What is the most appropriate hormonal contraceptive method for a hypertensive, obese woman?

Best Hormonal Contraceptive for Hypertensive, Obese Women

Progestin-only methods—specifically the levonorgestrel intrauterine device (LNG-IUD), etonogestrel implant, or progestin-only pills—are the best hormonal contraceptive options for women with hypertension and obesity, as combined hormonal contraceptives are contraindicated or carry unacceptable cardiovascular risk in this population. 1, 2

Why Combined Hormonal Contraceptives Should Be Avoided

Blood Pressure Contraindications

• Combined oral contraceptives, patches, and vaginal rings are absolutely contraindicated in women with severe hypertension (systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg). 1, 2, 3
• Women with moderate hypertension (systolic 140-159 mmHg or diastolic 90-99 mmHg) face a Category 3 classification, meaning risks usually outweigh benefits. 1
• Even adequately controlled hypertension carries a Category 3 classification for combined hormonal contraceptives. 1

Synergistic Risk with Multiple Risk Factors

• When a woman has multiple major cardiovascular risk factors—such as hypertension combined with obesity—combined oral contraceptive use may increase her risk to an unacceptable level. 1, 2
• The combination of obesity and hypertension creates a multiplicative rather than additive cardiovascular risk profile. 4
• Combined hormonal contraceptives increase blood pressure in many users, with small but detectable elevations even with modern low-dose formulations containing only 30 µg estrogen. 1

Obesity-Specific Concerns

• Women with obesity (BMI >30 kg/m²) using combined hormonal contraceptives receive a Category 2 classification (benefits generally outweigh theoretical risks), but this assumes no other cardiovascular risk factors. 1
• The presence of hypertension alongside obesity elevates the risk category substantially. 1, 2

Recommended Progestin-Only Options

First-Line: Long-Acting Reversible Contraceptives (LARCs)

Levonorgestrel Intrauterine Device (LNG-IUD)

• Category 1 classification (no restrictions) for women with any degree of hypertension, including severe hypertension and vascular disease. 1
• Category 1 for women with obesity. 1
• Highly effective with failure rate <1% in typical use. 1
• No systemic cardiovascular effects. 1

Etonogestrel Implant

• Category 1 classification for women with hypertension at any severity level. 1
• Category 1 for obesity. 1
• Failure rate <1% with typical use. 1
• Safe with no increased stroke or cardiovascular risk. 4

Second-Line: Progestin-Only Pills (POPs)

• Category 1 classification for women with adequately controlled hypertension; Category 1-2 for elevated blood pressure levels. 1
• Progestin-only pills show no significant association with blood pressure elevation in studies with up to 2-3 years of follow-up. 5
• Substantially less cardiovascular risk than combined hormonal contraceptives. 2
• Blood pressure monitoring is not generally required during progestin-only pill use. 2

Third-Line: Depot Medroxyprogesterone Acetate (DMPA)

• Category 2 classification for women with hypertension (systolic 140-159 or diastolic 90-99 mmHg). 1
• Category 3 for severe hypertension (systolic ≥160 or diastolic ≥100 mmHg). 1
• Important caveat: DMPA is associated with weight gain in a subset of users, particularly adolescents with obesity. 6
• If DMPA is chosen, monitor weight at 6 months; weight gain >5% body weight at this checkpoint predicts future excessive weight gain and should prompt switching to an alternative method. 6

Clinical Algorithm for Selection

1. Measure blood pressure before prescribing any hormonal contraceptive. 2

2. If BP ≥160/100 mmHg (severe hypertension):

   • Offer LNG-IUD or etonogestrel implant as first choice (Category 1). 1
   • Progestin-only pills are acceptable (Category 1-2). 1
   • Combined hormonal contraceptives are absolutely contraindicated. 1, 2

3. If BP 140-159/90-99 mmHg (moderate hypertension):

   • Offer LNG-IUD or etonogestrel implant as first choice (Category 1). 1
   • Progestin-only pills are acceptable (Category 1-2). 1
   • Avoid combined hormonal contraceptives (Category 3). 1

4. If BP is adequately controlled on medication:

   • Offer LNG-IUD or etonogestrel implant as first choice (Category 1). 1
   • Progestin-only pills are acceptable (Category 1). 1
   • Combined hormonal contraceptives carry Category 3 classification (risks usually outweigh benefits). 1

5. Consider patient preference for LARC vs. daily pill:

   • LARCs provide superior efficacy and eliminate adherence concerns. 1
   • If patient prefers oral method, prescribe progestin-only pills. 1

6. If considering DMPA despite obesity:

   • Counsel that weight gain occurs in a subset of users. 6
   • Schedule 6-month weight check; if >5% weight gain, switch methods. 6

Critical Monitoring Requirements

• Blood pressure must be measured before initiating any hormonal contraceptive. 2
• Women who had blood pressure measured before combined oral contraceptive use have 2-2.5-fold decreased risk of myocardial infarction and ischemic stroke compared to those who did not. 2
• If combined hormonal contraceptives are inadvertently started and blood pressure rises significantly without another identifiable cause, discontinue immediately. 2
• Progestin-only methods do not require routine blood pressure monitoring during use. 2

Common Pitfalls to Avoid

• Do not prescribe combined hormonal contraceptives simply because hypertension is "controlled" on medication—the Category 3 classification still applies, and progestin-only methods are safer. 1
• Do not assume all progestin-only methods are equivalent for weight concerns—DMPA carries higher risk of weight gain in obese patients, while LNG-IUD, implants, and progestin-only pills do not. 6
• Do not forget that the risk of unintended pregnancy must be weighed against contraceptive risks—entering pregnancy with hypertension and obesity carries substantially higher morbidity and mortality than using appropriate contraception. 2
• Do not use combined hormonal patches or vaginal rings as alternatives to pills in this population—they carry the same cardiovascular contraindications as combined oral contraceptives. 1, 7