umeå University, Umeå, Sweden [RV-865861]. None of the funding sources had an influence on the design or production of the article. We thank Professor emeritus Torbjörn Bäckström, Umeå, for valuable viewpoints on an early version of this paper. Author Contributions All authors contributed to the study conception and design, data collection and analysis. The first draft of the manuscript was written by Paul Pettersson-Pablo and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Conflict of interest None of the authors has a conflict of interest to declare. References Rosenbaum D, Giral P, Chapman J et al. Radial augmentation index is a surrogate marker of atherosclerotic burden in a primary prevention cohort. Atherosclerosis. 2013;231(2):436–441. Suzuki H, Kondo K. Pulse Wave Velocity in Postmenopausal Women. Pulse (Basel). 2013;1(1):4–13. Tentolouris N, Christodoulakos G, Lambrinoudaki I et al. Effect of hormone therapy on the elastic properties of the arteries in healthy postmenopausal women. J Endocrinol Invest. 2005;28(4):305–311. Teede HJ, Liang YL, Kotsopoulos D et al. A placebo-controlled trial of long-term oral combined continuous hormone replacement therapy in postmenopausal women: effects on arterial compliance and endothelial function. Clin Endocrinol (Oxf). 2001;55(5):673–682. Angerer P, Stork S, Kothny W et al. Effect of oral postmenopausal hormone replacement on progression of atherosclerosis: a randomized, controlled trial. Arterioscler Thromb Vasc Biol. 2001;21(2):262–268. Hodis HN, Mack WJ. Hormone replacement therapy and the association with coronary heart disease and overall mortality: clinical application of the timing hypothesis. J Steroid Biochem Mol Biol. 2014;142:68–75. M M, Ta S. Effect of Different Phases of Menstrual Cycle on Reflection Index, Stiffness index and Pulse wave velocity in Healthy subjects. J Clin Diagn Res. 2014;8(9):BC01-04. Hayashi K, Miyachi M, Seno N et al. Variations in carotid arterial compliance during the menstrual cycle in young women. Exp Physiol. 2006;91(2):465–472. Williams MR, Westerman RA, Kingwell BA et al. Variations in endothelial function and arterial compliance during the menstrual cycle. J Clin Endocrinol Metab. 2001;86(11):5389–5395. Willekes C, Hoogland HJ, Keizer HA et al. Female sex hormones do not influence arterial wall properties during the normal menstrual cycle. Clin Sci (Lond). 1997;92(5):487–491. Hickson SS, Miles KL, McDonnell BJ et al. Use of the oral contraceptive pill is associated with increased large artery stiffness in young women: the ENIGMA study. J Hypertens. 2011;29(6):1155–1159. Yu A, Giannone T, Scheffler P et al. The effect of oral contraceptive pills and the natural menstrual cYCLe on arterial stiffness and hemodynamICs (CYCLIC). J Hypertens. 2014;32(1):100–107. Priest SE, Shenouda N, MacDonald MJ. Effect of sex, menstrual cycle phase, and monophasic oral contraceptive pill use on local and central arterial stiffness in young adults. Am J Physiol Heart Circ Physiol. 2018;315(2):H357-H365. Enea C, Laffetas P, Pichon A et al. Arterial Stiffness and Hemodynamics in Young Women: The Effects of Oral Contraceptive Intake and Physical Habits. Int J Environ Res Public Health. 2021;18(7). Larsson G, Blohm F, Sundell G et al. A longitudinal study of birth control and pregnancy outcome among women in a Swedish population. Contraception. 1997;56(1):9–16. Lindh I, Hognert H, Milsom I. The changing pattern of contraceptive use and pregnancies in four generations of young women. Acta Obstet Gynecol Scand. 2016;95(11):1264–1272. Fernstrom M, Fernberg U, Eliason G et al. Aerobic fitness is associated with low cardiovascular disease risk: the impact of lifestyle on early risk factors for atherosclerosis in young healthy Swedish individuals - the Lifestyle, Biomarker, and Atherosclerosis study. Vasc Health Risk Manag. 2017;13:91–99. Priest SE, Shenouda N, MacDonald MJ. Effect of sex, menstrual cycle phase, and monophasic oral contraceptive pill use on local and central arterial stiffness in young adults. 2018;315(2):H357-H365. Heusinkveld MHG, Delhaas T, Lumens J et al. Augmentation index is not a proxy for wave reflection magnitude: mechanistic analysis using a computational model. J Appl Physiol (1985). 2019;127(2):491–500. Papakonstantinou E, Pikilidou M, Georgianos P et al. Wave reflections and systemic vascular resistance are stronger determinants of pulse pressure amplification than aortic stiffness in drug-naive hypertensives. Clin Exp Hypertens. 2020;42(3):287–293. van den Heuvel MW, van Bragt AJ, Alnabawy AK et al. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive. Contraception. 2005;72(3):168–174. Vlesko G, Meznerics FA, Hegyi P et al. Comparison of Combined Parenteral and Oral Hormonal Contraceptives: A Systematic Review and Meta-Analysis of Randomized Trials. J Clin Med. 2024;13(2). Lidegaard O, Nielsen LH, Skovlund CW et al. Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark 2001-10. BMJ. 2012;344:e2990. Dubey RK, Oparil S, Imthurn B et al. Sex hormones and hypertension. Cardiovasc Res. 2002;53(3):688–708. Mendelsohn ME, Karas RH. The protective effects of estrogen on the cardiovascular system. N Engl J Med. 1999;340(23):1801–1811. Norouzi V, Seifi M, Fallah S et al. Effect of oral contraceptive therapy on homocysteine and C-reactive protein levels in women: an observational study. Anadolu Kardiyol Derg. 2011;11(8):698–702. Fichtlscherer S, Zeiher AM. Endothelial dysfunction in acute coronary syndromes: association with elevated C-reactive protein levels. Ann Med. 2000;32(8):515–518. Venugopal SK, Devaraj S, Yuhanna I et al. Demonstration that C-reactive protein decreases eNOS expression and bioactivity in human aortic endothelial cells. Circulation. 2002;106(12):1439–1441. Blacher J, Raison J, Amah G et al. Increased arterial distensibility in postmenopausal hypertensive women with and without hormone replacement therapy after acute administration of the ACE inhibitor moexipril. Cardiovasc Drugs Ther. 1998;12(4):409–414. Grady D, Herrington D, Bittner V et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA. 2002;288(1):49–57. Tables Table 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files TABLESContraceptivePWVcIMT240902.docx Cite Share Download PDF Status: Published Journal Publication published 13 Mar, 2025 Read the published version in Endocrine → Version 1 posted Editorial decision: Revision requested 09 Jan, 2025 Reviews received at journal 05 Jan, 2025 Reviewers agreed at journal 31 Dec, 2024 Reviewers invited by journal 22 Sep, 2024 Editor assigned by journal 09 Sep, 2024 Submission checks completed at journal 09 Sep, 2024 First submitted to journal 02 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5018497","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":359815117,"identity":"3f5dd4e1-601b-4815-aee4-cc6bac47ad1b","order_by":0,"name":"Paul Pettersson-Pablo","email":"data:image/png;base64,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","orcid":"","institution":"Örebro University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"","lastName":"Pettersson-Pablo","suffix":""},{"id":359815118,"identity":"b6a66320-8aa2-4c7c-9b17-da7a8a66b061","order_by":1,"name":"Torbjörn K Nilsson","email":"","orcid":"","institution":"Umeå University","correspondingAuthor":false,"prefix":"","firstName":"Torbjörn","middleName":"K","lastName":"Nilsson","suffix":""},{"id":359815120,"identity":"57f570a8-c289-4659-96f3-8d6e05f53ee0","order_by":2,"name":"Anita Hurtig-Wennlöf","email":"","orcid":"","institution":"Jönköping University","correspondingAuthor":false,"prefix":"","firstName":"Anita","middleName":"","lastName":"Hurtig-Wennlöf","suffix":""}],"badges":[],"createdAt":"2024-09-02 12:54:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5018497/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5018497/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12020-025-04208-9","type":"published","date":"2025-03-13T15:57:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66750107,"identity":"ac8a579b-486a-49f9-a21d-dd05b2cfaf98","added_by":"auto","created_at":"2024-10-16 07:08:49","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":162791,"visible":true,"origin":"","legend":"\u003cp\u003eMean pulse-wave velocity for different menstrual phases for women (non-users of contraceptives)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5018497/v1/ade31b3aa1c520efb32089ef.jpeg"},{"id":78688984,"identity":"ee00728c-77c2-4b02-9851-192cd1b6c6c0","added_by":"auto","created_at":"2025-03-17 16:09:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":591218,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5018497/v1/44691d43-1eaa-4eae-a2f6-378dad5664dc.pdf"},{"id":66750144,"identity":"b89f6186-58ec-4640-8854-6d67898817eb","added_by":"auto","created_at":"2024-10-16 07:08:52","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":43624,"visible":true,"origin":"","legend":"","description":"","filename":"TABLESContraceptivePWVcIMT240902.docx","url":"https://assets-eu.researchsquare.com/files/rs-5018497/v1/fc6f8cb485926d601c1ade4f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Contraceptive use, both oral and parenteral, is associated with increased arterial stiffness in young healthy women","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAn increased arterial stiffness is associated with an increased cardiovascular risk and predicts cardiovascular events independently of established cardiometabolic risk factors blood pressure and hyperlipidemia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Men display higher pulse-wave velocity, PWV, considered as the gold standard of arterial stiffness measurements, than women, and have a higher risk of cardiovascular disease (CVD), but this changes after menopause, after which women experience an increasing risk, with the odds ratio of women to men approaching equality for the risk of cardiovascular disease [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Hormonal factors are thought to be involved but studies on the effect of hormonal replacement therapy (HRT) on post-menopausal women have been contradictive, with some studies reporting beneficial effects and others detrimental effects on measures of arterial stiffness [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In premenopausal women, studies on the relationship between the menstrual phases and arterial stiffness have also yielded conflicting results, with some studies reporting an increased stiffness and others a decreased arterial stiffness [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Contraceptives are delivered as oral contraceptive pills (OCP) or as parenteral contraceptives (PCP), the latter available in preparations such as subdermal, spiral, or vaginal. We identified only five studies that have investigated the effect of the use of oral contraceptives on blood pressure and arterial stiffness, whose results were discordant much like those of HRT in postmenopausal women. Hickson et al., in 2011 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and Yu et al., in 2014 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] observed higher PWV in the OCP group, while Priest et al., in 2018 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Enea et al., in 2021 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] observed no differences between the groups. However, Enea et al. observed higher central BP\u0026rsquo;s and AIx (augmentation index) in the OCP group. In Sweden, the use of OCP is prevalent, as shown in a 1997 study where 93% of the women reported having used OCP [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], but a study published in 2016 reported trends towards increasing prevalences of PCP contraceptive use [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In this study, we examined measures of vascular structure and function by analysing PWV, AIx, and cIMT in users of OCP and PCP as well as across the menstrual phases of the non-users of contraceptives, in a large cohort of young, healthy non-smoking women.\u003c/p\u003e"},{"header":"Subjects and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe cross-sectional Lifestyle, Biomarkers and Atherosclerosis study (LBA) population are young, healthy adults (ages 18 to 25.9). The LBA study recruitment was done through community advertising and has been previously described in detail [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. During two subsequent visits to the \u0026Ouml;rebro University physiology laboratory, the subjects underwent arterial stiffness examinations and filled out a questionnaire on their general health status, use of contraceptives or other medication and the date of the first day of their last menstruation. Women between 18 and 26 years of age, with a self-assessed good health, either using contraceptives or having had a menstruation within the last 35 days were included in the study. Smokers and subjects suffering from chronic disease were excluded. For subgroup comparison, the contraceptive users were grouped into users of OCP, vaginal contraceptives, intrauterine contraceptives, transdermal and subcutaneous contraceptives, and alternatively into users of estrogen containing contraceptives vs. all non-estrogen users (which includes users of gestagen CP). The date of onset of menstruation was used to assess the menstrual phase, with early follicular phase (EF) corresponding to day 1\u0026ndash;8, late follicular phase (LF) day 9\u0026ndash;15, early luteal phase (EL) day 16\u0026ndash;23 and late luteal phase (LL) day 24 and \u0026minus;\u0026thinsp;1. The study was approved by the Regional Ethics Review Board, Uppsala, ref 2014/224.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eArterial stiffness and cIMT measurements\u003c/h2\u003e \u003cp\u003eFor PWV, carotid and femoral pulse waves were recorded with applanation tonometry with simultaneously electrocardiography (ECG) recording to get the pulse transit time. For AIx, radial artery tonometry was performed at the subject\u0026rsquo;s right wrist and the aortic pressure waveform was derived from the radial waveform by a validated transfer function. An average of AIx_HR75, standardized to a heart rate of 75, was derived. cIMT was measured using a high-resolution ultrasound B-mode system, (GE Healthcare, Vivid E9, Chicago, Illinois, US) with a 12 MHz linear array transducer. An average of three measurements was reported for each subject. Details on the methodology has been previously described [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory investigations\u003c/h2\u003e \u003cp\u003eSamples were collected after an overnight fast into sodium citrate fluoride vacutainer tubes for glucose analysis and serum and plasma vacutainer tubes for the rest of the analyses (BD Vacutainer; BD AB, Stockholm, Sweden). HsCRP was analyzed on a Siemens ADVIA 1800 Chemistry instrument with a CV of 5% at 0.74 mg/L with the Siemens High Sensitivity CRP Assay (ADVIA 1800 Chemistry System; Upplands V\u0026auml;sby, Sweden). Total cholesterol (CHOL), Triglycerides (TG), high-density lipoprotein (HDL) and glucose were assayed colorimetrically with Vitros MicroSlide technology (5.1TM FS; Clinical Chemistry Instruments, Raritan, NJ, USA). Direct low-density lipoprotein (direct LDL) was assayed by a two-step colorimetric assay with Vitros MicroWell technology. CHOL (3% CV at 3.9 mmol/L), TG (CV of 4% at 1.3 g/L), HDL (6% CV at 1.0 mmol/L), LDL (5% CV at 2.4 mmol/L) and glucose (4% CV at 4.6 mmol/L) were analyzed on a Vitros 5.1 system (Vitros 5.1TM FS, Clinical Chemistry Instruments, Raritan, NJ, USA). Sex hormone binding globulin (SHBG) was measured on a Roche Cobas system (Roche Diagnostics, Basel, Switzerland).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed with statistical software SPSS version 22 (IBM, Armonk, NY, USA). Continuous data in the study population is shown as mean and standard deviation (SD) for normally distributed variables. Normal distribution was appraised by assessment of the size of the SD in comparison with the mean, as well as graphically displayed in a histogram and visually evaluated. Univariate and multivariate linear regression were used to statistically analyze the association between PWV, AIx and contraceptive use. Comparison of group means was done with ANOVA.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable 1 shows the distribution of OCP and PCP in the population. The number of OCP users are higher than PCP. Only one individual used a transdermal contraceptive. Employing variance analysis with ANOVA for subgroup comparison, we found no difference between the PWV, cIMT, or AIx measurements based on their hormonal delivery system. There were no age or BMI differences between the OCP and PCP groups. SHBG was markedly higher in the vaginal contraceptive group compared to other contraceptive types. Significantly higher SHBG was also observed in the oral contraceptive group compared to the non-using group and the other types, except the vaginal group (Table 1). SHBG was also higher in the estrogen using group compared to non-estrogen users (Table 2) and in the whole contraceptive using group vs non-using (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePopulation characteristics are shown in Tables 2 and 3. The contraceptive users of the study population measured higher vs. non-users on some of the CVD risk variables in this study: SBP, LDL-CH, TG, non-HDL-CH and CRP. The contraceptive group also had higher SHBG and PWV measurements.\u003c/p\u003e\n\u003cp\u003eTable 3 shows the values in contraceptive users, grouped into users of estrogen-containing contraceptives vs. all non-users of estrogen contraceptives (i.e., including users of gestagen containing contraceptives). The EU group had significantly higher SBP, LDL-CH and non-HDL-CH, triglycerides, CRP, and PWV but no difference in BMI, HDL-CH, fasting serum insulin, AIx or cIMT.\u003c/p\u003e\n\u003cp\u003eThere was variation in mean PWV measurements in the different menstrual phases, with a tendency towards the lowest mean in late luteal phase, but the differences were not statistically significant (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn multivariable linear regression, contraceptive use vs. non-use was positively associated with PWV, in three models (Table 4), and remained significant with adjustment for BMI, age, SBP and SHBG. The inclusion of BMI and systolic blood pressure has the greatest effect on the \u003cem\u003eR\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e and the \u0026beta; coefficient of the association between PWV and use of contraceptives, with adjustment for SHBG having a slightly lesser impact. Similar results were obtained by testing the same linear models but comparing EU vs NEU (Table 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study we found a significant association between use of hormonal contraceptives and PWV as a marker of arterial stiffness, but not with AIx or cIMT. This association remained significant after adjustment for established cardiometabolic risk factors BMI, age, blood pressure and SHBG. SHBG, included here as a marker of androgenicity, was strongly dependent on contrapeptive use and contrapeptive modes of administration (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), but had only a limited impact on the association between PWV and contraceptive use (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Furthermore, we found no statistically significant difference in PWV and AIx between OCP and PCP groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), or when comparing the menstrual phases of non-users of contraceptives (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith respect to OCP and arterial stiffness, our findings concord with those of Hickson et al [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and Yu et el [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], who found an increased arterial stiffness in their OCP groups. Furthermore, like them, we found no significant association between menstrual phase and arterial stiffness, although our cross-sectional study design is not optimal for assessing this particular factor. Our results with respect to PWV differ from those of Priest 2018 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and Enea 2021 [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Moreover, further contrasting with our findings, Enea et al. found an increased AIx in the OCP group that they stated was difficult to explain in light of the non-significance of PWV in their study. The lack of concordance between PWV and AIx in both our material and that of Enea, is a sign that, while both measurements aim at addressing \u0026ldquo;arterial stiffness\u0026rdquo;, they in fact probably correspond to slightly different properties, at different scales, in different parts of the arterial tree [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study is the first, to our knowledge, to measure arterial stiffness in a PCP group. There was a tendency towards higher PWV in the subcutaneous and vaginal groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). While PCP bypass first pass metabolism in the liver, permitting lower dosages than what is typically found in OCPs, pharmacokinetic studies have observed increased plasma concentrations of estrogen in PCP compared to OCP [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. OCP intake may also be less consistent, with OCP users displaying a lower compliance than parenteral methods [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Furthermore, PCPs have been found to confer a greater risk of thromboembolism than OCP [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The nature of the differences in CVD risk between OCP and PCP is unknown. Ethinyl-estradiol likely plays a role, being found in OCPs, but typically not as often in PCP, while both contain progestins. At the same time, both estrogens and progestins have been implicated in hypertension, by means of the activation of the renin-angiotensin-aldosterone system (RAAS), altered endothelial function, and oxidative stress [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The contraceptive using group in our material indeed had a significantly higher blood pressure than non-users (Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eIn this population of young, healthy women, the contraceptive using group, both OCP and PCP, showed increased CVD risk markers, such as a higher lipids and CRP concentration, which concord with the findings of a previous study [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The CRP induction caused by orally delivered estrogen has been attributed to the hepatic first-pass effect, not reflecting an increase in systemic inflammation typically associated with an increasing CRP. Nonetheless, our results raise concerns regarding the safety of OCP with respect to arterial health. CRP correlates with endothelial dysfunction [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and shows a proinflammatory effect on in vitro endothelium [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], which may be parts of the explanation, but its inclusion in multivariable models (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e4\u003c/span\u003e) showed a limited effect on the relationship between contraceptive use and PWV, implying that CRP is only a minor part of the mechanism.\u003c/p\u003e \u003cp\u003eAlthough the results of ours and previous studies on arterial properties in young women are conflicting, studies on hormone replacement therapy, HRT, in postmenopausal women describing beneficial effects on arterial stiffness are more plentiful [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Various mechanisms have been proposed, such as endothelin mediated effects on endothelial cells, and a downstream effect towards a more beneficial lipid profile. In a study with a longer follow up time, post-hoc analyses showed an initially detrimental effect of HRT, with the intervention group having more CVD events. After year 3, the inverse was seen, with fewer episodes in the HRT group. It was speculated that an initial estrogen induced prothrombotic effect was over time outweighed by the benefits of lipid profile changes on the evolution of underlying atherosclerosis [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, in our population of young women, the contraceptive group showed higher values for several of the established CVD risk variables, including lipids.\u003c/p\u003e \u003cp\u003eOur study is limited in its cross-sectional design, from which it is not possible to ascertain the order of the alterations in the variables examined. It may also not be fully representative of the young female population at large due to the recruitment mode. Future studies are warranted with a longitudinal design, examining the impact of OCP and PCP on stiffness and CVD risk markers on follow-up. The strengths of this study are that all subjects were young healthy non-smokers free of any chronic disorders, and its large population size, in a field of research where previous studies have typically studied small samples (\u003cem\u003en\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;100). This provided us with a higher power to detect even minor differences in the studied variables.\u003c/p\u003e \u003cp\u003eThere were statistically significant differences in SHBG between OCP, PCP, and the non-contraceptive using groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), which are indicative of differences in androgenicity that may also play an important role in CVD risk, nonetheless the small impact it had as an adjustment variable on our multivariable examinations on the effect of contraceptives on stiffness (Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e5\u003c/span\u003e) suggests that the relationship cannot be attributed to altered androgenicity profiles only.\u003c/p\u003e \u003cp\u003eIn conclusion, contraceptive using women exhibited an increased arterial stiffness compared to non-users measured as PWV. Despite significant differences in serum CVD risk biomarkers between NEU or NCU and EU or CU, the inclusion of these biomarkers in adjusted models only moderately affected the association between PWV and contraceptive use, suggesting that contraceptives exert direct actions on the arterial wall by as of yet unidentified additional factors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePWV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePulse-wave velocity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIMT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntima media thickness\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOCP,Oral contraceptive pills\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTotal cholesterol\u003c/div\u003e \u003cdiv class=\"Description\"\u003e\u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTriglycerides\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHDL-CH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehigh-density lipoprotein cholesterol\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDL-CH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow-density lipoprotein cholesterol\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCardiovascular disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This work was supported by AFA Insurance [grant 130275]; Region \u0026Ouml;rebro County\u0026rsquo;s Research Committee, \u0026Ouml;rebro, Sweden [OLL-780061]; and Ume\u0026aring; University, Ume\u0026aring;, Sweden [RV-865861]. None of the funding sources had an influence on the design or production of the article. We thank Professor emeritus Torbj\u0026ouml;rn B\u0026auml;ckstr\u0026ouml;m, Ume\u0026aring;, for valuable viewpoints on an early version of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design, data collection and analysis. The first draft of the manuscript was written by Paul Pettersson-Pablo and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors has a conflict of interest to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRosenbaum D, Giral P, Chapman J et al. Radial augmentation index is a surrogate marker of atherosclerotic burden in a primary prevention cohort. Atherosclerosis. 2013;231(2):436\u0026ndash;441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuzuki H, Kondo K. Pulse Wave Velocity in Postmenopausal Women. Pulse (Basel). 2013;1(1):4\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTentolouris N, Christodoulakos G, Lambrinoudaki I et al. Effect of hormone therapy on the elastic properties of the arteries in healthy postmenopausal women. J Endocrinol Invest. 2005;28(4):305\u0026ndash;311.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeede HJ, Liang YL, Kotsopoulos D et al. A placebo-controlled trial of long-term oral combined continuous hormone replacement therapy in postmenopausal women: effects on arterial compliance and endothelial function. Clin Endocrinol (Oxf). 2001;55(5):673\u0026ndash;682.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngerer P, Stork S, Kothny W et al. Effect of oral postmenopausal hormone replacement on progression of atherosclerosis: a randomized, controlled trial. Arterioscler Thromb Vasc Biol. 2001;21(2):262\u0026ndash;268.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHodis HN, Mack WJ. Hormone replacement therapy and the association with coronary heart disease and overall mortality: clinical application of the timing hypothesis. J Steroid Biochem Mol Biol. 2014;142:68\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM M, Ta S. Effect of Different Phases of Menstrual Cycle on Reflection Index, Stiffness index and Pulse wave velocity in Healthy subjects. J Clin Diagn Res. 2014;8(9):BC01-04.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayashi K, Miyachi M, Seno N et al. Variations in carotid arterial compliance during the menstrual cycle in young women. Exp Physiol. 2006;91(2):465\u0026ndash;472.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams MR, Westerman RA, Kingwell BA et al. Variations in endothelial function and arterial compliance during the menstrual cycle. J Clin Endocrinol Metab. 2001;86(11):5389\u0026ndash;5395.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWillekes C, Hoogland HJ, Keizer HA et al. Female sex hormones do not influence arterial wall properties during the normal menstrual cycle. Clin Sci (Lond). 1997;92(5):487\u0026ndash;491.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHickson SS, Miles KL, McDonnell BJ et al. Use of the oral contraceptive pill is associated with increased large artery stiffness in young women: the ENIGMA study. J Hypertens. 2011;29(6):1155\u0026ndash;1159.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu A, Giannone T, Scheffler P et al. The effect of oral contraceptive pills and the natural menstrual cYCLe on arterial stiffness and hemodynamICs (CYCLIC). J Hypertens. 2014;32(1):100\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePriest SE, Shenouda N, MacDonald MJ. Effect of sex, menstrual cycle phase, and monophasic oral contraceptive pill use on local and central arterial stiffness in young adults. Am J Physiol Heart Circ Physiol. 2018;315(2):H357-H365.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnea C, Laffetas P, Pichon A et al. Arterial Stiffness and Hemodynamics in Young Women: The Effects of Oral Contraceptive Intake and Physical Habits. Int J Environ Res Public Health. 2021;18(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarsson G, Blohm F, Sundell G et al. A longitudinal study of birth control and pregnancy outcome among women in a Swedish population. Contraception. 1997;56(1):9\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindh I, Hognert H, Milsom I. The changing pattern of contraceptive use and pregnancies in four generations of young women. Acta Obstet Gynecol Scand. 2016;95(11):1264\u0026ndash;1272.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFernstrom M, Fernberg U, Eliason G et al. Aerobic fitness is associated with low cardiovascular disease risk: the impact of lifestyle on early risk factors for atherosclerosis in young healthy Swedish individuals - the Lifestyle, Biomarker, and Atherosclerosis study. Vasc Health Risk Manag. 2017;13:91\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePriest SE, Shenouda N, MacDonald MJ. Effect of sex, menstrual cycle phase, and monophasic oral contraceptive pill use on local and central arterial stiffness in young adults. 2018;315(2):H357-H365.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeusinkveld MHG, Delhaas T, Lumens J et al. Augmentation index is not a proxy for wave reflection magnitude: mechanistic analysis using a computational model. J Appl Physiol (1985). 2019;127(2):491\u0026ndash;500.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapakonstantinou E, Pikilidou M, Georgianos P et al. Wave reflections and systemic vascular resistance are stronger determinants of pulse pressure amplification than aortic stiffness in drug-naive hypertensives. Clin Exp Hypertens. 2020;42(3):287\u0026ndash;293.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Heuvel MW, van Bragt AJ, Alnabawy AK et al. Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive. Contraception. 2005;72(3):168\u0026ndash;174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVlesko G, Meznerics FA, Hegyi P et al. Comparison of Combined Parenteral and Oral Hormonal Contraceptives: A Systematic Review and Meta-Analysis of Randomized Trials. J Clin Med. 2024;13(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLidegaard O, Nielsen LH, Skovlund CW et al. Venous thrombosis in users of non-oral hormonal contraception: follow-up study, Denmark 2001-10. BMJ. 2012;344:e2990.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDubey RK, Oparil S, Imthurn B et al. Sex hormones and hypertension. Cardiovasc Res. 2002;53(3):688\u0026ndash;708.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendelsohn ME, Karas RH. The protective effects of estrogen on the cardiovascular system. N Engl J Med. 1999;340(23):1801\u0026ndash;1811.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorouzi V, Seifi M, Fallah S et al. Effect of oral contraceptive therapy on homocysteine and C-reactive protein levels in women: an observational study. Anadolu Kardiyol Derg. 2011;11(8):698\u0026ndash;702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFichtlscherer S, Zeiher AM. Endothelial dysfunction in acute coronary syndromes: association with elevated C-reactive protein levels. Ann Med. 2000;32(8):515\u0026ndash;518.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVenugopal SK, Devaraj S, Yuhanna I et al. Demonstration that C-reactive protein decreases eNOS expression and bioactivity in human aortic endothelial cells. Circulation. 2002;106(12):1439\u0026ndash;1441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlacher J, Raison J, Amah G et al. Increased arterial distensibility in postmenopausal hypertensive women with and without hormone replacement therapy after acute administration of the ACE inhibitor moexipril. Cardiovasc Drugs Ther. 1998;12(4):409\u0026ndash;414.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrady D, Herrington D, Bittner V et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA. 2002;288(1):49\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"endocrine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"endo","sideBox":"Learn more about [Endocrine](https://www.springer.com/journal/12020)","snPcode":"12020","submissionUrl":"https://submission.nature.com/new-submission/12020/3","title":"Endocrine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Young female adults, Pulse-wave velocity, Endocrine hypertension, PWV, Menstrual phase, Contraceptive, Arterial stiffness, cIMT, Cardiovascular risk factors","lastPublishedDoi":"10.21203/rs.3.rs-5018497/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5018497/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003ePrevious studies on the impact on arterial health of contraceptive use, or across the menstrual phases, have yielded differing results. Furthermore, there is little research on the differences based on the delivery method of the contraceptive, oral vs parenteral contraceptives. In this study, we examine arterial health using three different clinical physiological measures of arterial function and structure in contraceptive users and non-users.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eYoung, healthy, non-smoking, women, between 18.0-25.9 years of age were enrolled in the study (n = 577). Menstrual phase and contraceptive use and type were assessed by questionnaire. Arterial stiffness was measured using pulse-wave velocity (PWV) and augmentation index (AIx). Arterial thickness was measured using carotid-intima media thickness (cIMT). Venous blood samples were analysed for various biomarkers, which were used in multivariate regressions to adjust for the effects of contraceptive use on the vascular measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eContraceptive users had a significantly higher PWV than non-users. The menstrual phase did not significantly impact PWV. The type of contraceptive, oral or parenteral, did not impact PWV. AIx and cIMT did not differ between any studied groups. Systolic blood pressure, Body Mass Index, serum lipids, C-reactive protein, and sex hormone binding globulin concentrations were higher in the contraceptive using group, but in multivariable models, adjusting for age, these biomarkers had only limited impact on the positive association between contraceptive use and PWV.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eContraceptive users have higher PWV than non-users already in young healthy women.\u003c/p\u003e","manuscriptTitle":"Contraceptive use, both oral and parenteral, is associated with increased arterial stiffness in young healthy women","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-16 07:08:20","doi":"10.21203/rs.3.rs-5018497/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-09T22:10:19+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-05T14:25:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"55940902235364567898834457040495518297","date":"2024-12-31T07:10:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-22T06:25:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-09T06:30:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-09T06:28:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Endocrine","date":"2024-09-02T12:53:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"endocrine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"endo","sideBox":"Learn more about [Endocrine](https://www.springer.com/journal/12020)","snPcode":"12020","submissionUrl":"https://submission.nature.com/new-submission/12020/3","title":"Endocrine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d0aca3db-8140-4fe8-865f-ccd0ec66d1e7","owner":[],"postedDate":"October 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T16:01:57+00:00","versionOfRecord":{"articleIdentity":"rs-5018497","link":"https://doi.org/10.1007/s12020-025-04208-9","journal":{"identity":"endocrine","isVorOnly":false,"title":"Endocrine"},"publishedOn":"2025-03-13 15:57:43","publishedOnDateReadable":"March 13th, 2025"},"versionCreatedAt":"2024-10-16 07:08:20","video":"","vorDoi":"10.1007/s12020-025-04208-9","vorDoiUrl":"https://doi.org/10.1007/s12020-025-04208-9","workflowStages":[]},"version":"v1","identity":"rs-5018497","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5018497","identity":"rs-5018497","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}