Charisse Loder, MD, MSc

Oral contraceptive pills are the most commonly used method of hormonal contraception in the United States. According to the National Survey of Family Growth conducted in 2015-2017, 80.5% of reproductive-aged women who had ever been sexually active had used oral contraceptive pills (OCPs) at some point. 

A survey of reproductive-aged women who have ever been sexually active found that 12.6% currently use pills.

There are two general types of OCPs—combined oral contraceptives (COCs), which contain both ethinyl estradiol (EE) and progestin, and progestin-only pills (POPs). Current COCs offer a range of doses and progestins to choose from.

COCs are a moderately effective method of contraception. They have a perfect use failure rate of <1% and a typical use failure rate of 9%.

 Several clinical trials have quoted failure rates of POPs between 1-13% in the first year.

Little data is available directly comparing the efficacy of different types of progestins; however, a few studies suggest no difference.5,6 It is likely that typical use failure rates are higher in POP users due to the strict dosing timeframe, including recommendations to take the pill within a 3-hour window.

EE and progestin each work separately, as well as synergistically, to provide contraceptive benefit. EE mainly works by suppressing the release of follicle-stimulating hormone (FSH) from the pituitary, which hinders folliculogenesis. 

It is also suggested that EE causes endometrial edema, which affects implantation. EE has an added benefit of stabilizing the endometrium, which reduces spotting—a favorable effect. As EE potentiates the effects of progestin, smaller doses of progestin may be used in COCs.

Progestin works in three major ways: 1) it suppresses GnRH release from the hypothalamus, decreasing LH and FSH release; 2) it prevents the LH surge from the pituitary, which prevents ovulation; and 3) it thickens cervical mucus, which impedes sperm entry into the uterus. 

There may be some inhibition of peristalsis and tubal mobility as well. Progestin causes endometrial atrophy, which impairs implantation. Each progestin has a different potency and dose for which it blocks ovulation. POPs rely on these multiple mechanisms to prevent pregnancy.

Although oral contraceptives are a great choice for many women, it is important to understand the conditions that may increase risk for the user. We will outline some of the risks below and the CDC Medical Eligibility Criteria chart can be referenced for more information.

It is important to remember that the risks and benefits must be weighed for each woman individually and that in most cases, pregnancy is more dangerous than pill use. 

In patients who have conditions in which pregnancy would increase their risk of adverse health outcomes (Table 1), long-acting reversible contraception (LARC) may be the best choice to avoid unintended pregnancy.10 It is also important to review a patient’s medication history, as there may be drug interactions that reduce efficacy of COCs and POPs.

EE is pro-coagulable and is contraindicated in a number of situations. Progestin also has risks to the user. Providers should screen for personal or family history of venous thromboembolism, as this increases coagulation risk in COC users. 

Additionally, because of hypercoagulability in the postpartum state, COCs should not be used until 6 weeks after childbirth. Women who smoke and are over age 35, women with migraine with aura, or those who have uncontrollable hypertension or vascular disease are at increased risk of stroke and should not use estrogen-containing methods.

There are self-screening tools available to check for COC eligibility, such as the one used in a study by Grossman et al, which showed a sensitivity of 83.2% and specificity of 88.8% in patients using the survey to determine true contraindications to COC use.

 These tools can be helpful to both providers and patients, particularly as we increase use of telemedicine (Table 2).

As with any medical decision, it is exceptionally important to utilize shared decision-making in choosing the right contraceptive method for each patient, which should improve satisfaction, encourage compliance, and reduce unintended pregnancy. 

Shared decision-making involves the patient and provider working together to make a decision through discussion of all options while taking patient preference into account.

Because there are many contraceptive options available, it is important to discuss values (including the acceptability of an unplanned pregnancy if there is a contraceptive failure), beliefs, dosing frequency, financial considerations, and risks and benefits of each method. 

Other considerations include how often women want to have withdrawal bleeding, and desired benefits such as improvement in dysmenorrhea, acne, and mood symptoms. All women should be provided with a multiple-month prescription to improve medication adherence.

As with any method, there are side effects of COCs and POPs that are important to discuss with patients as they decide which method is best for them. Of women who have ever discontinued using COCs or POPs, 34% reported that they were dissatisfied and 64.4% stopped due to side effects.

Some common side effects to discuss with women are breast tenderness, nausea, bloating, and breakthrough bleeding—all of which often improve or completely resolve after the first several months.

 Women may not always discuss their choice to stop taking COCs or POPs, making it essential for clinicians to ask about the experience of past side effects, as well as to provide preventive guidance about the possibility of side effects before starting a new method.

Once a woman and her provider have decided on using COCs, there are multiple options. Patients desiring a withdrawal bleed may prefer a pill pack with monthly placebo pills, while patients desiring fewer menses prefer continuous use without placebo pills and may opt for extended cycle use. 

Additionally, providers may identify other co-existing conditions that may be treated with COCs such as acne, undesired facial hair growth, bloating, and/or headaches. COCs can also help reduce risk of ovarian cysts, fibroids, and benign breast disease.

As mentioned earlier, all COCs have a progestin and EE component and doses differ by pill type. COCs have a range of EE between 10-35 mcg. 

A systematic review showed higher discontinuation rates for COCs with lower doses of EE, due to side effects such as breakthrough bleeding. To reduce estrogenic risks, it is reasonable to start at 20 mcg EE and increase if necessary,15 although for adolescents, data supports using a dose of 30 mcg EE or greater as lower doses of EE have been associated with impaired bone acquisition.

Providers should consider the progestin component of the COC, or which progestin to use on its own in a POP, as this may result in undesired side effects.

Some progestins are noted to have androgen-like effects, with users reporting oily skin, facial hair growth, or acne. Of note, all COCs have been shown to help with acne, but it is reasonable to choose a pill with a less androgen-like progestin and/or higher estrogen content if this is a concern.

First-generation progestins have a lower potency and half-life, which can result in breakthrough bleeding. While second-generation progestins are more potent with a longer half-life, they may have an androgen-like effect. Third-generation progestins maintain a high potency but have lower androgen-like effects. 

Some third-generation formulations are even approved to treat mild to moderate acne. Finally, the only fourth-generation progestin, drospirenone, has both anti-mineralocorticoid and anti-androgenic properties and is newly available in a progestin-only pill.

 It has an improved bleeding profile while matching COCs in efficacy, as well as extending the missed-pill window to 12 hours for ease of use23 (Table 3).

Many of the common side effects of COCs will resolve on their own in the first few months. Thus, in the absence of severe side effects, patients should be encouraged to continue their pills for an initial 3-month interval. If these side effects continue or are particularly bothersome, Table 4 shows some options providers can use to approach them.

In addition to bleeding patterns and progestin options, COCs can be monophasic or multiphasic. We recommend that most providers start with a monophasic preparation for ease of use and ability to extend to continuous use, although some data show that triphasic preparations—specifically those with newer progestins—help reduce acne, irregular bleeding, and menorrhagia.

Non-contraceptive benefits: dysmenorrhea and menorrhagia

In addition to contraception, COCs have non-contraceptive benefits that can be advantageous to patients. One of these benefits is helping to improve menstruation, reduce pain, and improve blood loss. Dysmenorrhea is the most common menstrual symptom complaint, affecting up to 90% of women.

COCs have been shown to reduce dysmenorrhea by 60%, and in those with severe dysmenorrhea even further (90%). This reduces absences for school or work, as well as a patient’s need for pain medication. In women who suffer from dysmenorrhea, it can be especially helpful to be on extended or continuous COC preparations to further decrease pain.

 The desogestrel-only POP has also been shown to help improve dysmenorrhea.

Menorrhagia is less common, yet still problematic, for patients, as it can lead to iron-deficiency anemia. COCs are particularly helpful for normalizing bleeding patterns and decreasing both amount and duration of bleeding. 

However, other forms of contraception, such as hormonal intrauterine devices, can have similar effects—enhancing the need for shared decision-making with a patient when deciding which hormonal method is right for her.

Additional benefits to COCs include the ability to allow a woman to predict her bleeding episodes and skip them if desired. While older generations of POPs often caused abnormal bleeding patterns in patients, new drospirenone-only pills have a more favorable bleeding profile.

COCs can also improve premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). A study looking at both POPs and COCs and their effect on premenstrual mood found that use of either one of these pills did not affect mood in over 71% of women. The remaining women were split as to whether their mood was improved or worsened. 

Having a history of premenstrual mood changes prior to starting a POP or COC was a strong predictor of the ability to improve mood, as was onset of premenstrual mood disturbance at a younger age. However, those with a history of depression prior to pill use were twice as likely than those without a history to have mood deterioration.

Studies have also shown that in women being treated for depression, COCs containing drospirenone can improve mood deterioration in the premenstrual period, as well as reduce both physical and behavioral symptoms of PMDD.

 Another way to reduce PMS and PMDD symptoms is with extended or continuous cycles and reduction of withdrawal bleeding.

Non-contraceptive benefits: Endometriosis

COCs can also be very useful to women who suffer from endometriosis. COCs have been shown to reduce pain associated with endometriosis and continuous cycles are often even more beneficial for pain reduction. 

However, it is important to remember that COCs work by causing endometriotic implants to undergo atrophy and become inactive. Upon discontinuation of COCs, the implants become active again, resulting in return of pain and other symptoms. 

Initiation of COCs after surgery for endometriosis can reduce recurrence rates of endometriomas, as well as the size and growth rates of those that do recur.31 For women who cannot take COCs but suffer from endometriosis, desogestrel-containing POPs have been shown to be equally effective in reducing endometriosis pain.

Oral contraceptive pills are a widely used form of contraception and nearly all providers in all specialties will encounter patients who are taking them. 

While different variations between pills can seem complicated, thereby making it hard to choose a pill, it is important to tailor the decision to each patient’s needs and desires. Sometimes it can take several adjustments to find the best OCP for a particular patient. 

As long as the provider and patient continue to work together through shared decision-making, many women will be able to satisfactorily find a reliable form of contraception while also taking advantage of the many non-contraceptive benefits that pills offer.

is a clinical assistant professor at Michigan Medicine, University of Michigan, Ann Arbor.

is a fourth-year medical student at the University of Michigan Medical School, Ann Arbor.

1. National Center for Health Statistics. National Survey of Family Growth 2015-2017. 

https://www.cdc.gov/nchs/nsfg/nsfg_2015_2017_puf.htm

2. David PS, Boatwright EA, Tozer BS, et al. Hormonal contraception update. 

3. Trussell J. Contraceptive failure in the United States. 

4. Broome M, Fotherby K. Clinical experience with the progestogen-only pill. 

5. Sheth A, Jain U, Sharma S, et al. A randomized, double-blind study of two combined and two progestogen-only oral contraceptives. 

6. Korver T. A double-blind study comparing the contraceptive efficacy, acceptability and safety of two progestogen-only pills containing desogestrel 75 μg/day or levonorgestrel 30 μg/day. 

7. Vessey MP, Lawless M, Yeates D, McPherson K. Progestogen-only oral contraception. Findings in a large prospective study with special reference to effectiveness. 

8. Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices. 

9. Centers for Disease Control and Prevention. Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use. 

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

10. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility for Contraceptive Use, 2016. 

11. Grossman D, Fernandez L, Hopkins K, Amastae J, Garcia SG, Potter JE. Accuracy of self-screening for contraindications to combined oral contraceptive use. 

12. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: A model for clinical practice. 

13. Rosenberg MJ, Waugh MS, Meehan TE. Use and misuse of oral contraceptives: Risk indicators for poor pill taking and discontinuation. 

14. Amat L, Bulach A, Leclercq M, et al. Bénéfices non contraceptifs des contraceptions. Additional Non-Contraceptive Effects of Contraception: CNGOF Contraception Guidelines. 

15. Gallo MF, Nanda K, Grimes DA, Lopez LM, Schulz KF. 20 µg versus >20 µg estrogen combined oral contraceptives for contraception. 

16. Golden NH. Bones and Birth Control in Adolescent Girls. 

17. Scholes D, Ichikawa L, LaCroix AZ, et al. Oral contraceptive use and bone density in adolescent and young adult women. 

18. Lawrie TA, Helmerhorst FM, Maitra NK, Kulier R, Bloemenkamp K, Gülmezoglu AM. Types of progestogens in combined oral contraception: effectiveness and side-effects. 

. 2011;11(5):CD004861.19. Raney EC, Scott SC, Cauthon KAB. Individualizing selection of hormonal contraception. 

20. Sitruk-Ware R. Pharmacology of different progestogens: The special case of drospirenone. In 

21. Thorneycroft IH. Update on androgenicity. 

22. Stanczyk FZ. All progestins are not created equal. 

23. Palacios S, Regidor PA, Colli E, et al. Oestrogen-free oral contraception with a 4 micrograms drospirenone-only pill: new data and a review of the literature. 

 2020;Apr 21;1-7. https://doi.org/10.1080/13625187.2020.1743828. Online ahead of print.

24. Barr NG. Managing adverse effects of hormonal contraceptives. 

25. Cedars MI. Triphasic oral contraceptives: Review and comparison of various regimens. 

26. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. 

27. Ahrendt HJ, Karckt U, Pichl T, Mueller T, Ernst U. The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: Results from two studies on oestrogen-related symptoms and dysmenorrhoea. 

28. Lethaby A, Wise MR, Weterings MAJ, Rodriguez MB, Brown J. Combined hormonal contraceptives for heavy menstrual bleeding. In 

29. Joffe H, Cohen LS, Harlow BL. Impact of oral contraceptive pill use on premenstrual mood: Predictors of improvement and deterioration. 

30. Yonkers KA, Brown C, Pearlstein TB, Foegh M, Sampson-Landers C, Rapkin A. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. 

31. Zorbas KA, Economopoulos KP, Vlahos NF. Continuous versus cyclic oral contraceptives for the treatment of endometriosis: a systematic review. In 

Articles

Oral contraceptive pills are a popular choice for many; providers should understand the options to guide patients effectively.

Choosing the right pill

Fertility awareness-based contraceptive methods (FABM) are behavioral methods of contraception that are used by approximately 2.2% to 3.2% of sexually active women.

 This low usage rate may be due to provider and patient knowledge and beliefs. One concern providers may have is that the typical use efficacy rate is lower than for other contraceptive methods. In addition, providers may be uncomfortablen counseling patients about appropriate usage.

Women who use FABM may choose it because they have values and/or beliefs that are aligned with using non-pharmacologic contraception. However, we must consider that the best form of contraception is the one the patient feels works for her. Given that FABM may be used as a contraceptive, and that there are patients who will choose it, ob/gyns must be familiar with it and ready to counsel about its use.

Nonjudgmental and open conversation with patients about their priorities is critical to all contraceptive counseling, particularly when discussing FABM. Generally, FABM is most suitable for patients who have regular menses (although some methods, such as TwoDay

, may not require this) and for whom variance in efficacy of a method-and therefore the real possibility of an unplanned pregnancy-is acceptable.

As such, an important part of counseling is reviewing medical comorbidities, obstetric history, and current medications so that the patient understands the risks of unplanned pregnancy to their health and the health of the fetus. Given that FABM requires abstinence or use of barrier methods on certain days, the ability to have open communication with a partner is paramount. Considering this, FABM may work best for patients whose partner(s) is highly motivated to avoid pregnancy and willing to avoid unprotected sex on certain days.

Thirty-six percent of women in the United States suffer sexual violence and coercion

; behavioral methods cannot protect against pregnancy in these cases. In addition, FABM does not offer protection against sexually transmitted infections.

It is important to note that studies of FABM effectiveness vary in quality, which makes it difficult to compare efficacy between specific methods.

 Overall, FABM collectively has a 15% typical-use first-year failure rate, but it can vary as much as 2% to 23%.

 There are many factors that impact effectiveness of FABM.

These include the ability of the provider to adequately counsel on how to use the method and the ability of the patient to follow and use the method instructions appropriately.

 Given that most studies show high first-year discontinuation rates for FABM,

 shared decision-making and clear instructions on how to properly use each technique are critical to successful patient use. Table 1 summarizes the methods and key requirements for each method.

Patients who choose FABM over other methods are likely doing so for reasons beyond its efficacy. It is well-studied that contraceptive counseling and recommendations should be patient-centered.

 If a patient is aware that FABM has variable efficacy rates, has been counseled on the factors that make a good FABM candidate, and accepts the risk of unintended pregnancy, there is no reason a clinician should be uncomfortable with aiding her in using that method.  

Advantages to FABM include little to no financial investment, few if any medical contraindications to use, no medications or devices needed, and possible alliance with religious and cultural beliefs about family planning.

In addition, many patients may choose to educate themselves about and use behavioral methods in the time leading up to planning a pregnancy. This is because these methods require more awareness of the body and the fertile time, which helps a patient to prevent pregnancy and also to become pregnant when she is ready.

The crux of FABM is understanding the menstrual cycle and using biological knowledge and cues to predict when fertilization is most likely.

 We know that ovulation most often occurs in the middle of a menstrual cycle; given that sperm can persist for 3 to 5 days in the female reproductive tract and the ovum has a lifespan of 12 to 24 hours, the fertile window lasts for approximately 6 days.

In cycles with lengths of 26 to 32 days, 78% of women will have a fertile window between Days 8 and 21.

 There are various methods that can be used to predict the fertility window-and therefore the period of “at-risk” days for pregnancy-during a menstrual cycle.

to predict these days, it is vital to discuss how they will avoid unprotected intercourse during the 10 to 17 “at-risk” days of their menstrual cycle.

 If they are interested in barrier methods (condom, diaphragm), ensuring proper instruction on how to use them is needed to ensure effectiveness of FABM.

Elena is a 28-year-old G0 who is considering pregnancy in the next 1 to 2 years. She and her husband prefer a method that does not involve exogenous hormones or medical devices. She asks you about using a fertility awareness-based method (FABM) for contraception She has tracked her regular periods for many years and is detail-oriented. Elena has no medical problems and takes a multivitamin daily.

Which of the following do you tell her is important to the success of using an FABM method?

B. Ability to avoid unprotected intercourse

C. Adequate knowledge about how to determine “at-risk” days

Patients are most likely to have success using FABM if they are able and committed to meticulous, daily attention and recording of various aspects of their cycle (depends on what method), able to avoid unprotected intercourse, and are well-informed about the specific method they are using.

For these reasons, we recommend the Standard Days® (CycleBeads®) method or the TwoDay® method, as they are the most straightforward methods for providers and patients.

The Standard Days Method® requires 6 months of menstrual cycle tracking prior to initiation. It requires that a menstrual cycle is between 26 and 32 days long. Patients who are breastfeeding or who have recently stopped hormonal contraception may not have anticipated efficacy with this method and should wait to observe their cycles before starting.

The Standard Days Method® relies on the fact that unprotected intercourse has a low likelihood of causing pregnancy on menstrual cycle Days 1 to 7 and from Day 20 until the end of the cycle. The patient should abstain from intercourse or use a barrier method on Days 8 to 19.

Cyclebeads® are a helpful way for a patient and her partner to keep track of cycles together; bead colors may indicate fertile and less fertile days, so they know when unprotected intercourse will avoid pregnancy. She can place the beads in a common area as a way to communicate with her partner. With perfect use, this method is 95% effective and with typical use, it is 88% effective.

The TwoDay Method® relies on a patient’s comfort, awareness, and tracking of vaginal secretions and on the fact that thin, watery, secretions make it possible for sperm to travel through the female reproductive tract and survive for several days.

The cervical fluid around the time of ovulation is particularly characteristic in that it is abundant, clear, and stretchy.

 Therefore, when a patient is dry or lacks vaginal secretions, it has been theorized she is less likely to become pregnant. A patient may use touch to assess for secretions, or observe them on underwear or a menstrual pad. If she does not experience vaginal secretions for 2 days in a row, the risk of pregnancy is low.

Patients should abstain from or use barrier methods for 3 days following unprotected intercourse, as the ejaculate interferes with the ability to assess for presence of vaginal secretions. Benefits of this method are that it can be used by women who have irregular cycles and that it is simple to understand and execute.

Patients should be warned that vaginal infections can interfere with symptom assessment. With perfect use, the TwoDay Method® is 97.5% effective, and with typical use, it is 86% effective.

For Elena, we can counsel her that both of these methods have similar perfect and typical use, are easy to understand, can help her 

Educating her about the Standard Days Method® may provide her with more information about ovulation and a fertile window, while the TwoDay Method® can inform her about the role of cervical mucous in fertility. Ultimately, we can discuss which method she feels most comfortable with and provide her with supplemental reading material.

The world of contraception is constantly changing, with improving technologies, new devices, and more options than ever before. In addition to staying up to date within the evolving field of Family Planning, ob/gyns should also be prepared to counsel and support patients who choose to use FABM.

These methods require an ob/gyn to be knowledgeable about it and able to engage in shared decision-making with the patient to determine which method is appropriate. There are many resources ob/gyns can use to refresh their knowledge about these methods-many of which are cited in this review.

We feel the Standard Days Method® (CycleBeads®) and TwoDay Method® are the simplest to use and counsel about and the easiest for patients to understand. With proper counseling and education, FABM may be a satisfactory option for your patient.

1. Polis CB, Jones RK. Multiple contraceptive method use and prevalence of fertility awareness based method use in the United States, 2013-2015. 

2. Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Obstetrician-gynecologists' views on contraception and natural family planning: a national survey. 

3. Smith SG, Zhang X, Kathleen C. Basile, et al. National Intimate Partner and Sexual Violence Survey: 2015 Data Brief-Update Release. [National Center for Injury Prevention and Control and Centers for Disease Control and Prevention]. 2018; https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf. Accessed January 21, 2020.

4. Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. 

5. ArÃ©valo M, Sinai I, Jennings V. A fixed formula to define the fertile window of the menstrual cycle as the basis of a simple method of natural family planning. 

6. Nelson AL, Sokol DC. Behavioral Methods of Contraception. In: Jensen JT, Creinin MD, eds. 

Speroff & Darney’s Clinical Guide to Contraception

. 6th ed. Philadelphia, PA: Wolters Kluwer; 2020.

7. Peragallo Urrutia R, Polis CB, Jensen ET, Greene ME, Kennedy E, Stanford JB. Effectiveness of Fertility Awareness-Based Methods for Pregnancy Prevention: A Systematic Review. 

8. Hatcher RA, Kowal D, Nelson AL, et al, eds. 

 21st ed. Atlanta, GA: Managing Contraception, LLC; 2018.

9. Kambic RT, Lamprecht V. Calendar rhythm efficacy: a review. 

10. Trussell J, Grummer-Strawn L. Contraceptive failure of the ovulation method of periodic abstinence. 

11. Wilcox AJ, Dunson D, Baird DD. The timing of the "fertile window" in the menstrual cycle: day specific estimates from a prospective study. 

12. Frank-Herrmann P, Freundl G, Gnoth C, et al. Natural family planning with and without barrier method use in the fertile phase: efficacy in relation to sexual behavior: a German prospective long-term study. 

14. Freundl G, Sivin I, Batar I. State-of-the-art of non-hormonal methods of contraception: IV. Natural family planning. 

15. Bhargava H, Bhatia JC, Ramachandran L, Rohatgi P, Sinha A. Field trial of billings ovulation method of natural family planning. 

16. A prospective multicentre trial of the ovulation method of natural family planning. II. The effectiveness phase. 

17. Grimes DA, Gallo MF, Grigorieva V, Nanda K, Schulz KF. Fertility awareness-based methods for contraception. 

19. Frank-Herrmann P, Freundl G, Baur S, et al. Effectiveness and acceptibility of the symptothermal method of natural family planning in Germany. 

20. Frank-Herrmann P, Heil J, Gnoth C, et al. The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: a prospective longitudinal study. 

21. Lamprecht VM, Grummer-Strawn L. Development of new formulas to identify the fertile time of the menstrual cycle. 

Behavioral methods of contraception are used by less than 3.2% of sexually active women; careful counseling could change that.

Familiarizing yourself with fertility awareness as a birth control option

Hypertension is a primary contributor to cardiovascular disease (CVD), which is a major cause of death in women. Traditionally defined as an average blood pressure of at least 140/90 mm Hg or use of antihypertensive medication, hypertension affects about 30% of US adults aged 18 or older.

 While the 140/90 mm Hg cutoff is used in the 

2004 Joint National Commission (JNC) report on hypertension

, more recently, the American College of Cardiology and the American Heart Association (ACC/AHA) 

 lowering the defining blood pressure for hypertension to 130/80 mm Hg.

 According to the new ACC/AHA guidelines, stage I hypertension is diagnosed by a systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg.  A blood pressure of ≥ 140 mm Hg systolic or 90 mm Hg diastolic defines stage II hypertension. Blood pressure should be taken by trained personnel who ensure that the patient has been at rest and seated in a chair with feet on the floor and has an empty bladder. A properly sized cuff encircles 75% to 100% of the patient’s arm. The diagnosis can be made by averaging at least two readings on at least two separate occasions using readings from ambulatory blood pressure monitoring, home self-monitoring, and/or a follow-up visit.

American College of Obstetricians and Gynecologists

 the new, lower diagnostic threshold for hypertension in its bulletin on chronic hypertension in pregnancy and recommends that patients diagnosed with hypertension using these values be managed in pregnancy using the guidelines for chronic hypertension. However, because ACOG adheres to the JNC cutoff in its definition of gestational hypertension, and given that the data currently available utilize the 140/90 threshold, we will also utilize the 140/90 cutoff in this article.

Among women, prevalence of hypertension rises from 10% in the 20- to 44-year-old age range to 78% by age 75.

 Significant disparities exist in medical treatment of hypertension. Approximately half of all adults (53.5%) and 52.1% of women have uncontrolled hypertension.

 Hypertension is more common among black adults (38.6% prevalence) and is less likely to be treated in this population. Women aged 18 to 39 are less likely than older women to have controlled hypertension, potentially predisposing women in this age group to pregnancy complications related to their hypertension. In addition, people who are Mexican-American, lack a usual medical care site, receive medical care less than twice per year, or lack health insurance are less likely to receive medical treatment for hypertension than other people with hypertension.

 Moreover, groups already at disproportionate risk of adverse pregnancy outcomes, such as black women and women lacking health insurance, are more likely to experience complications of hypertension. Given that many reproductive-aged women choose to receive their primary healthcare through their ob/gyn, there is an opportunity to diagnose, counsel on, and treat hypertension during the health maintenance exam. We have opportunities to engage in innovative patient-centered management of hypertension before, during, and after pregnancy to reduce disparities.


	Lifestyle modifications such as weight loss (for overweight or obese patients), a heart-healthy diet, sodium reduction, increased physical activity, and limitation of alcohol consumption

 are recommended for first-line management of hypertension. The first-line pharmacologic classes of antihypertensives are thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and calcium channel blockers.

 However, among women seeking pregnancy or who are currently pregnant, the preferred antihypertensive medications are methyldopa, nifedipine, and/or labetalol per the ACC/AHA.

 In clinical practice, methyldopa is less frequently used; per ACOG, it is less effective in the control of chronic hypertension and more likely to have side effects (drowsiness, headache, orthostatic hypotension).

 Women with hypertension should not be treated with ACE inhibitors, angiotensin receptor blockers, or direct renin inhibitors in pregnancy because of the risk of fetal renal damage.

 Exposure to these medications in the second and third trimesters is most concerning because of the risk of impaired fetal kidney function leading to oligohydramnios, which may in turn impair lung development. Data are less clear regarding exposure risk in the first trimester; however, most studies show a slight increased risk in congenital malformations with medications affecting the renin-angiotenin-aldosterone system.


	Hypertension is a risk factor for CVD, which itself is the top cause of death in the United States.

 Cardiovascular disorders are a top cause of maternal mortality in the United States and hypertensive disorders of pregnancy are specifically responsible for 9.4% of maternal deaths. Patients with a history of preeclampsia have quadruple the risk of developing chronic hypertension.


	Although most people with hypertension have no associated complications in pregnancy, hypertension is associated with increased risk for adverse health events as a result of pregnancy. In particular, chronic hypertension is associated with increased risk of gestational diabetes, postpartum hemorrhage, planned cesarean section, and preeclampsia.

 Given the increased risk of preeclampsia, women with chronic hypertension should initiate low-dose aspirin daily prior to 16 weeks’ gestation for preeclampsia prophylaxis per ACOG and the US Preventive Services Task Force.

 Chronic hypertension also carries fetal risks; growth restriction, stillbirth, and preterm birth are more common in pregnancies exposed to chronic hypertension.

 Both treated and untreated hypertension are associated with an increase in fetal congenital heart defects (RR 2, 95% CI [1.5-2.7] and RR 1.4, [1.2-1.7] respectively).


	In the following segments, we discuss the safety of various forms of contraception for people with different types of hypertension. Contraceptive counseling should be patient-centered, taking into account a woman‘s reproductive health goals and desires. Providers should consider a patient’s blood pressure control and overall cardiovascular health when discussing the risks and benefits of contraceptive methods as compared to the risks of an unintended pregnancy. Please note that the safety profiles mentioned here assume that the patient has no other comorbidities affecting the safety and suitability of these methods. We recommend a useful tool, the US Centers for Disease Control and Prevention’s Medical Eligibility Criteria (US MEC), which provides guidelines surrounding the safety of contraceptive methods for a range of given medical conditions. We have used these recommendations to inform our discussion of contraceptive methods for women with hypertension. It is important to note that the US MEC states that patients with hypertension and systolic pressures ≥ 160 mm Hg or diastolic pressure ≥ 100 mm Hg are at increased risk of adverse health events with pregnancy. As such, providers should take contraceptive efficacy into account when counseling patients. US MEC categories 1 and 2 indicate that a contraceptive method is safe and without restrictions for the specific medical condition and the advantages of the method generally outweigh any theoretical risks, respectively. Meanwhile, contraceptive methods in categories 3 and 4 should be avoided. Category 3 suggests that the theoretical or proven risks of the contraceptive method outweigh the benefits. Category 4 means that there is an unacceptable risk to the patient with use of the contraceptive method.

US MEC recommendations for hypertensive disease and contraceptive are presented in Table 1. 


	Estrogen therapy should be avoided in those with hypertension because it increases blood pressure while also increasing the risks of myocardial infarction and ischemic stroke.

 These relationships are thought to be dose-dependent, with higher doses of ethinyl estradiol posing a greater risk of CVD when compared to lower doses. Estrogen is theorized to activate the renin-angiotensin system and can increase systolic blood pressure by an average of 8 mm Hg.

The US MEC states that combined hormonal contraception (CHC) poses an increased risk (category 3) for those with hypertensive disorders.

 For those with systolic blood pressure ≥ 160 mm Hg or diastolic ≥ 100 mm Hg, the risks outweigh the advantages. Additionally, the US MEC states there are unacceptable risks in using CHC in those with blood pressures above 160/100 (category 4). It is important to note that even those with blood pressure that is well-controlled with antihypertensives are still at increased risk for CVD with estrogen use.


	Progestin methods are generally considered safe in patients with hypertension. For patients with adequately controlled hypertension, progestin-only pills (POPs), etonogestrel implants, and hormonal intrauterine devices are US MEC category 1. Injectable progestin contraception, depo medroxyprogesterone acetate (DMPA) is category 2, meaning that its advantages generally outweigh theoretical or proven risks. These categories hold for patients without a formal diagnosis of hypertension who have elevated blood pressure measurements < 160 mm Hg systolic or < 100 mm Hg diastolic. However, the risk/benefit balance tips when we consider use of DMPA for patients with a systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mmHg with patients who have vascular complications from hypertension. For these patients, DMPA is US MEC category 3 and all other forms of progestin are category 2. In addition, some data show that DMPA increases lipid levels with long-term use; therefore, patients with multiple risk factors for CVD-including hypertension, hyperlipidemia, diabetes, smoking, and obesity-should avoid using injectables.


	Nonhormonal methods such as behavioral methods, condoms, withdrawal, the copper intrauterine device (IUD) and permanent contraception via (partial) salpingectomy or vasectomy are safe for hypertensive patients. Regardless of the type of hypertension, the copper intrauterine device (IUD) is US MEC category 1.

 Although the copper IUD and permanent contraception have failure rates less than 1%, these other nonhormonal methods have higher failure rates and patients who choose to use barrier and behavioral methods of contraception should be informed of the failure rates of these methods in typical use.  The US MEC notes that long-acting reversible contraceptives like IUDs and implants may be the best choice for patients with hypertension, likely due to their high efficacy and good safety profiles. While those are important considerations, so are a patient’s values and preferences for a contraceptive method.  However, it is important to keep in mind that when weighing the risks of contraception that the alternative is potential pregnancy with its own set of risks and benefits. Shared decision-making with patients using validated tools for reproductive life planning and patient-centered guidelines for communication

 (Table 2) can improve patient satisfaction with contraceptive care.

A 34-year-old G2P2 presents to the office for her well-woman exam. She reports being in general good health. However, her primary care physician has been “keeping an eye on her blood pressure,” which was 142/78 at the woman’s last check-up. The only medication she is currently taking is an oral contraceptive pill. She is happy with this method and is considering a pregnancy in the next
	6 months. Her blood pressure is 164/100.


	A. You recommend treating her hypertension and keeping her contraceptive method.
	B. You recommend switching to a POP method of contraception, given the patient’s expressed preferences for pregnancy timing and medical history.
	C. You recommend switching to the progestin injectable.

Centers for Disease Control and Prevention (CDC). Vital Signs: Prevalence, Treatment, and Control of Hypertension – United States. 1999-2002 and 2005-2008. 

National Institutes of Health, National Heart, Lung and Blood Institute, National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.  

https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf

This installment of our Complex Contraceptives series examines contraception considerations for patients with high-blood pressure.

Charisse Loder, MD, MSc

Articles

Choosing the right pill

Familiarizing yourself with fertility awareness as a birth control option

Tips for counseling hypertensive patients on contraception

Migraine headache and hormonal contraception