What are the suitable contraceptive options for a patient with diabetes mellitus (DM), hypertension (HTN), and dyslipidemia?

Contraception Options for Patients with Diabetes, Hypertension, and Dyslipidemia

For patients with diabetes, hypertension, and dyslipidemia, intrauterine devices (IUDs), particularly non-hormonal copper IUDs, are the most appropriate first-line contraceptive option due to their safety profile and minimal impact on metabolic parameters. 1

Contraindications for Combined Hormonal Contraceptives

• Women with complicated diabetes should not use (U.S. MEC 4) or generally should not use (U.S. MEC 3) combined hormonal contraceptives, depending on the severity of the condition 1
• Women with severe hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥100 mm Hg) should not use combined hormonal contraceptives (U.S. MEC 4) 1
• Women with less severe hypertension (systolic pressure 140-159 mm Hg or diastolic pressure 90-99 mm Hg) or adequately controlled hypertension generally should not use combined hormonal contraceptives (U.S. MEC 3) 1
• Some women with hyperlipidemias generally should not use combined hormonal contraceptives (U.S. MEC 2/3, depending on the type and severity of the hyperlipidemia and presence of other cardiovascular risk factors) 1
• Combined oral contraceptives in women with dyslipidemia significantly increase the risk of myocardial infarction (OR 25,95% CI 6 to 109) 1
• Combined oral contraceptives in women with hypertension significantly increase the risk of myocardial infarction (OR range 6 to 68) 1

Recommended Contraceptive Options

First-Line Options:

• Non-hormonal copper IUDs:

  • Weight-neutral with no impact on metabolic parameters 2
  • No effect on glucose metabolism, lipid profiles, or blood pressure 1, 2
  • Highly effective with minimal contraindications 2

• Levonorgestrel-releasing IUDs:

  • Minimal systemic hormonal effects 2
  • May cause slight changes in body composition (2.5% increase in body fat mass and 1.4% decrease in lean body mass) but generally well-tolerated 2
  • Benefits of preventing unintended pregnancy outweigh potential side effects in high-risk women 2

Second-Line Options:

• Progestin-only pills:

  • Have only minor metabolic effects compared to combined hormonal contraceptives 3
  • Minimal impact on myocardial infarction risk (RR 0.98,95% CI 0.66 to 1.47) 1
  • Minimal impact on stroke risk (RR 1.02,95% CI 0.72 to 1.44) 1

• Barrier methods:

  • Weight-neutral with no metabolic effects 2
  • May be combined with other methods to increase effectiveness 2
  • No contraindications related to diabetes, hypertension, or dyslipidemia 2

Options to Avoid:

• Combined hormonal contraceptives (pills, patches, rings):
  • Can adversely affect glucose metabolism in diabetic women 1, 3
  • Can increase triglyceride levels by 13-75% 3
  • Can decrease HDL cholesterol levels by 5-16% with high-dose levonorgestrel formulations 3, 4
  • Can increase LDL cholesterol by 7-17% 5
  • Significantly increase cardiovascular risk in women with hypertension 1, 6

Monitoring Recommendations

• Blood pressure should be measured before initiating combined hormonal contraceptives if they are being considered despite risks 1
• Weight (BMI) measurement is not needed to determine medical eligibility for any contraceptive methods as all methods can be used (U.S. MEC 1) or generally can be used (U.S. MEC 2) among women with obesity 1
• Glucose and lipid screening before initiation of hormonal contraceptives is not necessary according to CDC guidelines, but should be monitored in women with pre-existing diabetes and dyslipidemia 1
• For women with diabetes using hormonal methods, regular monitoring of glycemic control is recommended 1

Special Considerations

• When choosing glucose-lowering medications for people with type 2 diabetes and contraceptive methods, consider potential interactions and prioritize medications with beneficial effects on weight 1
• For women with diabetes requiring obesity pharmacotherapy, reliable contraception is essential as many weight loss medications are contraindicated in pregnancy 1
• The risk of thromboembolic complications is significantly higher with combined hormonal contraceptives in women with multiple cardiovascular risk factors 6
• The clinical significance of lipid changes with hormonal contraceptives varies by formulation, with progestin-only methods having the most favorable profiles 3, 7

Algorithm for Contraceptive Selection in Women with Diabetes, Hypertension, and Dyslipidemia

1. First assess severity of conditions:

   • If diabetes is complicated (end-organ damage), avoid all combined hormonal contraceptives
   • If hypertension is severe (≥160/100 mmHg), avoid all combined hormonal contraceptives
   • If hypertension is moderate (140-159/90-99 mmHg), generally avoid combined hormonal contraceptives
   • If dyslipidemia is severe or multiple cardiovascular risk factors exist, avoid combined hormonal contraceptives

2. Recommend contraceptive options in this order:

   • Non-hormonal copper IUD (first choice)
   • Levonorgestrel-releasing IUD (second choice)
   • Progestin-only pills (third choice)
   • Barrier methods (fourth choice or as adjunct)

3. Avoid:

   • All combined hormonal contraceptives (pills, patches, rings)
   • Depot medroxyprogesterone acetate (DMPA) injections in women concerned about weight gain