Progestin-Only Pills for Women with Hypertension, Diabetes, or Smoking History
Direct Recommendation
Progestin-only pills (POPs) are the preferred oral contraceptive option for women with hypertension, diabetes, or who smoke, as they avoid the cardiovascular and thrombotic risks associated with estrogen-containing contraceptives. 1, 2
Why POPs Are Appropriate for These Populations
Cardiovascular Safety Profile
POPs do not increase venous thromboembolism (VTE) risk in healthy women (RR 0.90,95% CI 0.57-1.45), making them appropriate for women with contraindications to estrogen, including those with hypertension or history of thrombosis. 2
Women with uncontrolled hypertension should not use combined oral contraceptives (COCs), but POPs remain a viable option since they lack estrogen's blood pressure-raising effects. 1
Smoking women over age 35 should avoid COCs due to increased myocardial infarction and stroke risk (approximately two-fold increase), but POPs are safer as observational data suggest no increased myocardial infarction risk with progestin-only formulations. 1
Women with diabetes can use POPs without the metabolic concerns associated with estrogen, though glycemic control should be optimized before conception. 1
POP Formulations and Initiation
Available Options
Traditional POPs (norethindrone or norgestrel) can be started anytime, with backup contraception needed for 2 days if started >5 days after menses. 1
Drospirenone POP requires backup contraception for 7 days if started >1 day after menses. 1
No examination or blood pressure measurement is required before initiating POPs, unlike COCs which require blood pressure assessment. 1
Mechanism and Effectiveness
POPs work primarily by thickening cervical mucus rather than consistently inhibiting ovulation, which contributes to their slightly lower effectiveness compared to combined methods. 2, 3
With typical use, approximately 9 out of 100 women become pregnant in the first year, emphasizing the critical importance of strict adherence. 2, 4
Critical Adherence Requirements
Timing Considerations
Traditional POPs must be taken within 3 hours of the same time each day—this strict timing requirement is non-negotiable for effectiveness. 2
If a dose is missed, take one pill immediately, continue daily pills at the same time, use backup contraception for 2 consecutive days of correct pill use, and consider emergency contraception if unprotected intercourse occurred. 2
The desogestrel-containing POP has shown similar contraceptive effectiveness to COCs, potentially offering more forgiveness with timing than traditional formulations. 3
Managing Expected Side Effects
Bleeding Irregularities
Irregular bleeding patterns are the most frequently reported side effect because POPs do not consistently inhibit ovulation. 2
Enhanced counseling about expected bleeding patterns during the first 3-6 months significantly reduces discontinuation rates. 4
NSAIDs can be used for 5-7 days to manage bleeding irregularities if they become problematic. 2
If unscheduled spotting or bleeding persists beyond 3-6 months and is unacceptable to the patient, consider alternative contraceptive methods after ruling out pregnancy, medication interactions, or pathologic uterine conditions. 4
Medication Considerations for Comorbidities
Hypertension Management
Women with chronic hypertension should be counseled that their antihypertensive regimen may need adjustment, avoiding ACE inhibitors, ARBs, and atenolol if pregnancy is planned, as these are associated with fetal renal anomalies and lower birth weight. 1
Blood pressure should be properly evaluated with multiple measurements, not a single reading, before determining contraceptive eligibility. 1
Diabetes Management
Women with diabetes should be counseled about the importance of glycemic control and that most oral antidiabetic agents should be discontinued and insulin started if pregnancy is desired; metformin may be continued in the preconception period. 1
ACE inhibitors, ARBs, and statins should be avoided in women of reproductive age with diabetes due to teratogenic risks. 1
Drug Interactions
Anticonvulsants and Antimicrobials
Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine) and rifampin/rifabutin therapy may reduce POP effectiveness—consider alternative contraceptive methods or additional backup contraception. 1
Broad-spectrum antibiotics, antifungals, and antiparasitics do not affect POP effectiveness. 1
St. John's wort may reduce POP effectiveness and should be avoided. 1
Follow-Up and Monitoring
No routine follow-up visit is required after initiating POPs, but women should be advised to return if they experience unacceptable side effects or want to change methods. 2
POPs do not protect against sexually transmitted diseases—consistent and correct condom use is recommended for STD protection. 4
Annual immunization status review and blood pressure monitoring should continue as part of routine care for women of reproductive age. 1
Common Pitfalls to Avoid
Do not prescribe POPs without explicitly counseling about the strict 3-hour timing window for traditional formulations—this is the most common reason for method failure. 2
Do not discontinue POPs due to irregular bleeding in the first 3-6 months without adequate counseling, as this is expected and generally resolves. 2, 4
Do not assume POPs are less effective than COCs when taken correctly—the desogestrel formulation has comparable effectiveness. 3
Do not forget to assess for drug interactions, particularly with anticonvulsants and rifampin, which significantly reduce effectiveness. 1