Unique Considerations in Contraceptive Counseling for Women with Cardiovascular Disease

Counseling regarding contraceptive options is the joint responsibility of the primary care provider, obstetrician & gynecologist, and cardiologist in persons for whom pregnancy would be detrimental to cardiovascular health, explained a speaker at the 2022 Women’s Cardiometabolic Health and Wellness Masterclass. Review the CardioNerds CardioObstetrics Series for a comprehensive review on the implications and management of pregnancy in persons with or at risk of cardiovascular illness.

Dr. Rachel Perry, associate professor of obstetrics and gynecology at the University of California, Irvine described key components of contraceptive counseling that include shared decision making, emphasizing the most effective methods of contraception while honoring autonomy, acknowledging that patient values about contraception may differ from provider values, and considering the need for dual protection against sexually transmitted infections. Cardiologists who are less familiar with contraceptive counseling may reference patient-oriented resources including Bedsider.org and the Centers for Disease Control (CDC) website.

Physicians must address unique considerations when counseling women with cardiovascular risk or disease regarding contraception. Such considerations include whether contraception, especially combined hormonal contraceptive options, could affect blood pressure, volume status, glycemic control, lipid profile, risk of thromboembolism, or affect the metabolism of other medications.

Dr. Perry counsels, “the one piece of the physical exam you absolutely need before prescribing combined oral contraception is the blood pressure.” Studies have demonstrated that combined hormonal contraception may increase systolic blood pressure on average 8mmHg and diastolic blood pressure 6 mmHg.[1]

When making decisions regarding the relative risk profile of contraceptive options in women with cardiovascular disease, clinicians may employ the CDC Medical Eligibility Criteria, a 4 point scale ranging from 1 (no restrictions for a contraceptive method for the medical conditions) to 4 (unacceptable health risk).[2] For example, in patients with a history of ischemic heart disease, estrogen-containing combined hormonal contraceptives carry a category 4 classification indicating an unacceptable health risk, while non-injection progestin containing contraceptives carry a category 2 classification indicating that the benefits of use generally outweigh the risks. DMPA, an injectable formulation of progestin, is associated with unfavorable lipoprotein changes, resulting in increased cardiovascular risk.[3] Patients with severe hypertension with BP >160/100 have a similar risk profile using the Medical Eligibility Criteria.

Patients with an elevated cardiovascular risk profile may warrant referral to a complex contraception clinic to ensure that contraceptive methods are weighed appropriately.

Dr. Perry explains, “patients getting sent to me from specialists specifically for a contraception consult are my favorite types of visits. If you have a complex contraception clinic at your institution, send us patients.”

References:

[1] Cardoso F, Polonia J, Santos A, et al. Low-dose oral contraceptives and 24-hour ambulatory blood pressure. Int J Gynaecol Obstet. 1997 Dec;59(3):237-43. doi: 10.1016/s0020-7292(97)00239-7.

[2] Teal S, Edelman A. Contraception Selection, Effectiveness, and Adverse Effects: A Review. JAMA. 2021;326(24):2507–2518. doi:10.1001/jama.2021.21392

[3] ACOG Practice Bulletin No. 206: Use of Hormonal Contraception in Women With Coexisting Medical Conditions. Obstetrics & Gynecology: February 2019 – Volume 133 – Issue 2 – p e128-e150 doi: 10.1097/AOG.0000000000003072