What are the recommendations for using combined oral contraceptives (COCs) in women with hypertension?

Combined Oral Contraceptives and Hypertension: Recommendations and Risk Assessment

Combined oral contraceptives (COCs) are contraindicated in women with uncontrolled hypertension and should generally be avoided in women with controlled hypertension due to increased cardiovascular risks. 1

Blood Pressure Effects of COCs

• COCs result in mild blood pressure elevation in most women
• Established hypertension develops in approximately 5% of COC users 1
• Blood pressure typically returns to normal within 6 months of discontinuation 1
• Even low-dose estrogen formulations (30μg) can cause small but significant blood pressure increases (2.3/1.6 mmHg) 1

Risk Stratification for COC Use Based on Blood Pressure

Blood Pressure Status	Recommendation	Category
Normal BP (<140/90 mmHg)	COCs can be used	Category 1
Adequately controlled hypertension	Generally avoid COCs	Category 3 [1]
BP 140-159/90-99 mmHg	Generally avoid COCs	Category 3 [1]
BP ≥160/100 mmHg	Do not use COCs	Category 4 [1]
Vascular disease	Do not use COCs	Category 4 [1]

Cardiovascular Risk Assessment

COCs significantly increase cardiovascular risks in hypertensive women:

• Hypertensive COC users have higher risk for stroke and myocardial infarction compared to hypertensive non-COC users 2
• Women with severe hypertension using COCs have up to 25.7-fold increased risk of hemorrhagic stroke 3
• Multiple risk factors compound risk - smoking, age >35, obesity, and dyslipidemia 4, 3
• Current COC use is associated with increased risk of myocardial infarction (RR 1.7) and ischemic stroke (RR 1.6) 4

Monitoring Requirements

• Blood pressure measurement is mandatory before initiating COCs 1
• Women who did not have blood pressure measured before COC initiation have higher risk of ischemic stroke and myocardial infarction 2
• Regular blood pressure monitoring throughout COC therapy is recommended, with prescriptions limited to 6 months to ensure semi-annual reevaluations 1

Alternative Contraceptive Options for Hypertensive Women

• Progestogen-only pills (POPs) are a safer alternative for women with hypertension 5, 6, 7
• Studies consistently report no significant association between POPs and hypertension with up to 2-3 years of follow-up 5
• POC (progestogen-only contraceptive) therapy is associated with substantially lower risk of cardiovascular events than COCs 6

Special Considerations

• Age >35 years significantly increases cardiovascular risk with COC use 3, 6
• Smokers who use COCs have 10-fold increased risk of myocardial infarction 6
• Multiple cardiovascular risk factors may increase risk to unacceptable levels 1
• Discontinuation of COCs in women with hypertension may improve blood pressure control 6

Clinical Approach Algorithm

1. Measure blood pressure before considering COC initiation
2. Assess for additional cardiovascular risk factors (smoking, age >35, obesity, dyslipidemia)
3. If BP ≥160/100 mmHg or vascular disease present: Do not prescribe COCs (Category 4)
4. If BP 140-159/90-99 mmHg or controlled hypertension: Generally avoid COCs (Category 3)
5. If multiple cardiovascular risk factors present: Consider progestogen-only methods
6. If COCs are used in women with normal BP: Monitor BP regularly and limit prescriptions to 6 months

Following these guidelines will help minimize morbidity and mortality risks associated with contraceptive use in women with hypertension.