What birth control methods are recommended for women with hypertension?

Birth Control Options for Women with Hypertension

For women with hypertension, progestin-only contraceptives are recommended as the first-line hormonal option, while combined hormonal contraceptives should be avoided due to increased cardiovascular risk. 1, 2

Understanding the Relationship Between Contraception and Hypertension

• Combined oral contraceptives (COCs) cause a small but detectable increase in blood pressure in most women, with approximately 5% developing frank hypertension 1
• The Nurses' Health Study found that current users of oral contraceptives had a significantly increased risk of hypertension (RR 1.8; 95% CI 1.5-2.3) compared to never users 1, 3
• Blood pressure typically returns to pre-treatment levels within 3 months of discontinuing oral contraceptives, indicating the effect is reversible 1, 4
• The hypertensive effect appears to be related to the progestogenic potency of the preparation, not the estrogenic component 1

Recommended Birth Control Options for Hypertensive Women

First-Line Options:

• Progestin-only methods are considered safe with respect to hypertension risk 2:
  • Progestin-only pills (POPs) with a first-year perfect use failure rate of 0.5% 5
  • Levonorgestrel intrauterine devices (LNG-IUD) with failure rates as low as 0.1% 5
  • Injectable contraceptives like Depo-Provera (failure rate 0.3%) 5
  • Implantable contraceptives (failure rate 0.05%) 5

Second-Line Options:

• Non-hormonal methods:
  • Copper IUD (failure rate 0.6-0.8%) 5
  • Barrier methods such as condoms, diaphragms, and cervical caps 5
  • Permanent sterilization for those who have completed childbearing 5

Contraindicated Options:

• Combined hormonal contraceptives (containing estrogen and progestin) are contraindicated in women with hypertension, even if well-controlled 1
• This includes combined oral contraceptives, vaginal rings, and transdermal patches 1

Management Algorithm for Contraception in Hypertensive Women

1. Assess baseline cardiovascular risk:

   • Measure blood pressure before initiating any hormonal contraception 6
   • Evaluate for additional risk factors (age >35 years, smoking, obesity, family history of hypertension) 1

2. For women with controlled hypertension (BP <140/90 mmHg):

   • Recommend progestin-only methods as first choice 1, 2
   • Consider non-hormonal methods as alternatives 5
   • Avoid all combined hormonal contraceptives 1

3. For women with uncontrolled hypertension (BP ≥140/90 mmHg):

   • Recommend non-hormonal methods as first choice 5
   • Consider progestin-only methods with careful monitoring 2
   • Strictly avoid all combined hormonal contraceptives 1

4. Monitoring recommendations:

   • For women using any hormonal method, check blood pressure at least every 6 months 1
   • If blood pressure increases significantly, consider switching to a non-hormonal method 4, 7
   • Stopping combined oral contraceptives can reduce systolic BP by approximately 15 mmHg and diastolic BP by 10 mmHg in hypertensive women 4

Special Considerations and Pitfalls

• Pregnancy risk: The risk of unintended pregnancy must be balanced against the cardiovascular risks of contraceptive methods 1
• Age considerations: Women over 35 years have increased susceptibility to contraceptive-induced hypertension 1
• Duration of use: Longer duration of oral contraceptive use (>8 years) is associated with higher blood pressure levels in hypertensive women 7
• Medication interactions: Some antihypertensive medications may have interactions with hormonal contraceptives 1
• Emergency contraception: Emergency contraceptive pills can be used by women with hypertension as they are used for a very short duration 5

Impact of Stopping Combined Oral Contraceptives

• Stopping combined oral contraceptives is an effective intervention for blood pressure control in hypertensive women 4
• Women who discontinued oral contraceptives showed a mean decrease of 15.1 mmHg in systolic BP and 10.4 mmHg in diastolic BP, compared to minimal changes in those who continued use 4
• The odds of achieving a significant blood pressure reduction (≥20 mmHg systolic or ≥10 mmHg diastolic) were significantly higher in women who stopped oral contraceptives 4