Can medroxyprogesterone acetate (Depo‑Provera) be given to a patient with uncontrolled hypertension?

Depo-Provera Should Not Be Given to Patients with Uncontrolled Hypertension

Depo-Provera (medroxyprogesterone acetate) is contraindicated in women with uncontrolled hypertension and should be avoided in severe or uncontrolled cases. The 2017 ACC/AHA hypertension guidelines explicitly state that oral contraceptives should be avoided in women with uncontrolled hypertension, and while they specifically mention using progestin-only forms as alternatives to combined estrogen-containing contraceptives, this recommendation applies to women whose hypertension is controlled 1.

Guideline Recommendations on Hormonal Contraception and Hypertension

The ACC/AHA guidelines provide clear direction on contraceptive use in hypertensive patients:

• Oral contraceptives should be used for the shortest duration possible and avoided in severe or uncontrolled hypertension 1
• Low-dose estrogen agents (20-30 mcg ethinyl estradiol) or progestin-only forms are preferred when contraception is needed in women with controlled hypertension 1
• Alternative forms of birth control (barrier methods, abstinence, IUD) should be considered where appropriate in women with uncontrolled hypertension 1

The guidelines list oral contraceptives among medications that can elevate blood pressure and recommend avoiding their use in patients with uncontrolled hypertension 1.

Clinical Evidence on Depo-Provera and Blood Pressure

While the evidence specifically on Depo-Provera and blood pressure is reassuring compared to combined oral contraceptives, this does not override the guideline recommendation to avoid hormonal contraceptives in uncontrolled hypertension:

• Depo-Provera has no appreciable effects on blood pressure or thrombosis risk, providing an advantage over combined oral contraceptives 2
• In a study of 24 women receiving 150 mg MPA injections, mean blood pressure actually decreased from 124.1/79.4 to 115.6/73.2 mm Hg over three months 3
• Progestogen-only pills show no significant association with high blood pressure in studies with 2-3 years of follow-up 4

However, these studies were conducted in women with normal or controlled blood pressure, not in patients with uncontrolled hypertension.

Practical Clinical Algorithm

For a patient with uncontrolled hypertension needing contraception:

1. First priority: Control the blood pressure before initiating any hormonal contraception 1

   • Target blood pressure <140/90 mmHg minimum, ideally <130/80 mmHg 1
   • Optimize antihypertensive therapy using guideline-recommended combinations (ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic) 1

2. Offer non-hormonal contraception immediately:

   • IUD (copper or levonorgestrel) is highly effective and does not affect blood pressure 1
   • Barrier methods (condoms) provide STI protection and no cardiovascular risk 1

3. Once blood pressure is controlled (<140/90 mmHg):

   • Depo-Provera can be considered as it is safer than combined oral contraceptives regarding blood pressure effects 4, 2, 3
   • Continue close blood pressure monitoring every 2-4 weeks initially, then every 3 months 1

4. If blood pressure remains uncontrolled:

   • Do not initiate Depo-Provera 1
   • Refer to hypertension specialist if blood pressure remains ≥160/100 mmHg despite optimal therapy 1

Critical Caveats

The term "uncontrolled hypertension" is key here. The guidelines distinguish between:

• Controlled hypertension on medication: Progestin-only contraception can be used with monitoring 1
• Uncontrolled hypertension (≥140/90 mmHg): Hormonal contraceptives should be avoided until blood pressure is controlled 1

Common pitfall: Assuming that because Depo-Provera doesn't raise blood pressure in normotensive women, it's safe in uncontrolled hypertension. The guideline recommendation to avoid hormonal contraceptives in uncontrolled hypertension is based on the principle of not adding any potentially contributory factor when cardiovascular risk is already elevated 1.

Adolescent considerations: While Depo-Provera is highly effective in adolescents with typical-use failure rates of approximately 6%, the same blood pressure control principles apply before initiation 1.