What are the best birth control options for a 37-year-old woman with poorly controlled hypertension, depression, anxiety, obesity (Body Mass Index (BMI) over 40), a smoking history, and a history of headaches (not migraines)?

Contraception Recommendations for 37-Year-Old with Multiple Cardiovascular Risk Factors

This patient should use progestin-only contraceptives (pills, implants, or IUDs) or non-hormonal methods (copper IUD, barrier methods), while combined hormonal contraceptives are absolutely contraindicated due to her poorly controlled hypertension, smoking history, obesity, and age. 1, 2

Why Combined Hormonal Contraceptives Are Contraindicated

Combined oral contraceptives, patches, and vaginal rings are Category 4 (unacceptable health risk) for this patient due to her poorly controlled hypertension, making them absolutely contraindicated. 1

• Women with systolic BP ≥160 or diastolic ≥100 mmHg have a Category 4 contraindication to combined hormonal methods. 1
• The combination of poorly controlled hypertension, age >35 years, smoking history, and obesity (BMI >40) creates a 6.1-68.1 times higher risk of myocardial infarction compared to women without these risk factors. 2
• Risk of ischemic stroke increases 8-15 fold in hypertensive women using combined oral contraceptives versus women without either risk factor. 2
• Combined hormonal contraceptives should be avoided even in women with adequately controlled hypertension (Category 3), and this patient's hypertension is poorly controlled. 1

Recommended Contraceptive Options

First-Line: Progestin-Only Methods

Progestin-only contraceptives are Category 1-2 (safe to use) for women with hypertension and carry substantially less cardiovascular risk than combined methods. 1, 2, 3

Progestin-only pills (norethindrone):

• Category 2 (advantages generally outweigh risks) for women with poorly controlled hypertension. 1
• No significant association with elevated blood pressure in studies following women for 2-3 years. 4
• Must be taken at the same time every day; backup contraception needed if taken >3 hours late. 5
• Depression and anxiety are not contraindications (Category 1). 1
• Obesity (BMI >40) is Category 1 for progestin-only pills. 1

Etonogestrel implant (Nexplanon):

• Category 2 for women with poorly controlled hypertension. 1
• Highly effective (>99%) with no daily adherence requirements. 6
• Category 1 for obesity, depression, and anxiety. 1
• Lasts 3 years with rapid return to fertility after removal. 5

Levonorgestrel IUD:

• Category 2 for women with poorly controlled hypertension. 1
• Highly effective with minimal systemic hormone absorption. 1
• Category 1 for obesity, depression, anxiety, and non-migrainous headaches. 1

Second-Line: Non-Hormonal Methods

Copper IUD:

• Category 1 (no restrictions) for all of this patient's conditions including poorly controlled hypertension, obesity, smoking, depression, and headaches. 1
• Highly effective (>99%) with no hormonal effects on blood pressure or cardiovascular risk. 1
• Lasts up to 10 years. 1

Barrier methods (condoms, diaphragm):

• No medical contraindications but lower typical-use effectiveness (82-88%). 1
• Should be considered if patient prefers non-hormonal, non-invasive option. 1

Critical Management Steps

Before Initiating Any Contraceptive Method

Blood pressure must be properly measured and documented on at least two separate occasions to confirm severity. 1

• Measure BP in both arms; differences >20 mmHg systolic or >10 mmHg diastolic require vascular evaluation. 1
• Assess for other cardiovascular risk factors: smoking status (current vs. former), duration of hypertension, family history of early cardiovascular disease. 1, 7
• Rule out secondary causes of hypertension given poor control: renal disease, sleep apnea (especially with obesity and headaches), medication effects. 1

Hypertension Management Takes Priority

This patient's poorly controlled hypertension must be addressed urgently before or concurrent with contraceptive initiation. 1

• Discontinue any substances that impair BP control: NSAIDs, decongestants, excessive caffeine (>300 mg/day), herbal supplements (Ma Huang, St. John's Wort). 1
• Initiate or intensify antihypertensive therapy with goal BP <130/80 mmHg. 1
• If currently on combined hormonal contraceptives, discontinue immediately as they increase plasma renin substrate and activate the renin-angiotensin-aldosterone system, worsening hypertension. 2, 8

Ongoing Monitoring Requirements

Blood pressure must be checked at least every 6 months for any woman using hormonal contraceptives, and more frequently (every 1-2 months) until hypertension is controlled. 2, 6

• Women who have BP measured before contraceptive use have 2-2.5 fold decreased risk of myocardial infarction and ischemic stroke. 3
• Monitor for irregular bleeding patterns with progestin-only methods, which are common but not dangerous. 5
• Evaluate any new severe or persistent headaches, as this requires discontinuation and evaluation. 5

Addressing Specific Patient Factors

Smoking History

• If currently smoking: strongly advise cessation as smoking combined with any hormonal contraceptive increases cardiovascular risk. 5, 3
• Current smokers >35 years using combined hormonal contraceptives have 10-fold increased risk of myocardial infarction. 3
• Progestin-only methods remain safer options even for current smokers. 1, 3

Obesity (BMI >40)

• Obesity alone is Category 2 for combined methods, but combined with other risk factors makes them Category 4. 1
• Progestin-only pills, implants, and both IUDs are Category 1 for obesity. 1
• Weight should be monitored as oral contraceptives can cause fluid retention. 8

Depression and Anxiety

• All contraceptive methods are Category 1 for depressive disorders. 1
• Very rarely, progestin-only methods have been associated with mood changes, but this is not a contraindication. 5

Non-Migrainous Headaches

• Non-migrainous headaches are Category 1-2 for progestin-only methods. 1
• Combined hormonal contraceptives would be Category 3-4 if these were migraines, but are already contraindicated due to hypertension. 1
• Monitor for any change in headache pattern; new severe or persistent headaches require evaluation. 5

Common Pitfalls to Avoid

Do not prescribe combined hormonal contraceptives (pills, patches, rings) under any circumstances for this patient. 1, 2

Do not assume blood pressure will improve with weight loss alone—active pharmacologic management is required for poorly controlled hypertension. 1

Do not fail to assess smoking status—if currently smoking, intensive cessation counseling is mandatory as this is the most modifiable cardiovascular risk factor. 5, 3

Do not prescribe progestin-only methods without counseling about irregular bleeding patterns, which are common (not dangerous) and the most frequent reason for discontinuation. 5

Do not restart any form of combined hormonal contraceptive even if blood pressure becomes controlled—the multiple cardiovascular risk factors remain. 1, 2