Hormonal contraception for women with hypertension

October 13, 2020

Although hypertension is a modifiable risk factor for cardiovascular disease (CVD), certain hormonal contraceptives increase the risk of stroke and myocardial infarction in women with the disorder.

Selecting the appropriate type of contraception for women with hypertension should be based on age and degree of hypertension, according to a clinical insight in JAMA.

Recommendations from the authors’ expert opinion gleaned from the 2019 American College of Obstetricians and Gynecologists Practice Bulletin and the U.S. Medical Eligibility Criteria for Contraceptive Use note that progestin-only pills (POPs) are generally safe in women with hypertension, but that combined oral contraceptives should be prescribed carefully and restricted to women younger than 35 years old.

“One in four women of reproductive age have hypertension, and less than half of those women are aware of it; even fewer have blood pressure control,” said senior author Chrisandra Shufelt, MD, MS, associate director of the Barbra Streisand Women’s Heart Center in the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles. “This insight was an opportunity for awareness and also to address how contraceptive choices in women with hypertension may increase cardiovascular risk in this setting.”

Dr. Shufelt said there has been increased attention to blood pressure with recent updated guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).

To properly measure blood pressure to confirm a diagnosis of hypertension, the patient should avoid smoking, caffeine, and exercise for 30 minutes beforehand. The patient also needs to remain seated and relaxed with feet flat and an empty bladder, without talking, for 3 to 5 minutes.

In addition, blood pressure requires confirmation with either two or three office visits, multiple home readings or 24-hour ambulatory monitoring.

Cardiovascular risk factors should be ruled out, such as hyperlipidemia, diabetes, smoking, obesity, a family history of premature CVD, and physical inactivity.

For healthy women who are 35 years old or younger with well-controlled hypertension, options considered safe to use include non-hormonal methods like condoms, spermicide, or a diaphragm, cervical cap, or copper intrauterine device (IUD), as well as a levonorgestrel-releasing IUD device (LNG-IUD), an implant, or POPs.

Given that barrier methods have a higher failure rate, one must also balance the risks of a pregnancy versus contraception in women with hypertension.

Combined hormonal contraceptives and depot medroxyprogesterone acetate (DMPA) may be considered with caution if other options have been tried first.

For patients older than 35 with adequately controlled hypertension or any age with systolic blood pressure (SBP) between 140 mm Hg and 159 mm Hg and diastolic blood pressure (DBP) from 90 mm Hg to 99 mm Hg, the nonhormonal options, LNG-IUD, implant, and POPs also are safe to use. DMPA can be used with caution, while combined hormonal contraceptives should be avoided.

For women of any age with SBP ≥ 160 mm Hg and DBP ≥ 100 mm Hg, the use of combined hormonal contraceptives is contraindicated and DMPA should be avoided. Safe to use are nonhormonal options, and the LNG-IUD, implant, and POPs can be used with caution.

“Clinicians should be aware that hypertension is common in reproductive-aged women and that this needs to be taken into consideration when selecting certain contraception,” Dr. Shufelt told Contemporary OB/GYN.

It will be important to understand how the new updated AHA/ACC guidelines for blood pressure might impact hormonal contraception counseling, according to Dr. Shufelt, because stage I hypertension is now defined as SBP between 130 mm Hg and 139 mm Hg or DBP from 80 mm Hg to 89 mm Hg, “which is 10 mm Hg lower than the previous recommendations,” she said.

Further studies also are required to understand the safety profiles of the non-oral hormonal preparations and ultra-low-dose hormonal contraception in women with hypertension.

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Dr. Shufelt reports no relevant financial disclosures.

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Reference

  1. Shufelt C, LeVee A. Hormonal contraception in women with hypertension. JAMA. Published online September 21, 2020. doi:10.1001/jama.2020.11935