Contraception Guide for Patients with Hypertension
Primary Recommendation
Progestin-only contraceptives are the first-line hormonal contraceptive option for women with hypertension, while combined hormonal contraceptives (pills, patches, and vaginal rings) are absolutely contraindicated regardless of blood pressure control status. 1, 2
Contraindicated Methods
Combined Hormonal Contraceptives - Absolute Contraindication
- All combined hormonal contraceptives are contraindicated in women with hypertension, even when blood pressure is well-controlled. 1, 3
- This includes combined oral contraceptive pills, transdermal patches, and vaginal rings. 4
- Combined hormonal contraceptives containing ≥20 mcg ethinyl estradiol cause measurable blood pressure elevations (systolic BP increases 0.7-5.8 mmHg, diastolic BP increases 0.4-3.6 mmHg). 4
- Women with uncontrolled hypertension (BP ≥160/110 mmHg) face the highest risk and have an absolute Category 4 contraindication. 4, 5
Cardiovascular Risk Amplification
- Hypertensive women using combined oral contraceptives have 6.1-68.1 times higher odds of myocardial infarction compared to normotensive non-users. 1
- Risk of ischemic stroke increases 8-15 fold in hypertensive women using combined hormonal contraceptives. 1, 5
- The hypertensive effect is related to the progestogenic potency of the preparation, not the estrogenic component. 4
- Combined hormonal contraceptives stimulate hepatic synthesis of angiotensinogen, activating the renin-angiotensin-aldosterone system and further raising blood pressure. 1
Recommended Contraceptive Options
Tier 1: Long-Acting Reversible Contraceptives (Most Effective)
Copper Intrauterine Device (IUD)
- Category 1 (no restrictions) for all women with hypertension, regardless of severity or control status. 5
- No hormonal effects on blood pressure or cardiovascular risk. 5
- Failure rate <1% with typical use. 4
- Most appropriate for women with uncontrolled hypertension or multiple cardiovascular risk factors. 5
Levonorgestrel Intrauterine Device
- Category 2 (benefits generally outweigh risks) for women with poorly controlled hypertension. 5
- Minimal systemic hormone absorption due to local delivery. 2, 5
- Failure rate <1% with typical use. 4
- Effective for up to 5 years and reduces menstrual blood loss by 71-95%. 2
Etonogestrel Subdermal Implant
- Category 2 for women with poorly controlled hypertension. 5
- Highly effective with no daily adherence requirements. 5
- Failure rate <1% with typical use. 4
Tier 2: Progestin-Only Pills
Norethindrone or Drospirenone Pills
- Category 2 for women with poorly controlled hypertension; safe and appropriate first-line hormonal option. 1, 2
- No significant association with elevated blood pressure in prospective studies. 5, 6
- WHO Collaborative Study found no increased odds of cardiovascular disease among progestin-only pill users, even in women with hypertension. 1
- Failure rate 6-12% with typical use due to need for same-time daily dosing. 4
- Associated with irregular bleeding patterns. 4
Depot Medroxyprogesterone Injection
Tier 3: Non-Hormonal Barrier Methods
- Includes condoms, diaphragms, spermicides, and natural family planning. 4
- Failure rates 18-28% with typical use. 4
- No cardiovascular contraindications but significantly less effective. 4
Permanent Sterilization
- Tubal ligation or male sterilization for women who wish to avoid future pregnancies. 4
- No hormonal effects or cardiovascular risks. 4
Pre-Prescription Assessment
Baseline Evaluation Required
- Measure blood pressure on at least two separate occasions before initiating any hormonal contraception. 1, 5
- If differences >20 mmHg systolic or >10 mmHg diastolic between measurements, vascular evaluation is required. 5
- Assess additional cardiovascular risk factors: age >35 years, smoking, obesity, family history of hypertension. 1
- Exclude pregnancy with pregnancy test before prescribing progestin therapy. 2
Risk Stratification
Women with controlled hypertension (BP <140/90 mmHg):
- Progestin-only methods are first choice. 1
- Combined hormonal contraceptives remain contraindicated. 1, 3
Women with uncontrolled hypertension (BP ≥140/90 mmHg):
- Address hypertension urgently before or concurrent with contraceptive initiation; goal BP <130/80 mmHg. 5
- Copper IUD is the safest option with no restrictions. 5
- Progestin-only methods are Category 2 (acceptable with monitoring). 5
Women with severe uncontrolled hypertension (BP ≥160/110 mmHg):
- Combined hormonal contraceptives are Category 4 (unacceptable health risk). 4, 5
- Prioritize copper IUD or progestin-only methods while aggressively treating hypertension. 5
Monitoring Requirements
Ongoing Blood Pressure Surveillance
- Check blood pressure at least every 6 months for any woman using hormonal contraceptives, including progestin-only methods. 4, 1, 2
- More frequent monitoring is required until hypertension is controlled. 5
- Blood pressure measurement is essential at both initial and all follow-up contraceptive consultations. 3
Response to Blood Pressure Elevations
- If hypertension develops or worsens on combined hormonal contraceptives, discontinue immediately; blood pressure typically returns to baseline within 2-6 months. 4
- Stopping combined oral contraceptives in hypertensive women results in adjusted systolic BP reduction of 15.1 mmHg and diastolic BP reduction of 10.4 mmHg. 7
- Women who stop combined oral contraceptives have 3.6 times higher odds of achieving ≥20 mmHg systolic or ≥10 mmHg diastolic BP reduction. 7
Special Populations and Considerations
Women with History of Contraceptive-Induced Hypertension
- Women with past history of oral contraceptive-induced hypertension who restart low-dose combined hormonal contraceptives have an 8.2% risk of redeveloping hypertension. 8
- Even low-dose formulations (35 mcg ethinyl estradiol) carry recurrence risk. 8
- Progestin-only methods are strongly preferred for this population. 1, 2
Women with Multiple Cardiovascular Risk Factors
- Women with poorly controlled hypertension plus age >35 years, smoking, or obesity must use progestin-only or non-hormonal methods; combined hormonal contraceptives create multiplicative cardiovascular risk. 5
- Current smokers using combined hormonal contraceptives have 10-fold increased risk of myocardial infarction. 5
- Obesity alone is Category 2 for combined methods, but combined with hypertension makes them Category 4. 5
Postpartum Women with Hypertensive Disorders of Pregnancy
- Women with history of hypertensive disorders of pregnancy should receive long-acting reversible contraceptives (intrauterine devices or subdermal implants) as first-line options given their excellent efficacy and safety. 4
- Combined hormonal contraceptives and transdermal patches are contraindicated in women with uncontrolled postpartum hypertension (BP >160/110 mmHg). 4
- Increased thromboembolism risk with combined hormonal contraceptives, patches, and vaginal rings in women with hypertension history. 4
Drug Interactions
- Some antihypertensive medications may interact with hormonal contraceptives; review medication list before prescribing. 1
- Oral progesterone shows no significant interactions with common antihypertensives like amlodipine or telmisartan. 2
Clinical Pitfalls to Avoid
Common Errors
- Never prescribe combined hormonal contraceptives to women with "well-controlled" hypertension; the contraindication is absolute regardless of control status. 1, 3
- Do not assume modern low-dose combined hormonal contraceptives are safe in hypertensive women; even formulations with ≤35 mcg ethinyl estradiol cause measurable BP elevations and cardiovascular risk. 4, 8
- Avoid limiting contraceptive prescriptions to 6 months without ensuring semiannual blood pressure reevaluations are actually occurring. 4
Underrecognized Risks
- Nearly 1-in-5 women aged 20-34 years are unaware of their hypertension diagnosis, and >50% have uncontrolled hypertension. 4
- Family history of hypertension, age ≥35 years, obesity, and duration of oral contraceptive use increase susceptibility to contraceptive-induced hypertension. 4
- Cumulative exposure to blood pressure elevations substantially increases long-term cardiovascular disease risk. 1