What are the criteria for renewing birth control in patients with a history of blood clots, hypertension, or diabetes?

Criteria for Birth Control Renewal

Birth control can be safely renewed for most patients without a routine visit by assessing health status changes, blood pressure (for combined hormonal contraceptives only), and screening for new Category 3 or 4 medical conditions based on U.S. Medical Eligibility Criteria. 1

Essential Screening at Renewal

For All Contraceptive Methods

• Assess any changes in health status including new medications that would change the method's appropriateness for safe and effective continued use based on Category 3 and 4 conditions 1
• Evaluate patient satisfaction with current method and address any concerns about method use 1
• No routine physical examination is required for hormonal contraception renewal—medical history and blood pressure (for combined methods) are sufficient 2

Method-Specific Requirements

Combined Hormonal Contraceptives (Pills/Patch/Ring):

• Measure blood pressure at renewal visits 1
• Screen for new thrombotic risk factors, as combined oral contraceptives increase venous thromboembolism risk three to fourfold 3, 4

Progestin-Only Methods and IUDs:

• Blood pressure measurement is not required 1
• For IUD users, consider checking for presence of IUD strings 1

Critical Medical Conditions Requiring Method Change

History of Blood Clots (DVT/PE)

Combined hormonal contraceptives (pills/patch/ring) are contraindicated in women with history of DVT/PE 1:

• Higher risk for recurrent DVT/PE (known thrombophilia, active cancer, history of recurrent DVT/PE): Category 4—do not use combined hormonal methods 1
• Lower risk for recurrent DVT/PE (no ongoing risk factors): Category 3—risks generally outweigh benefits for combined hormonal methods 1

Safe alternatives for women with blood clot history:

• Progestin-only pills: Category 2 (benefits generally outweigh risks) 1
• DMPA injection: Category 2 1
• Implants: Category 2 1
• Levonorgestrel IUD: Category 2 1
• Copper IUD: Category 2 1

Hypertension

The classification depends on blood pressure control and severity 1:

For Combined Hormonal Contraceptives:

• Adequately controlled hypertension: Category 3 (risks generally outweigh benefits)
• Systolic ≥160 or diastolic ≥100: Category 4 (unacceptable health risk)
• Vascular disease: Category 4

Safe alternatives for hypertensive patients:

• All progestin-only methods (pills, DMPA, implants) and IUDs are generally Category 1-2 for hypertension 1

Diabetes

For Combined Hormonal Contraceptives:

• Diabetes without vascular disease: Category 2 (benefits generally outweigh risks) 1
• Diabetes with nephropathy, retinopathy, neuropathy, or vascular disease: Category 3-4 (risks outweigh benefits) 1
• Duration >20 years: Category 3-4 1

Progestin-only methods are safer alternatives for diabetic patients, particularly those with complications 1

Practical Renewal Algorithm

Step 1: Screen for New Category 3 or 4 Conditions

Ask specifically about:

• New blood clots or family history of thrombophilia 1
• New hypertension diagnosis or uncontrolled blood pressure 1
• New diabetes complications (nephropathy, retinopathy, neuropathy) 1
• New cardiovascular disease, stroke, or migraine with aura 1
• New liver disease or tumors 5
• Active cancer or cancer treatment 1
• New medications that may interact (anticonvulsants, rifampin) 1

Step 2: Measure Blood Pressure (Combined Hormonal Methods Only)

• If systolic ≥160 or diastolic ≥100: discontinue combined hormonal contraceptives and switch to progestin-only or non-hormonal method 1
• If systolic 140-159 or diastolic 90-99: consider switching to progestin-only method 1

Step 3: Address Bleeding Concerns

• Reassure that unscheduled bleeding in first 3-6 months is common and not harmful 3, 6
• For persistent breakthrough bleeding: rule out pregnancy, STIs, and structural lesions before treating 6
• Consider NSAIDs for 5-7 days during bleeding episodes 1, 6

Step 4: Counsel on Continuation

• No routine follow-up visit is required if patient is satisfied and has no new medical conditions 1
• Advise patient to return for side effects, concerns, or desire to change methods 1
• For IUD/implant users, inform when device needs removal or replacement 1

Common Pitfalls to Avoid

• Do not require pelvic examination for hormonal contraception renewal—this creates unnecessary barriers to access 2
• Do not dismiss new hypertension in combined hormonal contraceptive users—measure blood pressure at every renewal 1
• Do not continue combined hormonal contraceptives in women who develop new thrombotic risk factors 1
• Do not overlook medication interactions that may reduce contraceptive efficacy 1
• Do not assume all contraceptives carry equal risk—progestin-only and non-hormonal methods have substantially lower thrombotic risk than combined hormonal methods 4

When to Switch Methods

Immediate switch required:

• New diagnosis of DVT/PE, stroke, or cardiovascular disease while on combined hormonal contraceptives 1
• Blood pressure ≥160/100 on combined hormonal contraceptives 1
• Development of migraine with aura on combined hormonal contraceptives 1
• New diagnosis of breast cancer 1

Consider switching:

• Uncontrolled hypertension (140-159/90-99) on combined hormonal contraceptives 1
• Diabetes with vascular complications on combined hormonal contraceptives 1
• Persistent unacceptable bleeding despite treatment 1, 6
• Patient dissatisfaction with current method 1