Update on contraceptive options: A case-based discussion
ABSTRACTAs health care providers, we must engage our female patients in a dialogue about their contraceptive and fertility decisions. Empowering and educating our patients about their bodies’ hormones, the menstrual cycle, and the risk of unintended pregnancy are central to effective contraceptive counseling. Selecting an appropriate method for a patient and her medical profile is rewarding and challenging in view of new medications, novel delivery systems, and evolving research.
KEY POINTS
- Hormonal contraceptives have a number of noncontraceptive benefits, such as regulating the menstrual cycle.
- The Pearl index is the number of unintended pregnancies per 100 women per year. Rates are 15% using male condoms, 8% with oral contraceptives, 3% with depot medroxyprogesterone acetate (Depo-Provera) injections, and less than 1% with intrauterine devices or female or male sterilization.
- Estrogen-containing products should be avoided in patients with hypertension or who are at risk of venous thromboembolism.
CASE 5: HYPERTENSION
A 33-year-old woman who has been pregnant twice experienced preeclampsia in her last pregnancy, and now her blood pressure is consistently approximately 140/90 mm Hg on multiple office visits and ambulatory monitoring. She desires contraception. How do you counsel her?
Avoid estrogen-containing products
According to the WHO and CDC guidelines,5 women with controlled or uncontrolled hypertension should not be offered combined oral contraceptives, the patch, or the ring (category 3—theoretical or proven risks outweigh the benefits, and category 4 for systolic blood pressure greater than 160 mm Hg or diastolic blood pressure greater than 100 mm Hg).
The progesterone-only pill (“mini pill”), medroxyprogesterone acetate (intramuscular or subcutaneous), Mirena IUS, the copper intrauterine device, and the etonogestrel implant are all safer options.
A small subset of patients develop elevated blood pressure after starting hormonal contraceptives. Estrogen-containing hormones can increase the liver’s output of angiotensinogen, which is a renin substrate that activates the renin-angiotensin-aldosterone system. If this becomes clinically apparent, these patients should refrain from estrogen-containing products and use progestin-only formulations as a safer alternative.
Patients with isolated elevated hypertriglyceridemia should avoid oral contraceptives. However, the patch, the ring, and progestin-only methods may be acceptable.
Diabetic patients with microvascular complications of retinopathy or nephropathy and any patient with macrovascular disease (stroke, cardiovascular disease) should not be offered estrogen-containing contraception.
