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Hypertension Raises
Method Choice Cautions
A woman with high blood pressure (hypertension) may have fewer desirable contraceptive
method options than other women. Her options will depend upon the history and severity of
her disease, the presence of complications (such as related vascular disease or organ
damage), and whether her blood pressure can be monitored.
Caution is called for when considering the use of combined oral contraceptives (OCs) in
women with severe hypertension (180/110 millimeters of mercury [mm Hg] or greater,
systolic pressure over diastolic pressure);* hypertension with related vascular disease;
or moderate hypertension (160-179/100-109 mm Hg).1
In both industrial and developing countries, women with high blood pressure who use OCs
have at least three times the relative risk of heart attack or ischemic stroke
(obstruction of a blood vessel in the brain) than OC users without hypertension. Women
with high blood pressure who currently use OCs may face 10 times the risk of hemorrhagic
stroke (bleeding in the brain from a blood vessel) than current users without
hypertension.2 These conclusions by an international panel of
experts are based upon several large studies, including the World Health Organization
(WHO) Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception
conducted in 21 locations in Africa, Asia, Europe and Latin America.
A combination of hypertension, cigarette smoking and OC use substantially increases
risk for coronary artery heart disease. Thus, a hypertensive woman who smokes should be
encouraged to quit smoking and should be offered a contraceptive method other than OCs.3 (In a related development, a recent study involving 46,000
healthy women found no evidence for any long-term serious health consequences from OCs,
including any greater risk of cardiovascular disease, years after OC use ceased.4
Little is known about the risks posed by progestin-only contraceptives when used by
hypertensive women. A recent case-control study found that, among hypertensive women,
those who used progestin-only pills (POPs) were slightly more likely (1.3 times) to have a
stroke than women who did not use pills. However, this difference was neither
statistically nor clinically significant, because the number of stroke cases involved was
small. The authors of the study recommended further investigation of a possible
relationship between progestin-only contraceptives and hypertension.5
Recommendations for contraceptive use by hypertensive women include the following:
Women with a history of hypertension or who currently have mild hypertension
(140-159/90-99 mm Hg) -- OCs and combined injectable contraceptives (Cyclofem or
Mesigyna) are usually undesirable methods of choice. Good options include progestin-only
methods (injectables such as depot-medroxyprogesterone acetate or DMPA, progestin-only
pills and Norplant), particularly if women do not smoke or suffer from diabetes,
hyperlipidemia or obesity -- a constellation of factors contributing to risk for heart
disease. All types of intrauterine devices can be used. Hypertension increases general
anesthesia risks during sterilization.
Women with moderate hypertension (160-179/100-109 mm Hg) -- OCs and combined
injectables are usually undesirable, even if blood pressure can be monitored periodically.
If a woman's moderate hypertension worsens while using OCs, she should stop using the
method. All other contraceptive methods are good choices, although barrier methods are
less effective in typical use than other methods. Hypertension increases general
anesthesia risks during sterilization.
Women with severe hypertension (180/110 mm Hg or greater) or related vascular
disease -- Women in this category should not use OCs or combined injectables.
Progestin-only injectables like DMPA require careful clinical judgment. All other
contraceptive methods, including Norplant and progestin-only pills, which can be
discontinued rapidly, are good choices. However, barrier methods are less effective in
typical use than other modern methods. Hypertension increases general anesthesia risks
during sterilization.
Pregnancy concerns
The risks of contraception in hypertensive women must be weighed against those
associated with pregnancy. Since pregnancy burdens a woman's circulatory system, a
hypertensive pregnant woman runs several serious risks.
Among possible complications is pre-eclampsia, characterized by increasing
hypertension, passing protein in urine and swelling of the legs. Preeclampsia can lead to
seizures.
The health of her fetus is also at risk. Placental and fetal circulation can be
affected, and fetal organs damaged. Hypertensive pregnancies are also associated with
increased risk of intrauterine growth retardation, premature delivery and fetal death.6
Measures to control high blood pressure in non-pregnant women include weight reduction,
exercise, and restriction of salt and alcohol. Both pregnant and non-pregnant women should
be encouraged to stop cigarette smoking, which worsens blood vessel damage due to
hypertension.
Various drugs -- methyldopa, hypdra-lazine and ß-blockers -- have successfully
controlled hypertension in pregnant women,7 although animal
data have raised concerns that angiotensin-converting enzyme (ACE) inhibitors could harm a
fetus and thus should be avoided during pregnancy.8
-- Kim Best
* Desirable blood pressure for people of reproductive age is generally
below 100 to 140 mm Hg systolic and 80 to 100 mm Hg diastolic (the lower the reading, the
better). Worldwide, an estimated 690 million people suffer from hypertension.
Diabetic Women Need
Effective Contraception
By Roberto Rivera, MD
FHI Director of International Medical Affairs
In general, pregnancy worsens diabetic complications. At the same time, diabetes may
have an adverse effect on pregnancy outcome. For diabetic women who wish to become
pregnant, controlling diabetes is essential before attempting pregnancy; meanwhile,
contraception should be used.
Access to effective contraceptive choices is often an important part of the medical
management of diabetic women of reproductive age. In addition to being counseled about
their contraception options, the potential risks of pregnancy should be explained.
The proportion of reproductive-age women with diabetes varies among populations. The
World Health Organization studied the prevalence of diabetes and impaired glucose
tolerance in women ages 20 to 39 years in 29 population groups from 19 countries. While
diabetes alone was uncommon in most groups, the prevalence of diabetes and impaired
glucose tolerance combined exceeded 10 percent for about a third of the population groups.
For example, prevalence of these conditions was greater than 10 percent among blacks and
Hispanics in the United States.9
The effects of pregnancy on diabetic women vary, depending mainly on genetic
predisposition, age, number of previous pregnancies, years of being diabetic, and the
presence of vascular complications. In general, the hormonal changes associated with
pregnancy have the potential to accelerate or worsen the vascular complications of
diabetes. For this reason, most medical specialists agree that pregnancy is not
recommended in a diabetic woman with advanced vascular complications, such as retinopathy
(noninflammatory eye disease) or nephropathy (kidney disease). Women with these conditions
should consider the use of very effective methods, permanent or reversible.
Diabetes' effect on pregnancy outcome can be serious. Infants of diabetic women are at
higher risk of congenital malformations, premature birth, stillbirth and abnormally large
body size. Also, the children of diabetic women have a higher risk of becoming diabetic
during their lives.
With few exceptions, diabetic women have the same contraceptive options as non-diabetic
women.
Hormonal methods -- Low-dose combined oral contraceptives (OCs) do not have
clinically significant effects on glucose metabolism or on the control of diabetes, and
current international guidelines indicate that they can generally be used in diabetic
women without vascular disease. No studies indicate that OC use accelerates the
progression of diabetic vascular disease.
However, in women with nephropathy, retinopathy, neuropathy (peripheral nervous system
disease) or other vascular disease, or with diabetes for more than 20 years, the use of
OCs is not recommended due to concern about possible adverse effects on a woman's
cardiovascular condition. Given the high risks associated with pregnancy in these women,
use of other effective means of contraception should be considered. Progestin-only
injectables (DMPA and NET-EN) are usually undesirable methods because of concern about the
possible negative effect on lipid metabolism, possibly affecting the progression of
nephropathy, retinopathy or other vascular diseases; however, progestin-only pills and
implants may be used safely by diabetic women, including those with vascular disease.
Intrauterine devices (IUDs) -- Copper IUDs, such as the TCu-380 A,
are considered safe for diabetic women, with or without vascular disease. As with healthy
women, IUDs are not recommended for diabetic women at risk of sexually transmitted
diseases, since IUD insertion may increase the risk of pelvic inflammatory disease (PID).10 Concerns that IUD efficacy decreases in insulin-dependent
women appear to be unfounded, according to one study. In the study of Copper IUD insertion
in 103 insulin-dependent women and in 119 non-diabetic women, rates of unintended
pregnancy for both groups were similar and low, with one pregnancy occurring in each
group.11
Sterilization -- Pregnancy can have devastating effects in diabetic women who
already have vascular disease, particularly nephropathy or retinopathy, which can progress
to kidney failure or blindness, respectively. These women and their partners should
consider tubal ligation or vasectomy as contraceptive methods. However, a woman or man
opting for this method should be fully aware of the method's permanence. Also, vasectomy
does not become effective until several weeks to months after the procedure is performed.
The sterilization procedure should be conducted when the diabetic condition is under
control. Additional medical support may be necessary when sterilizing diabetics with
vascular complications.
Barrier and natural family planning methods -- These methods should also be
among contraceptive choices for diabetic women. However, the higher rate of unintended
pregnancies associated with use of these methods may expose some diabetic women to the
unacceptable risks of a dangerous pregnancy. These methods may not be the best option for
a diabetic woman with vascular disease. Couples interested in using these methods should
understand, through careful counseling, that dependable effectiveness requires consistent
and correct use.
DMPA Good Choice for
Women with Sickle Cell
By David Grimes, MD
FHI Vice President of Biomedical Affairs
Women and men with sickle cell disease may have impaired fertility, with fertility
particularly compromised in younger men.12 However, people
with sickle cell disease often can still conceive and may need access to contraception.
A United Kingdom survey found that 64 percent of women with sickle cell disease had
experienced an unintended pregnancy.13 Although many women
with sickle cell disease have successful pregnancies, the disease places them at higher
risk of maternal and fetal mortality and morbidity, including spontaneous abortion and
intrauterine growth retardation.14
Most contraceptive methods are appropriate for women with sickle cell disease, but the
first choice for many women may be depot-medroxyprogesterone acetate (DMPA) injections.
Not only does DMPA provide highly effective, reversible contraception, but it may also
prevent painful sickling crises (in which red blood cells clog blood vessels). A study in
Jamaica comparing DMPA injections with placebo among 23 women with sickle cell disease
found significantly fewer pain crises.15
In sickle cell disease, hypoxia (reduced oxygen in the bloodstream) leads to sickling
(crinkling in the shape) of red blood cells. Clumps of these abnormally shaped red blood
cells get stuck in tiny blood vessels. If enough blood vessels become clogged in this way,
blood supply to tissue is reduced, causing a painful sickling crisis.
 |
| Illustration by Dr. Eugene Orringer, UNC Clinical Research Center,
shows sickle-shaped cells clogging a blood vessel, in the second frame, unlike normal
blood cells, shown in the first frame. |
Use of combined oral contraceptives (OCs) by women with sickle cell disease has long
been controversial. While substantial evidence shows that use of OCs increases the small
risk of thromboembolic (clotting) events in women in general, numerous studies have found
OC use by women with sickle cell disease to be safe.
No case-control or prospective cohort studies to examine the relationship between OCs
and the formation of blood clots in women with sickle cell disease have been conducted.16 In a U.S. study, however, researchers found only negligible
effects of OCs on the blood viscosity and coagulation tests of five patients. In another
26 women, followed from three months to nine years, only one had a mild increase in sickle
cell crisis frequency after starting OCs.17 In a similar
study at the same U.S. institution, researchers found no evidence that OCs aggravated the
course of sickle cell disease among 71 women who used them for 10 years.18
Other observational studies confirm that OCs are safe for women with sickle cell disease.19
Recommendations concerning OCs for women with sickle cell anemia vary widely. The World
Health Organization (WHO) considers the health benefits of OC use in women with sickle
cell disease to outweigh the potential risks. However, in much of Europe, the disease is a
contraindication to use.
All other methods of contraception are medically appropriate for women or men with
sickle cell disease.
Other hormonal methods -- Little is known about the use of progestin-only pills
or combined injectable contraceptives among women with sickle cell disease. Regarding
Norplant, one study of 25 women in Nigeria showed no significant effects from the
subdermal levonorgestrel implants on the blood of women with sickle cell disease.20 The fact that Norplant provides lower blood levels of
progestin than does DMPA may explain why the DMPA-associated benefits for women with
sickle cell disease are not seen with the use of Norplant.
Intrauterine devices (IUDs) -- Increased blood loss associated with Copper T
IUDs is of some concern for women with anemia. Nevertheless, WHO considers that the health
benefits of Copper IUDs for women with sickle cell disease outweigh possible health risks.
WHO places no restrictions on use of progestin-releasing IUDs, which decrease menstrual
blood loss.
Sterilization -- Both men and women with sickle cell disease have increased
surgical risks, such as pulmonary, cardiac, or neurological complications. However,
because female sterilization may require general anesthesia, vasectomy is usually a better
option, even for men with sickle cell disease, because of the use of local anesthesia.
Barrier methods -- Barrier methods, including condoms and diaphragms, are
acceptable contraceptive options, but more effective methods may be preferable in order to
reduce the possibility of an unintended and high-risk pregnancy. A study in Ghana
concluded that simply switching from barrier methods to more reliable choices, such as
OCs, DMPA or sterilization, would "substantially reduce the toll of pregnancy-related
illness and death among women with sickle cell disease" in sub-Saharan Africa. The
study by Korle-Bu Hospital in Accra and FHI compared the number of unintended pregnancies
by method choice among women with sickle cell disease, which is more common in sub-Saharan
Africa than other parts of the world.21
Hormonal Methods May
Affect Headaches
By David Grimes, MD
FHI Vice President of Biomedical Affairs
Headaches are among the most common medical conditions experienced by women of
reproductive age. Several issues should be considered when exploring contraceptive options
with such women.
Of particular concern is the use of combined oral contraceptives (OCs) by women who
suffer from severe, recurrent headaches with focal neurological symptoms (including some
migraine headaches), in contrast to tension headaches. Tension headaches -- the most
common form of headache -- are often associated with stress and are usually dull and
constant. Women with tension headaches can use OCs and other hormonal contraceptive
methods without concern.
 As many
as 15 percent of women report having had a migraine headache,22
of which there are two types. The first occurs with aura, symptoms that include visual
disturbances, such as spots of flashing lights, zigzag lines, or decreased vision in some
fields. Dizziness or weakness on one side of the body can occur as well, usually followed
by a one-sided and throbbing headache. The second type of migraine headache -- without
aura -- is not associated with neurological symptoms and tends to affect both sides of the
head. Both types of migraine tend to be pulsating and associated with nausea, vomiting, or
loss of appetite.
Concern exists that women with migraine headaches might be at increased risk of stroke
while taking OCs, but no solid data support this idea. No evidence of a relationship
between migraine and stroke in high-dose pill users was found in a case-control study of
568 young women from the United Kingdom hospitalized for stroke.23
The International Headache Society, an organization of neurologists, concurs with this
assessment that women suffering from migraine headaches who use pills are not at increased
risk of stroke.24
A recent case-control study found a significant link between migraine and stroke due to
cerebral thromboembolism, with women migraine sufferers having three times the risk of
this type of stroke compared with women without a migraine history. However, OC use did
not exaggerate that risk.25
There is no contraindication to the use of OCs in women suffering migraines without
aura. The World Health Organization (WHO) recommends that women who suffer migraines with
aura not use OCs, although there is no conclusive evidence to support this guideline.
Whether OCs worsen migraine headache itself is debatable. Some data suggest that OC use
increases the severity and frequency of migraines; however, as many as a third of women
suffering from migraines report improvement of their condition with OC use.26
About 60 percent of women with migraine experience their headaches just before or during
menses, and some women with menstrual migraines may find relief by delaying menses with
OCs. Extending active pills from three weeks to a regimen of six to 12 weeks without
interruption has been observed to benefit women with menstrual-related problems, including
menstrual migraine.27
Women who develop headaches while taking OCs or whose headaches worsen or become more
frequent should stop OC use for a while to see whether the headaches improve. A woman who
develops a severe, persistent or different type of headache should be promptly evaluated
for possible neurological problems.
Issues to consider in recommending the use of other contraceptive methods in women with
migraine headaches include the following:
Combined injectable contraceptives -- WHO guidelines for such combined
injectable contraceptives as Cyclofem or Mesigyna do not differ from those for combined
OCs. There is no contraindication for their use in women suffering from migraines without
aura, but they are not recommended for women who suffer from migraines with aura.
Long-acting, progestin-only methods -- The use of depot-medroxyprogesterone
acetate (DMPA), norethindrone enanthate (NET-EN), or subdermal levonorgestrel implants
(Norplant) may increase the frequency of severe headaches.28
This is an important consideration since these methods are not easily discontinued if
problems arise.
Intrauterine devices (IUDs) -- Use of the Copper T IUD is not restricted.
There is some concern that levonor-gestrel-releasing IUDs (LNg-IUDs) may cause headaches
to increase, although there are no restrictions on the use of the device for this reason.
Sterilization -- Headaches are not known to increase the surgical risks
associated with tubal sterilization or vasectomy.
Epilepsy Drugs May Reduce
Method Effectiveness
Pregnancy in epileptic women can be dangerous. Complications of seizures due to
untreated epilepsy during pregnancy include maternal or fetal injury and neonatal
distress. Use of anticonvulsant drugs used to treat epilepsy -- such as valproic acid or
phenytoin -- has been associated with increased rates of birth defects among infants of
epileptic mothers.
Because of these risks, effective contraception is especially important. Copper
intrauterine devices (IUDs) are good contraceptive choices for epileptic women, as is
voluntary sterilization. Barrier methods may be good choices for epileptic women who can
use them consistently and correctly.
However, most hormonal methods for epileptic women raise several concerns.
Combined oral contraceptives (OCs) -- OCs do not appear to affect seizure
frequency or severity.29 However, some antiepileptic drugs --
such as phenobarbital, phenytoin, carbamazepine and paramethadione -- may cause more rapid
metabolism of progestin or estrogen in combined OCs.30 This
may reduce contraceptive effectiveness, resulting in pregnancy and exposure of the fetus
to the potential defect-causing properties of the antiseizure drugs.
Thus, the use of OCs with less than 35 mg of ethinyl estradiol is less desirable.
Switching to a higher dose pill should be considered if spotting persists for more than
three months. Since estrogen can change the metabolism of anticonvulsants, blood levels of
these drugs should also be monitored after starting OCs.31
Progestin-only methods -- Anticonvulsant drugs have been shown to speed the
metabolism of levonorgestrel, reducing contraceptive efficacy.32
Thus, Norplant is not a good choice for epileptic women using such drugs. However, the
high level of progestin in the injectable depot-medroxyprogesterone acetate or DMPA not
only makes this method effective in women taking anticonvulsant drugs but has been shown
to reduce seizure frequency.33 The levonorgestral-releasing
IUD is another excellent contraceptive choice for women with epilepsy.
-- Kim Best
References
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- Lidegaard O. Oral contraceptives, pregnancy and the risk of cerebral
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