Contraception in Women with Cardiovascular Risk Factors
1/18/2017 - Margaret M. Boozer, MD
Mentor: Todd Jenkins, MD
Editor: Christopher M. Zahn, MD
Cardiovascular risk factors include hypertension, diabetes, obesity, smoking and increasing age, and may limit options for contraception, particularly hormonal methods.
Hypertension: Long-acting reversible methods, including implants and intrauterine systems, as well as progestin-only pills, do not appear to have increased risk of cardiovascular or cerebrovascular events in women with hypertension. Depo-medroxyprogesterone (DMPA) can generally be used in women with hypertension, except for those with severe hypertension (systolic ≥ 160 mm Hg or diastolic ≥ 100 mm Hg) or vascular disease (US Medical Eligibility Criteria (USMEC) Category 3). In women with hypertension, combined hormonal contraceptives (CHCs) use is associated with a higher risk of stroke and acute myocardial infarction compared to non-use. If CHC’s are used, blood pressure should be measured before initiating this method. 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. Women with hypertension (systolic BP of 140 – 159 mm Hg or diastolic BP 90 – 99 mm Hg) or those with adequately controlled hypertension should generally not use CHCs as the theoretical or proven risk generally outweighs the benefit (USMEC Category 3). Women with severe hypertension should not use CHCs (USMEC Category 4).
Diabetes: The levonorgestrel intrauterine system appears preferable, regardless of end-organ disease, and use of the copper IUD is unrestricted. DMPA should generally not be used in women with complicated diabetes. 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 should not be used in patients with complicated diabetes. The contraceptive implant may cause mild insulin resistance, but has not been shown to have an effect on serum glucose levels in healthy women. Additionally, the implant has no adverse effects on the lipid profile.
Obesity: The levonorgestrel intrauterine system should be considered in obese women because it offers protection against their increased risk for endometrial hyperplasia. Obese adolescent DMPA users are at increased risk for weight gain compared to other users and non-users. Despite concerns regarding decreased efficacy, both CHC and POC are generally safe in women with BMI greater than 30 kg/m2. Limited evidence demonstrates that obese women who use CHC’s 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 and are 35 or older.
Increased age: All contraceptive methods are generally safe in healthy, non-smoking, non-obese women older than age 35. Due to the increased risk of VTE associated with obesity and the increased risk of cardiovascular disease associated with age, CHC should only be used in women 40 or older in the absence of these co-morbidities.
Multiple risk factors: Non-hormonal contraceptive methods include the copper IUD, barrier methods, and female and male sterilization. These methods, as well emergency contraception, are safe and can be used without restriction in patients with cardiovascular risk factors. Generally, POCs and non-hormonal contraception represent a safe alternative, although DMPA should be used with caution. CHC should be used with caution, if at all, in any patient with two or more risk factors for arterial cardiovascular disease.
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.
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
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.
Initial approval: June 2015; Reviewed January 2017, Revised May 2018
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