1/18/2017

Contraception in Women with Cardiovascular Risk Factors

Author: Margaret M. Boozer, MD

Mentor: Todd Jenkins, MD

Editor: Elizabeth Ferris-Rowe, MD

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Cardiovascular risk factors include hypertension, diabetes, obesity, smoking and increasing age, and may limit options for contraception, particularly hormonal methods. Clinicians should use the USMEC to guide their counseling and engage in shared decision making with patients recognizing that contraception of any form is often safer than pregnancy and that patient ability and willingness to use contraception effectively is an important part of decision-making.

Hypertension

Non hormonal and progestin only methods of contraception, including implants, intrauterine systems, and progestin-only pills, do not appear to have increased risk of cardiovascular or cerebrovascular events in patients with hypertension. Depo-medroxyprogesterone (DMPA) can generally be used in women with hypertension, though in cases of severe hypertension (systolic ≥ 160 mm Hg or diastolic ≥ 100 mm Hg) or vascular disease US Medical Eligibility Criteria (USMEC), DMPA use is considered Category 3, meaning theoretical or proven risk generally outweighs the benefit. In such situations, clinical judgement and shared decision making should be utilized. In patients with hypertension, combined hormonal contraceptives (CHCs) use is associated with a higher risk of stroke and acute myocardial infarction compared to non-use. When initiating CHCs, blood pressure should be measured in advance. In a systematic review, those patients who did not have blood pressure measurements before starting CHCs had a higher risk of acute myocardial infarction or ischemic stroke compared to women in whom blood pressure was measured. CHC use in patients with adequately controlled hypertension or hypertension with systolic BP of 140 – 159 mm Hg or diastolic BP 90 – 99 mm Hg is USMEC Category 3. CHC use in patients with systolic BP > 160 mm Hg or diastolic BP > 100 mm Hg is a USMEC Category 4, meaning the method poses an unacceptable health risk and should not be used.

Diabetes

In the absence of associated vascular disease, all contraceptive options are considered relatively safe (category 1 or 2). Progestin only methods, including the progestin only pill, the contraceptive implant and the DMPA shot have little effect on short or long-term diabetes control, hemostatic markers or lipid profile. Neither CHC nor progestin only contraception (POC) appears to affect glycemic control or disease progression in diabetic patients or in patients with a history of gestational diabetes. However, CHCs and DMPA are considered category 3 in patients with complicated diabetes (i.e. nephrophathy, neuropathy, retinopathy), other vascular disease, or diabetes of greatr than 20 years duration.

Obesity

All methods of contraception should be offered to patients with obesity. Any progestin containing method offers protection against endometrial hyperplasia. In observational studies, obese adolescent DMPA users had an increased risk for weight gain compared to other users and non-users, though this finding has not been repeated in randomized trials. Therefore, DMPA should be offered to these patients with appropriate counseling. Both CHC and POC are generally safe in women with BMI greater than 30 kg/m2. Limited evidence demonstrates that obese women who use CHCs do not have a higher risk for acute myocardial infarction or stroke compared to non-CHC users. The advantages of using hormonal contraception generally outweigh the risks. Nevertheless, obese women using CHC are at small increased risk of venous thromboembolism.

Smoking

POC and non-hormonal contraception are preferred. CHC use is associated with both an age and dose-related increased risk of myocardial infarction, so they should not be used in patients who smoke >/= 15 cigarettes daily and are 35 or older. In patients under 35 with no other cardiovascular risk factors, CHC use is USMEC Category 2, where advantages generally outweigh theoretical or proven risks.

Age

All contraceptive methods are generally safe in healthy, non-smoking, non-obese women older than age 35 .However, cardiovascular risk increases with age. Clinicians should consider all cardiovascular risk factors when counseling patients over 40 on CHC use. In the absence of other clinical conditions, CHC can be used until menopause.

Multiple risk factors

Non-hormonal contraceptive methods include the copper IUD, emergency contraception, barrier methods, and female and male sterilization are safe for patients with multiple cardiovascular risk factors. Generally, POCs are also safe, though DMPA should be used with caution. CHC should generally be avoided in patients with two or more risk factors for arterial cardiovascular disease.

Further Reading:

Curtis KM, Jatlaoui TC, Tepper NK, et al., U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(4):1-66. doi:10.15585/mmwr.rr6504a1.

Available at: https://www.cdc.gov/mmwr/volumes/65/rr/rr6504a1.htm?s_cid=rr6504a1_w

Curtis KM, Tepper NK, Jatlaoui TC, et al., U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. Morbidity and Mortality Weekly Report (MMWR), Recommendations and Reports / July 29, 2016 / 65(3);1–104

Available at: https://www.cdc.gov/mmwr/volumes/65/rr/rr6503a1.htm?s_cid=rr6503a1_w

Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Long-acting reversible contraception: implants and intrauterine devices., Obstet Gynecol. 2017 Nov;130(5):e251-e269. doi: 10.1097/AOG.0000000000002400. Reaffirmed 2021.

Initial approval: June 2015; Revised November 2019. Revised July 2021, Revised January 2023

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