Incidence and Risk Factors of Striae Distensae Following Breast Augmentation Surgery: A Cohort Study

Background

The significant increase in the popularity of breast augmentation surgeries has led to an increase in the number and types of complications; among these is the postoperative occurrence of Striae Distensae (SD). The objective of this study was to investigate the incidence of SD and describing its occurrence in association with age, breast implant volume, history of SD, history of pregnancies and breastfeeding, body mass index (BMI), changes in postoperative weight, smoking habits, and use of oral contraceptives.

Methods

A cohort study was conducted and the patient data from a specific social group that underwent augmentation mammaplasty with silicone breast implants in a private clinic was analyzed.

Results

563 patients entered the cohort, while 538 completed the study. The SD incidence was 7.06%. The risk was almost the double at 22–28 years of age and triple in women of 21 years of age or less. The women who did not use oral contraceptives were 2.59 times more likely of developing SD. A higher incidence of SD was observed among those with normal or low BMI values, smokers, and in those who had implants larger than 300 ml.

Conclusions

Young age, larger implant volumes, smoking, and normal or low BMI values were the risk factors responsible for the development of SD; while using oral contraceptives was found to be a protective factor.     

Isometric strength and endurance during the menstrual cycle.

Seven healthy young women, 3 whom had been taking oral contraceptives, were examined during the course of 2 menstrual cycles to assess their isometric strength, their endurance during a series of 5 fatiguing isometric contractions at a tension of 40% MVC, and their blood pressures and heart rates during those fatiguing contractions. Two sets of experiments were performed, one in which the subject's forearm temperature was allowed to vary as a function of T A, and one with the muscle temperature stabilized by immersion of the forearm in water at 37 degrees C. During exposure to ambient temperatures, isometric strength and both the heart rate and blood pressure responses at rest and at the end of a fatiguing, sustained isometric exercise, were not significantly different during any phase of the menstrual cycle in any subject. In contrast, the isometric endurance in the women not taking oral contraceptives varied sinusoidally in all 5 contractions with a peak endurance midway through the ovulatory phase and the lowest endurance mid-way through the luteal phase of the menstrual cycle. The isometric endurance of the women taking oral contraceptives did not vary during their menstrual cycle. After stabilization of the temperature of the muscles of the forearm in water at 37 degrees C, the isometric endurance of the normal subjects showed a hyperbolic response with the maximal endurance at the beginning and end of their cycles, and the shortest endurance at mid-cycle. Here again, however, the isometric endurance of the women taking oral contraceptives did not vary after immersion of their forearms in the 37 degree C water.     

Influence of contraceptive pill and menstrual cycle on serum lipids and high-density lipoprotein cholesterol concentrations.

The fluctuations of serum lipid and lipoprotein concentrations within one cycle were studied both in women using and not using oral contraceptives. High-density lipoprotein cholesterol decreased significantly from 1.47 mmol/l (57 mg/100 ml) to 1.30 mmol/l (50 mg/100 ml) during one contraceptive cycle in eight women and rose again to the initial value during the pill-free days. The mean concentration of total cholesterol also fell significantly as a result of the decrease of high-density lipoprotein cholesterol and of a not significant decrease of low-density lipoprotein cholesterol. The mean serum triglyceride concentration did not change significantly. The fluctuations in the concentration of serum lipids and lipoproteins in 10 women not using oral contraceptives were smaller than in the women using oral contraceptives and no significant changes in the concentrations were found during one cycle. Thus, high-density lipoprotein cholesterol concentration decreases during each contraceptive cycle. The time of blood sampling during the cycle is, therefore, of vital importance in interpreting the effect of oral contraceptives on high-density lipoprotein cholesterol. In women not using oral contraceptives blood can be sampled on random days during the cycle.     

Oestrogen containing oral contraceptives and antithrombin III activity

67 women taking oral contraceptives were studied and compared with a group of normal women not taking oral contraceptives. In the oral contraceptive group, 31 were taking Infecundin, a compound with high estrogen content, and 36 were taking Bisecurin, a compound with less estrogen. Basic anthithrombin 3 (AT3) activity, as well as serum AT3, was determined in the presence of .25 IU/ml of heparin which normally increases thrombin inactivation. A paradoxical decreased effect was obtained with heparin, more frequent in the Bisecurin group. The basic determination of AT3 showed a decrease in 6 of 29 women taking Infecundin but a decrease was noted in 13 of the 29 controls, except in 1 case. A fall in AT3 activity does not imply formation of intravascular clots but may be a factor if other disturbances are also present. The determination may serve as a screening method.     

Altered haemorheology in oral-contraceptive users.

The haemorheological profile of the menstrual cycle was determined in 12 women who did not take oral contraceptives and compared with that in two groups of women (n = 8 and n = 30) who had been taking oral contraceptives for at last six months. Packed cell volume, platelet count, erythrocyte deformability, plasma fibrinogen concentration, and plasma and whole-blood viscosity varied cyclically throughout the menstrual cycle in the 12 non-users. This variation was abolished by the use of oral contraceptives, and the values of these indices were raised by an amount likely to predispose to thrombosis.     

Reduced uterine response to PGF2α under oral contraceptives

The effect of prostaglandin F2α (PGF2α) on the non-pregnant human uterus was a evaluated in 35 patients. The compound was administered both by intra-uterine and intra-venous routes. Two groups of volunteers were studeid; fifteen cases who were under oral contraceptive and twenty women with normal ovulatory cycles. The uterus under the influence of oral contraceptives showed a reduced response to local and systemic administration fo PGF2α at all phases of the menstrual cycle. The implications of these findings in certain physiological and pathological conditions related to reproduction are discussed.     

Blood Clotting and Platelet Aggregation during Oral Progestogen Contraception: A Follow-up Study

A two-year follow-up study of progestogen-only contraception with chlormadinone acetate indicates no increase of the level of factors VII and X, as found after three cycles with all oestrogen-progestogen oral contraceptives. Clotting factors which were raised with combined preparations became normal after the sixth monthly cycle of progestogen and remained normal during the two-year period of study.From 12 months onwards significant changes in the thromboelastograph pattern were recorded, but not to the same extent as with combined preparations. At two years platelet aggregation was significantly accelerated with chlormadinone acetate but was not as rapid as with combined preparations.     

Pregnancy induced hypertension: evidence for increased cell membrane permeability to sodium.

In a cross sectional study of 137 women of childbearing age (16-40) the effects of normal pregnancy, hypertensive pregnancy, and oral contraceptives on red cell electrolyte content and sodium efflux rates were examined and the results compared with values in a control group of normotensive, non-pregnant women. Efflux rate constants were significantly increased in normotensive pregnancy and in women taking oral contraceptives. This was associated with a significant increase in sodium permeability in the contraceptive group. A much larger increase in sodium permeability and efflux rate constant was seen in the hypertensive group. The results permit a hypothesis that the hormonal changes induced by pregnancy and oral contraceptives increase membrane permeability to sodium and stimulate sodium efflux. The rise in blood pressure associated with use of oral contraceptives may have a similar aetiology to that occurring in pregnancy induced hypertension.     

Thrombosis and Oral Contraceptives: Possible Predisposition

The coagulation factors and components of the fibrinolytic system were examined in 31 women with a previous history of phlebographically-verified thrombosis during the use of oral contraceptives of the combined type. Special attention was given to the histochemically-determined fibrinolytic activator content of the wall of biopsy specimens of superficial veins. None of the patients was taking contraceptives at the time of the investigation. Pathological changes, particularly in the fibrinolytic defence system, were found in most of the patients. They may be regarded as predisposed to thrombosis, and one might wonder whether these patients would sooner or later have had their thrombosis even if they had not used contraceptives. The concentration of antithrombin III was normal, indicating that this test is of no value for detecting patients predisposed to thrombosis, who should preferably not take oral contraceptives.     

P300 and the menstrual cycle

Event-related potentials (ERPs) were elicited with an auditory discrimination paradigm in 20 adult female subjects on the first day of their menstrual cycles and approximately 14 days later. The amplitude and latency of the N1, P2, N2 and P3 (P300) components were measured for the two assessment times. No differences in either amplitude or latency for any of the components were observed as a function of menstrual cycle. Half the subjects who took oral contraceptives were compared to the other half who did not. No differences or interactions between these subgroups were obtained for any component amplitude or latency. It was concluded that menstrual cycle and use of oral contraceptives do not affect the P3 or other ERP components.     

Fluctuations of serum and bile lipid concentrations during the menstrual cycle.

We measured fasting serum and bile lipid concentrations at three intervals during the normal menstrual cycles of 11 healthy women not taking oral contraceptives. In nine of them cholesterol saturation of bile, and therefore presumably the risk of developing gall stones, was higher nine days after midcycle than at the end of menstruation. This change in bile cholesterol saturation was preceded by a significant fall in serum lipid concentrations: during the nine days after mid-cycle serum triglyceride and cholesterol concentrations fell in nine and eight of the 11 women respectively. Changes in the composition of serum and biliary lipids during the menstrual cycle are presumably due to a direct effect of sex hormones on the liver.     

Risk of venous thromboembolism among users of third generation oral contraceptives compared with users of oral contraceptives with levonorgestrel before and after 1995: cohort and case-control analysis

ObjectiveTo compare the risk of idiopathic venous thromboembolism among women taking third generation oral contraceptives (with gestodene or desogestrel) with that among women taking oral contraceptives with levonorgestrel.DesignCohort and case-control analyses derived from the General Practice Research Database.SettingUK general practices, January 1993 to December 1999.ParticipantsWomen aged 15-39 taking third generation oral contraceptives or oral contraceptives with levonorgestrel.ResultsThe adjusted estimates of relative risk for venous thromboembolism associated with third generation oral contraceptives compared with oral contraceptives with levonorgestrel was 1.9 (95% confidence interval 1.3 to 2.8) in the cohort analysis and 2.3 (1.3 to 3.9) in the case-control study. The estimates for the two types of oral contraceptives were similar before and after the warning issued by the Committee on Safety of Medicines in October 1995. A shift away from the use of third generation oral contraceptives after the scare was more pronounced among younger women (who have a lower risk of venous thromboembolism) than among older women. Fewer cases of venous thromboembolism occurred in 1996 and later than would have been expected if the use of oral contraceptives had remained unchanged.ConclusionsThese findings are consistent with previously reported studies, which found that compared with oral contraceptives with levonorgestrel, third generation oral contraceptives are associated with around twice the risk of venous thromboembolism.     

Effects of oral contraceptives and of the ovarian cycle on auditory performance at 4 and 6 kHz. Demonstration by functional audiometry

Absolute thresholds at 4 and 6 kHz were tested in 3 sessions before and after 20 min exposure to 105 dB (A) pink noise in 12 young normal cycling females 11 young females under oral contraceptives and 8 young men. Women under oral contraceptives show lower resting thresholds, more important TTS2 and higher recovery rate than normal cycling women and men. In normal cycling females, non parametric analysis of the data provides evidence that absolute thresholds at 4 and 6 kHz tend significantly to be higher at menses and lower during the postovulatory phase of the cycle.     

Estriol concentrations in plasma of normal, non-pregnant women.

Using a rabbit antisera directed against estriol-3-0-carboxy methyl ether complexed to BSA, an immunoassay for estriol (1) was developed. The mean plus or minus SE concentration of estriol in 18 women in days 5-7 of their cycle was 7.9 plus or minus 0.6 pg/ml which was significantly (P less than 0.01) less than the mean value of 11.1 plus or minus 0.8 pg/ml in 15 women in days 20-22 of the cycle. In 3 of 6 women in whom plasma samples were drawn frequently during their cycle, an estriol peak occurred coincident with the estradiol peak. In 3 women from whom plasma was obtained several times during the course of a day estriol levels did not appear to vary significantly. In 8 women who were on oral contraceptives the mean level of estriol was 7.6 plus or minus 1.5 pg/ml. In 8 post-menopausal women the mean level was 6.0 plus or minus 1.2 pg/ml which is significantly (P less than 0.01) less than the mean luteal phase value but not less (P greater than 0.1) than the follicular phase or oral contraceptive user values. We conclude that some of the circulating estriol is directly secreted by the ovary of normal women.     

Amenorrhoea after Discontinuing Combined Oestrogen-Progestogen Oral Contraceptives

Out of 210 women seen at the Middlesex Hospital with secondary amenorrhoea the 63 who developed it after stopping oral contraceptives were fully investigated. Five had organic disease sufficient to account for the amenorrhoea (one had severe diabetes, one a pituitary tumour, and three premature ovarian failure); two patients had galactorrhoea (one of whom also had the pituitary tumour); two had anorexia nervosa.Of the 63 women 40 (63%) had suffered from amenorrhoea or prolonged or irregular menstrual cycles before taking the pill, and this suggested that combined oestrogen-progestogen oral contraceptives should be used with caution for women with irregular menstruation.Nineteen patients wished to become pregnant and 12 have so far done so after treatment with clomiphene or gonadotrophins.In another study 204 women recorded when their first menstrual cycle occurred after stopping the pill. Seventy-four had a cycle longer than five weeks but only five exceeded three months, and only one of the five had more than six months'' amenorrhoea. These results confirm that the incidence of amenorrhoea after stopping oral contraceptives is low.     

Different thermal sensitivity to exercise and cold in men and women

Rectal temperature gain for sweating and shivering was investigated in men (M) and women during exercise and cold exposure. Women, taking and not taking oral contraceptives, were tested during follicular (F) and luteal (L) phases of the menstrual cycle. The gains for sweating (M, 4.85; F, 5.00; L, 12.25 kPa °C⁻¹) and shivering (M, 6.50; F, 2.75; L, 2.00 ml kg min⁻¹ °C⁻¹) differed between sexes, as well as between F and L, and were affected by the oral contraceptives (5.45 and 8.00 kPa °C⁻¹, P<0.01, and 6.00 and 4.25 ml kg min⁻¹ °C⁻¹, P<0.05, respectively).     

Clinical Trial of a Combination of Lynestrenol and Mestranol (Lyndiol) as an Oral Contraceptive Agent

Contraception with lynestrenol-mestranol (Lyndiol) was studied in 332 Mexican women during a period of two and one-half years. Side effects were minimal or transient. No pregnancies occurred in those who took the medication according to instructions. The women were followed with yearly pelvic examinations and Papanicolaou smears, serial endometrial biopsies and extensive studies of blood, liver and glandular function. Complete ophthalmological studies were done on 30 patients. No clinical or laboratory evidence of harmful effects could be demonstrated. Return to ovulation (using pregnanediol excretion and endometrial biopsies as parameters) occurred in all of 22 women studied in the first three post-treatment cycles. Eight posttreatment pregnancies and the resulting offspring were normal. The first post-treatment cycle, as with other oral contraceptives, was unpredictable and tended to be prolonged. It varied in length from 22 to 60 days.     

Transcortin as an indicator of estrogenic potency in oral contraceptives

Serum cortisol-binding globulin (CBG) was measured before, during and following a 21-day application period of 5 oral contraceptives used in the GDR. In a second group of patients determinations were carried out at the end of a 24-month treatment period and the end of the first post-treatment cycle. From a third group of volunteers blood samples were taken at the end of the first, second and third treatment cycles. All the drugs tested produced a marked increase of CBG in serum, reaching its maximum at the end of the second treatment cycle. Within four weeks following termination of application the level fell to the control range. There were no significant differences between the various contraceptives.     

Ovarian neoplasms,functional ovarian cysts,and oral contraceptives.

The incidence of ovarian neoplasms and functional ovarian cysts diagnosed at laparotomy or laparoscopy among the 17,000 women taking part in the Oxford Family Planning Association contraceptive study was investigated. Epithelial cancer of the ovary was only 25% as common among those who had ever taken oral contraceptives as those who had never done so (95% confidence interval 8% to 67%). There was little evidence of any important association between use of oral contraceptives and benign teratoma or cystadenoma. Functional cysts of the ovary occurred much less commonly in women who had recently (in the six months preceding diagnosis) taken combined oral contraceptives (but not in those who had taken progestogen only oral contraceptives) than in those who had never taken oral contraceptives or had taken them in the past. This protective effect was more pronounced for corpus luteum cysts (78% reduction; 95% confidence interval 47% to 93%) than for follicular cysts (49% reduction; 95% confidence interval 20% to 70%). It is estimated that about 28 (95% confidence interval 16 to 35) operations for functional ovarian cysts are avoided among every 100,000 women who take oral contraceptives each year.     

Investigation of Relation between Use of Oral Contraceptives and Thromboembolic Disease. A Further Report

The results of a previous study of the use of oral contraceptives by married women discharged from hospital with a diagnosis of thromboembolic disease in the years 1964–6 were reported by us last year. The present paper adds results relating to patients discharged during 1967 and a few data, that could not be sought previously, for patients discharged with cerebral or coronary thrombosis from three of the hospitals in the earlier period.Of 84 patients with deep-vein thrombosis or pulmonary embolism 42 (50%) had used oral contraceptives during the month preceding the onset of their illness, while only 23 of the 168 controls (14%) had done so. No differences in risk were found either for the types of preparation or for the duration of use. After allowance for age and height, the patients with venous thromboembolism were about 10 lb. (4,535 g.) heavier than the control patients, irrespective of whether they were using oral contraceptives or not. No appreciable difference was found between the smoking habits of patients with and without venous thromboembolism treated during 1967, nor between women who were using oral contraceptives and those who were not. The trend in hospital admissions for venous thromboembolism with time corresponded to the trend in the use of oral contraceptives, and there was no evidence to suggest that the number of admissions was affected by publicity about the risk of using the preparations. Of 19 patients with cerebral thrombosis 11 (58%) had been using oral contraceptives, compared with an expected figure of 3.5 from the experience of the control subjects. All the published data (clinical, angiographic, and post-mortem) show that the thrombosis affects the cerebral arteries rather than the cerebral veins. Of 17 patients with coronary thrombosis 2 (12%) had been using oral contraceptives, compared with an expected figure of 2.1. The patients with coronary thrombosis smoked more than the control patients and were, on average, 8.3 lb. (3,765 g.) heavier than control women of the same age and height.The new evidence strengthens the belief that oral contraceptives are a cause of venous thromboembolism and cerebral thrombosis but does not indicate that they are a cause of coronary thrombosis.