Is Nuvaring (etonogestrel/ethinyl estradiol) safe for patients with hypertension?

Nuvaring and Hypertension

Nuvaring should be avoided in patients with severe or uncontrolled hypertension, but may be used with caution in patients with well-controlled hypertension while monitoring blood pressure regularly.

Risk Assessment for Hormonal Contraception in Hypertensive Patients

The 2018 ACC/AHA Hypertension Guidelines specifically address the use of oral contraceptives in patients with hypertension, recommending that they should be:

• Used for the shortest duration possible
• Avoided in patients with severe or uncontrolled hypertension
• Used in low-dose formulations (20-30 mcg ethinyl estradiol) when necessary
• Considered for replacement with progestin-only contraception or alternative forms of birth control 1

Nuvaring Specific Considerations

Nuvaring contains etonogestrel (120 mcg/day) and ethinyl estradiol (15 mcg/day), which is a relatively low dose of estrogen compared to many oral contraceptives. However, the FDA labeling for etonogestrel indicates:

• An increased risk of myocardial infarction is attributed to hormonal contraceptive use, particularly in women with underlying risk factors such as hypertension
• The risk is very low in women under age 30 but increases with age
• Hypertension compounds the risk of both thrombotic and hemorrhagic strokes in hormonal contraceptive users 2

Blood Pressure Effects of Nuvaring

Research shows that Nuvaring may cause slight increases in blood pressure:

• A prospective study found that after six cycles of Nuvaring use, there was a significant increase in 24-hour diastolic blood pressure (2.75±5.13 mmHg) and mean blood pressure (2.69±5.35 mmHg) 3
• Heart rate also increased in the 24-hour period (3.39±5.85 beats/min) 3

Clinical Decision Algorithm

1. Assess hypertension severity:

   • Well-controlled hypertension (<140/90 mmHg): Consider Nuvaring with regular BP monitoring
   • Uncontrolled hypertension (≥140/90 mmHg): Avoid Nuvaring
   • Severe hypertension (≥160/100 mmHg): Absolutely contraindicated

2. Evaluate additional risk factors:

   • Age >35 years
   • Smoking
   • Diabetes
   • Hyperlipidemia
   • History of cardiovascular disease
   • Family history of early cardiovascular events

3. Consider alternatives for higher-risk patients:

   • Progestin-only contraceptives
   • Non-hormonal methods (copper IUD, barrier methods)
   • Permanent contraception if family is complete

Monitoring Recommendations

For hypertensive patients using Nuvaring:

• Check blood pressure within 1-3 months of initiation
• Monitor blood pressure at least every 6 months thereafter
• Discontinue if blood pressure increases significantly or becomes uncontrolled
• Watch for signs of thrombotic events (headaches, visual changes, chest pain, leg swelling)

Important Caveats

• The risk of stroke is approximately doubled in users of combined hormonal contraceptives compared to non-users 1, 4
• Patients with hypertension using combined hormonal contraceptives have a significantly higher risk of cardiovascular events 2
• Uncontrolled blood pressure in patients with apparent treatment-resistant hypertension is associated with a 31% increased risk of stroke 5

Summary

While Nuvaring delivers a relatively low dose of estrogen, it still carries cardiovascular risks similar to other combined hormonal contraceptives. The decision to use Nuvaring in hypertensive patients should be based on the severity of hypertension, presence of other cardiovascular risk factors, and availability of alternative contraceptive options. Regular blood pressure monitoring is essential for hypertensive patients using Nuvaring.