What are the recommended contraceptive options for a woman with hypertension and type 2 diabetes mellitus (T2DM) with diabetic nephropathy?

Contraceptive Recommendations for a 42-Year-Old Woman with Hypertension and Diabetic Nephropathy

The copper IUD is the single best contraceptive option for this patient, as it is the only Category 1 (no restrictions) method for women with poorly controlled hypertension, diabetes with complications, and nephropathy, with <1% failure rate and no hormonal effects on blood pressure or glucose metabolism. 1

Why Combined Hormonal Contraceptives Are Absolutely Contraindicated

This patient has an absolute contraindication (Category 4) to any combined hormonal contraceptive (pills, patches, rings) due to the combination of:

• Systolic blood pressure ≥140 mmHg or diastolic ≥90 mmHg combined with vascular disease (diabetic nephropathy qualifies as vascular disease), which creates an absolute contraindication to combined hormonal methods 1
• The risk of ischemic stroke increases 8-15 fold in hypertensive women using combined oral contraceptives versus women without either risk factor 1, 2
• Combined hormonal contraceptives containing ≥20 mcg ethinyl estradiol cause measurable blood pressure elevations (systolic BP increases of 0.7-5.8 mmHg and diastolic BP increases of 0.4-3.6 mmHg), which would worsen her already poorly controlled hypertension 2

Recommended Contraceptive Options in Order of Preference

First-Line: Copper IUD

• Category 1 (no restrictions) for women with poorly controlled hypertension, diabetes with complications, and nephropathy 1
• Failure rate <1% with typical use 1, 2
• No hormonal effects on blood pressure or glucose metabolism 1
• No systemic absorption, making it the safest option for this patient with multiple cardiovascular risk factors 2

Second-Line: Progestin-Only Methods (All Category 2)

Levonorgestrel IUD:

• Category 2 for poorly controlled hypertension 1, 2
• Failure rate <1% 1
• Minimal systemic hormone absorption compared to other hormonal methods 1, 2
• Additional benefit of reducing menorrhagia if present 3

Etonogestrel Subdermal Implant (Nexplanon):

• Category 2 for poorly controlled hypertension 1, 2, 4
• Failure rate <1% 1, 2
• No daily adherence requirements 1, 2
• Recommended as first-line hormonal option for women with hypertension 4
• May reduce dysmenorrhea symptoms 3

Progestin-Only Pills:

• Category 2 for poorly controlled hypertension 2
• No significant association with elevated blood pressure in studies 2, 5
• However, failure rate of 6-12% with typical use makes them less desirable than long-acting reversible contraceptives 2
• Require daily adherence, which is a significant disadvantage 2
• Associated with irregular bleeding patterns 2

Critical Management Considerations for Diabetic Nephropathy

• Target blood pressure for diabetic patients with nephropathy is <130/80 mmHg, and aggressive monitoring and control of hypertension is essential to reduce the risk of worsening diabetic nephropathy, retinopathy, and cardiovascular disease 1
• This patient's blood pressure of 145/95 mmHg is poorly controlled and must be addressed urgently before or concurrent with contraceptive initiation 2
• Patients with proteinuria >190 mg/24h are at increased risk for hypertensive disorders during pregnancy, making highly effective contraception critical 1
• Combined oral contraceptives must be avoided in cases of diabetic nephropathy with proteinuria or active proliferative retinopathy 6

Mandatory Ongoing Monitoring

• Blood pressure must be checked at least every 6 months for any woman using hormonal contraceptives, and more frequently until hypertension is controlled 1, 2, 4
• Baseline cardiovascular risk assessment should be performed before initiating any hormonal contraceptive 1, 4
• Regular blood pressure monitoring is essential even with progestin-only methods 4

Common Pitfalls to Avoid

• Do not prescribe combined hormonal contraceptives even if the patient requests them—this is an absolute contraindication, not a relative one 1, 6
• Do not assume progestin-only pills are equivalent to long-acting reversible contraceptives—their 6-12% typical-use failure rate makes them inferior for this high-risk patient who must avoid pregnancy 2
• Do not delay addressing the poorly controlled hypertension—blood pressure control is essential both for contraceptive safety and to prevent progression of diabetic nephropathy 1, 2
• Be aware that injectable progestogen (Depo-Provera) has been implicated in increased cardiovascular risk, though it may have a role in specific circumstances 7, 8

Special Consideration for Age 42

• At age 42, this patient is approaching menopause, making progestin-only methods particularly appropriate as they provide effective contraception without cardiovascular risks associated with estrogen 4
• Age >35 years combined with other cardiovascular risk factors (hypertension, diabetes with nephropathy) creates a 6.1-68.1 times higher risk of myocardial infarction with combined hormonal contraceptives 2