Can Oral Contraceptive Pills (OCPs) (Hormonal Contraceptives) increase Hypertension?

From the Guidelines

Oral contraceptive pills (OCPs) can increase blood pressure in some women, with the most recent evidence suggesting a small but significant elevation in blood pressure associated with OCP use. According to the study published in 2023 1, the average increases in systolic blood pressure (SBP) ranged from 7–17 mmHg and in diastolic blood pressure (DBP) from 3–11 mmHg, with a hypertension incidence of 4–18%. The study also found that the risk of incident hypertension was higher among current OCP users compared to non-users after adjustment for age, ethnicity, parity, and cardiovascular disease risk factors.

The mechanism of OCP-related blood pressure increase is thought to involve estrogen's effects on the renin-angiotensin-aldosterone system, which regulates blood pressure, and its ability to increase angiotensinogen production in the liver. Women with pre-existing hypertension, those over 35 years old, smokers, and those with obesity or diabetes face higher risks of OCP-related blood pressure increases.

Some key points to consider when prescribing OCPs include:

• Measuring blood pressure before starting OCPs and monitoring it regularly during use
• Limiting contraceptive prescriptions to 6 months to ensure at least semiannual reevaluations
• Withdrawing the offending contraceptive agent in cases of contraceptive-induced hypertension, but considering continuation of therapy in some women and combining it with antihypertensive therapy if necessary
• Considering progestin-only contraceptives (mini-pills, implants, or hormonal IUDs) as safer alternatives for women concerned about blood pressure effects, as they generally have minimal impact on blood pressure 2.

Overall, healthcare providers should be aware of the potential for OCPs to increase blood pressure and take steps to monitor and manage this risk in their patients.

From the Research

Oral Contraceptive Pills and Blood Pressure

• The relationship between oral contraceptive pills (OCPs) and blood pressure is complex, with some studies suggesting that OCPs can increase blood pressure in certain individuals 3.
• The incidence of OCP-induced hypertension (OCPIH) ranges from 1-8.5% among OCP users, and OCPIH shares common risk factors and pathophysiological mechanisms with hypertensive disorders of pregnancy (HDP) 3.
• The use of combined oral contraceptives (COCs) is associated with an increased risk of arterial and venous thromboembolic events, and the risk of myocardial infarction does not correlate to the length of therapy and disappears after treatment termination 4.
• The presence of poorly controlled hypertension is associated with approximately 3-fold increased risks of myocardial infarction and ischemic stroke, while the risk of haemorrhagic stroke rises 15-fold 4.
• Women with hypertension may experience an improvement in blood pressure control after discontinuation of COCs 4.

Risk Factors and Contraindications

• The absolute risk of coronary events is very low in women under 35 who are non-smokers, have no history of coronary heart disease, and have normal blood pressure 5.
• The absolute risk of stroke is low in young women who are not hypertensive and do not smoke, but it is higher in the case of arterial hypertension 5.
• Obesity, a family history of deep vein thrombosis, and hereditary clotting disorders are risk factors for deep vein thrombosis 5.
• History, physical examination, and simple laboratory tests before prescribing or renewing oral contraceptives are sufficient to detect the main contraindications, such as arterial hypertension, a history of coronary or cerebrovascular conditions, deep vein thrombosis, and hypercholesterolaemia 5.

Clinical Considerations

• Blood pressure level should be assessed before initiation of oral contraceptives 6.
• Non-contraceptive benefits of oral contraceptives include reduced risk of ovarian and endometrial cancers, more favorable bleeding patterns, and improvement in menstruation-related symptoms such as acne, migraine headaches, and premenstrual dysphoric disorder 6.
• Optimal contraceptive selection requires patient and clinician discussion of the patient's tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences 7.