What is the best course of action for a 28-year-old patient with hypertension, depression, and tachycardia, who is currently on estrogen and progesterone birth control and seeing counseling for trauma and depression?

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From the Guidelines

This 28-year-old female patient with hypertension and depression should prioritize switching to a progesterone-only pill, such as norethindrone (0.35mg) daily without breaks, to minimize cardiovascular risks associated with estrogen-containing contraceptives, as recommended by the 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 1.

Birth Control

For her birth control needs, the patient should take the progesterone-only pill at the same time each day for maximum effectiveness and use backup contraception for the first 48 hours after starting. Given her history of undesirable effects with Depo and Nexplanon, a progesterone-only pill is a suitable alternative. It is essential to discuss the expected failure rates of contraceptive options and the anticipated maternal and fetal risks of unplanned pregnancy, as outlined in the 2018 AHA/ACC guideline for the management of adults with congenital heart disease 1.

Depression

For her depression, continuing weekly counseling sessions is beneficial, as she reports they are helpful. Considering a selective serotonin reuptake inhibitor (SSRI) such as sertraline starting at 50mg daily may be effective for depression with minimal cardiovascular effects, as suggested by the palliative care for people living with heart failure: European Association for Palliative Care task force expert position statement 1. However, it is crucial to monitor for potential hypertension as a side effect of SSRIs.

Tachycardia and Palpitations

Regarding her tachycardia and palpitations, the patient should monitor and document episodes (frequency, duration, associated symptoms) and consider wearing a Holter monitor for 24-48 hours to capture any arrhythmias. This approach will help in understanding the nature of her symptoms and guide further management.

Hernia Follow-up

For her hernia follow-up, exploring patient assistance programs at the surgeon's office can help address cost barriers. Ensuring follow-up care is essential for preventing potential complications and promoting overall health.

Overall Management

The patient's depression appears to be situational due to past trauma and family circumstances, and her current counseling approach seems appropriate. However, medication may provide additional benefit if symptoms persist or worsen. A multidisciplinary approach, including cognitive behavioral therapy and aerobic exercise training, may also be beneficial in managing her depression and improving quality of life, as recommended by the palliative care guideline 1.

From the Research

Patient History and Current Concerns

  • The patient is a 28-year-old female with a past medical history (PMH) of hypertension (HTN) and depression.
  • She has experienced trauma in her life due to the loss of her brother and son, but denies any suicidal or homicidal thoughts and reports that counseling is helping her.
  • The patient is currently taking estrogen and progesterone birth control, but due to headaches and cardiovascular risk related to hypertension, the physician plans to prescribe a progesterone-only birth control method 2, 3.

Birth Control and Hormonal Effects

  • The patient has tried Depo and Nexplanon in the past, but refused due to undesirable effects.
  • She reports taking her current birth control pills as directed, but was late taking one pill by an hour and used a backup method during that time.
  • Research suggests that progesterone can have both positive and negative effects on mood, and its metabolite allopregnanolone may be useful for treating postpartum depression, but may trigger negative symptoms in women with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) 2, 3, 4.

Depression and Anxiety

  • The patient presents with symptoms of depression, including poor concentration, and reports that counseling is helping her.
  • She denies any suicidal or homicidal thoughts and reports no recent alcohol or drug use.
  • Studies suggest that fluctuations in sex steroids, including progesterone, may contribute to mood and anxiety disorders in women, particularly during reproductive transitions 3, 4.

Cardiovascular Effects

  • The patient reports elevated heart rate and palpitations, but cardiology evaluations have not found any underlying conditions.
  • Research suggests that progesterone may have beneficial effects on cardiovascular function, particularly in postmenopausal women, and may help reduce cardiovascular risk 5.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Progesterone - Friend or foe?

Frontiers in neuroendocrinology, 2020

3
Research

Progesterone, reproduction, and psychiatric illness.

Best practice & research. Clinical obstetrics & gynaecology, 2020

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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