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.15
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 1.11 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 communication16 (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.
WHICH STATEMENT BELOW IS CORRECT?
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. 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.