Contraception and hypertension
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.11 US MEC recommendations for hypertensive disease and contraceptive are presented in Table 1.
Estrogen and hypertension
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.12 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.13
The US MEC states that combined hormonal contraception (CHC) poses an increased risk (category 3) for those with hypertensive disorders.14 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.11
- Centers for Disease Control and Prevention (CDC). Vital Signs: Prevalence, Treatment, and Control of Hypertension – United States. 1999-2002 and 2005-2008. MMWR Morb Mortal Wkly Rep. 2011;60(4):103-108.
- 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. Accessed August 31, 2019.
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324.
- ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstet Gynecol. 2019;133(1):e26-e50.
- Centers for Disease Control and Prevention (CDC). Vital signs: awareness and treatment of uncontrolled hypertension among adults--United States, 2003-2010. MMWR Morb Mortal Wkly Rep. 2012;61:703-709.
- D’Alton ME, Friedman AM, Bernstein PS, et al. Putting the “M” back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States. Am J Obstet Gynecol. 2019 Oct;221(4):311-317.
- Aliskiren. In: Micromedex. Greenwood Village (CO): Truven Health Analytics; publication year . Available from: www.micromedexsolutions.com. Subscription required to view.
- Brahmbhatt Y, Gupta M, Hamrahian S. Hypertension in Premenopausal and Postmenopausal Women. Curr Hypertens Rep. 2019;21(10):74.
- U.S. Preventive Services Task Force. Final Recommendation Statement: Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: Preventive Medication. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication. Accessed September 9, 2019.
- Ramakrishnan A, Lee LJ, Mitchell LE, Agopian AJ. Maternal Hypertension During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Meta-analysis. Pediatr Cardiol. 2015;36(7):1442-1451.
- Centers for Disease Control and Prevention. Contraceptive guidance for health care providers.https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm. Accessed September 20, 2019.
- Curtis KM, Mohllajee AP, Martins SL, Peterson HB. Combined oral contraceptive use among women with hypertension: a systematic review. Contraception. 2006;73(2):179-188.
- Cardoso F, Polonia J, Santos A, Silva-Carvalho J, Ferreira-de-Almeida J. Low-dose oral contraceptives and 24-hour ambulatory blood pressure. Int J Gynecol Obstet. 1997;59(3):237–243.
- Centers for Disease Control and Prevention. Reproductive Health: Classifications for Combined Hormonal Contraceptives. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixD.html#mec_cardio. Accessed September 5, 2019.
- Dilshad H, Yousuf RI, Shoaib MH, Jamil S, Khatoon H. Cardiovascular disease risk associated with the long-term use of depot medroxyprogesterone acetate. Am J Med Sci. 2016;352(5):487-492.
- Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: Best practices to ensure quality communication and enable effective contraceptive use. Clin Obstet Gynecol. 2014;57(4):659-673.