What is the best oral contraceptive for a perimenopausal woman with hypertension and taking Hydrochlorothiazide (HCTZ)?

From the Guidelines

For perimenopausal women with hypertension who are taking hydrochlorothiazide, a progestin-only pill (POP) such as norethindrone (0.35 mg daily) or drospirenone (4 mg daily) is the best oral contraceptive option. This recommendation is based on the need to minimize the risk of thrombosis and further increases in blood pressure, which are concerns with combined hormonal contraceptives containing estrogen, especially in women over 35 1. Progestin-only methods, on the other hand, do not contain estrogen and therefore do not significantly impact blood pressure or increase thrombotic risk.

Key Considerations

• Drospirenone has mild anti-mineralocorticoid properties that may complement hydrochlorothiazide's antihypertensive effects, making it a favorable option in this context.
• When starting a POP, it is recommended to continue taking it daily without breaks, even during menstruation, to maintain its contraceptive efficacy.
• Side effects of POPs may include irregular bleeding, which typically improves over time.
• If contraception is the primary goal rather than managing perimenopausal symptoms, non-hormonal options like copper IUDs could also be considered, as they are effective and do not carry the same risks as hormonal contraceptives in women with hypertension 1.
• For managing perimenopausal symptoms while on POPs, non-hormonal approaches such as lifestyle modifications may be needed, as POPs provide less symptom relief than estrogen-containing options.

Oral Contraceptive Options

• Combined hormonal contraceptives: Not recommended due to increased risk of thrombosis and further elevation of blood pressure.
• Progestin-only pills (POP): Recommended, with options including norethindrone (0.35 mg daily) or drospirenone (4 mg daily).
• Intrauterine devices (IUDs): Can be considered, especially non-hormonal options like copper IUDs, for their efficacy and safety profile in women with hypertension.

From the FDA Drug Label

1. Elevated blood pressure An increase in blood pressure has been reported in women taking oral contraceptives (68) and this increase is more likely in older oral contraceptive users (69) and with continued use (61) Data from the Royal College of General Practitioners (12) and subsequent randomized trials have shown that the incidence of hypertension increases with increasing quantities of progestogens. Women with a history of hypertension or hypertension-related diseases, or renal disease (70) should be encouraged to use another method of contraception If women elect to use oral contraceptives, they should be monitored closely and if significant elevation of blood pressure occurs, oral contraceptives should be discontinued.

The best oral contraceptive for perimenopause in the setting of hypertension and taking hydrochlorothiazide is not specified in the provided drug label. However, it is recommended that women with a history of hypertension should be encouraged to use another method of contraception. If oral contraceptives are used, close monitoring is necessary, and they should be discontinued if significant elevation of blood pressure occurs 2.

From the Research

Oral Contraceptives for Perimenopause with Hypertension and Hydrochlorothiazide Use

• The management of perimenopause disorders, including the use of hormonal contraceptives, should consider individual risk factors and comorbidities 3.
• For women with hypertension, the choice of oral contraceptive is crucial, as some may exacerbate hypertension or interact with antihypertensive medications like hydrochlorothiazide.
• A study on hypertensive postmenopausal women treated with an ACE-inhibitor or a diuretic (hydrochlorothiazide) found that estrogen plus progestin therapy (EPT) may counteract the unfavorable metabolic and hemodynamic effects of thiazide diuretics 4.
• The effects of estrogen on hypertension are complex and multifactorial, and hormone therapy may improve cardiovascular outcomes in recently menopausal women 5.
• A systematic review on postmenopausal hormone therapy and cardiovascular outcomes suggested that transdermal estrogen with <50 μg/day of estrogen combined with micronized progesterone may be a safer choice with respect to thrombotic and stroke risk 6.
• For perimenopausal women with hypertension taking hydrochlorothiazide, a low-dose oral or transdermal hormonal contraceptive may be considered, taking into account individual risk factors and cardiovascular health 6, 7.
• It is essential to weigh the benefits and risks of hormonal contraceptives in perimenopausal women with hypertension and to consider alternative non-hormonal options when necessary 6, 7.