Version July 2025
INTRODUCTION —
Hormonal contraceptives, including oral and nonoral estrogen-containing contraceptives and combined estrogen-progestin contraceptives, can increase blood pressure. These effects depend, in part, upon the drug, dose, and route of delivery. Because of the cumulative nature of cardiovascular risk, the impact of contraception on blood pressure is important when considering contraceptive options for individuals with elevated blood pressure, hypertension, and/or other risk factors for cardiovascular disease (CVD).
This topic will review the impact of estrogen and progestin hormones on blood pressure and our approach to the selection of hormonal contraception for individuals with, or at risk for, hypertension and/or CVD. An overview of cardiovascular risk factors is presented separately. (See "Overview of established risk factors for cardiovascular disease" and "Overview of atherosclerotic cardiovascular risk factors in females".)
Of note, this content does not apply to menopausal hormone therapy. Overview discussions of contraception selection and menopausal hormone therapy are presented separately:
●(See "Contraception: Counseling and selection".)
●(See "Menopausal hormone therapy: Benefits and risks", section on 'Cardiovascular effects'.)
●(See "Menopausal hormone therapy and cardiovascular risk".)
Nonhormonal contraceptives do not impact blood pressure or other CVD risk factors. These options are discussed in separate, dedicated topic reviews:
●(See "Intrauterine contraception: Background and device types", section on 'Copper IUDs'.)
●(See "External (formerly male) condoms".)
●(See "Internal (formerly female) condoms".)
●(See "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge".)
Information on contraceptive counseling and selection for patients without hypertension or cardiovascular risk factors is discussed separately. (See "Contraception: Counseling and selection".)
In this topic, when discussing study results, we will use the term "women" as it is used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-diverse patients as they relate to the information presented in the topic.
BLOOD PRESSURE THRESHOLDS FOR CONTRACEPTIVE SELECTION —
For women considering estrogen- or progestin-containing contraceptives, we use a blood pressure threshold of ≥140 mmHg systolic or ≥90 mmHg diastolic for cardiovascular risk stratification. While the American College of Cardiology/American Heart Association definitions of hypertension use a cutoff of 130/80 mmHg when standardized blood pressure measurement strategies are used (eg, standardized office measurement, self-measured blood pressure, or ambulatory blood pressure measurement (table 1)), studies assessing the impact of hormone-containing contraceptives on patients with systolic pressure 130 to 139 mmHg or diastolic pressure 80 to 89 mmHg are lacking. Until data specific to this group are available, we use a cutoff of 140/90 mmHg to leverage the data from existing studies and ensure that women with blood pressures between 130 to 139 mmHg systolic and/or 80 to 89 mmHg diastolic are not denied hormonal contraceptive options. This advice is consistent with other scientific organizations [1-3]; however, we recognize that, on a population basis, the risk of incident hypertension due to estrogen-containing contraception is probably higher if one uses the lower threshold of 130/80 mmHg.
Discussions of blood pressure measurement and definitions of hypertension are presented separately. (See "Hypertension in adults: Blood pressure measurement and diagnosis".)
IMPACT OF HORMONES ON BLOOD PRESSURE
●Oral estrogens – Oral estrogens have the potential to increase blood pressure, though the effect is small (figure 1). In older studies using high doses of ethinyl estradiol (eg, ≥50 mcg), new-onset hypertension was reported in approximately 5 percent of users [4-7]. Contemporary estrogen-containing oral contraceptives use lower doses of ethinyl estradiol (≤35 mcg) or contain forms of estrogen (eg, 17-beta estradiol, estetrol, estradiol valerate) that appear to have less impact on estrogen-sensitive hepatic globulins and coagulation factors [8]. In one observational study of 68,000 patients, oral contraceptive use (multiple formulations, almost all ≤35 mcg of ethinyl estradiol or the equivalent) was associated with small mean increases in systolic and diastolic blood pressure that were not clinically significant for most patients (0.7 mmHg, 95% CI 0.4-1.0, and 0.4 mmHg, 95% CI 0.2-0.6, respectively) [9]. If additional risk factors for hypertension are present (eg, family history, age, obesity, and previous hypertensive disorders of pregnancy), these increase the patient's risk of developing hypertension when using oral estrogens [10]. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Candidates'.)
Formulations and dosing are presented in the table (table 2) and through the DailyMed database.
●Nonoral estrogens – When compared with oral estrogens, nonoral estrogen-containing contraceptives have an even smaller impact on blood pressure, although available data are limited [11]. These include vaginal rings, transdermal contraceptive patches, and combined estrogen-progesterone injections (available outside of the United States and Canada).
●Progestin-only contraceptives – Progestin-only contraceptives, including progestin-only pills, etonogestrel implants, levonorgestrel-releasing intrauterine devices, and depot medroxyprogesterone acetate injections, are not associated with elevations in blood pressure. Though drospirenone acetate appears to lower blood pressure, it has also been associated with an increased venous thromboembolism (VTE) risk [10,12,13]. (See "Contraception: Progestin-only pills (POPs)", section on 'Risks'.)
●Combined estrogen-progestin contraceptives – Combined estrogen-progestin hormonal contraception (CHC) may increase blood pressure due to the estrogen component, as above. Progestin has also been hypothesized to enhance the effects of estrogen on blood pressure through off-target effects on the androgen and estrogen receptors [14,15]. CHC use is also associated with an increased risk of myocardial infarction, stroke, and dyslipidemia, though the absolute risk remains low for most individuals, especially among those taking CHCs with very low estrogen. CHCs also carry an increased risk of VTE. The cardiovascular effects of combined estrogen-progestin contraceptives are discussed in further detail separately. (See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Cardiovascular effects'.)
PATIENT COUNSELING
Recognize the need for counseling — Contraceptive counseling should consider the patient's contraceptive goals, the potential impact of the contraceptive and/or pregnancy on the patient's medical conditions, and contraceptive efficacy. Patients may initiate the conversation to discuss contraception for pregnancy prevention or for noncontraceptive benefits (eg, reduction of dysmenorrhea or treatment of endometriosis). Providers may initiate a shared decision-making discussion to educate a patient with uncontrolled hypertension regarding the risk of unintended pregnancy and associated adverse obstetric outcomes.
Despite the increased risks of adverse obstetric outcomes in patients with hypertension, patients are often not asked about pregnancy plans or counseled on contraceptive options. In one database study of over 8000 individuals at risk for unintended pregnancy, nearly 75 percent of hypertensive individuals and 80 percent of individuals without hypertension did not receive contraceptive counseling (weighted proportion 0.26, 95% CI 0.21-0.32 for hypertensive individuals; weighted proportion 0.21, 95% CI 0.19-0.22 for nonhypertensive individuals) [16]. For patients with hypertension, Black individuals were 13 percentage points less likely to receive counseling compared with White counterparts, after adjusting for confounders (difference in difference -0.13, 95% CI -0.23 to -0.03). The care of pregnant patients with pre-existing hypertension is discussed in further detail separately. (See "Chronic hypertension in pregnancy: Prenatal and postpartum care".)
Assess other medical conditions and comorbidities — Contraceptive counseling requires a comprehensive understanding of the patient's medical conditions and comorbidities that may affect the safety of specific contraceptives [17]. We review the following when determining hormonal contraceptive options [2,3]:
●Patient age
●Current blood pressure
●Cardiovascular disease (CVD) history
•Ischemic heart disease
•Stroke
•Peripheral artery disease
•Aortic atherosclerosis
●Other CVD risk factors
•Hyperlipidemia.
•Diabetes.
•Chronic kidney disease.
•Obesity (body mass index [BMI] >30 kg/m2).
•Use of tobacco products, including traditional cigarette or cigar smoking, e-cigarettes (ie, vaping), water pipes (ie, hookahs), and smokeless tobacco.
•History of gestational hypertension.
•Family history of premature CVD.
•Ten-year atherosclerotic CVD (ASCVD) risk using a validated risk assessment calculator (calculator 1). The approach to ASCVD risk assessment is discussed separately. (See "Atherosclerotic cardiovascular disease risk assessment for primary prevention in adults".)
●History of venous thromboembolism (VTE) – Patients with a history of VTE require more detailed risk-based assessment and counseling to inform the choice of contraception. (See "Contraception: Counseling regarding inherited thrombophilias", section on 'Individualized risk-based counseling'.)
CONTRACEPTIVE OPTIONS BASED ON CVD RISK, BLOOD PRESSURE, AND AGE —
Our approach varies by the patient's risk factors for cardiovascular disease (CVD), blood pressure, and age and is generally consistent with the World Health Organization (WHO) 2015 medical eligibility criteria for contraceptive use and the Centers for Disease Control and Prevention's (CDC) summary chart of United States medical eligibility criteria [2,3].
Patients with known CVD or high CVD risk — For patients with a history of CVD, including ischemic heart disease, stroke, peripheral artery disease, or aortic atherosclerosis, we avoid estrogen-containing contraceptives because of the small increased risk of cardiovascular events associated with these methods [2]. (See 'Impact of hormones on blood pressure' above.)
Instead, we offer nonhormonal contraceptives, progestin-only pills, levonorgestrel-releasing intrauterine devices (IUDs), or etonogestrel implants. We avoid depot medroxyprogesterone acetate (DMPA) injections in patients with known CVD due to its association with thromboembolic events and unfavorable changes in lipid metabolism.
We also apply the same advice for patients with high CVD risk (≥20 percent 10-year atherosclerotic CVD [ASCVD] risk using a validated risk calculator (calculator 1)). Further details on the risk of cardiovascular events with oral estrogen-containing contraception and DMPA are reviewed separately:
Hypertension with blood pressure ≥140 mmHg systolic and/or ≥90 mmHg diastolic — For patients of any age with blood pressure ≥140/90 mmHg, further evaluation and management of hypertension are warranted. (See "Hypertension in adults: Blood pressure measurement and diagnosis", section on 'Additional evaluation and follow-up'.)
We take the following approach to contraceptive counseling in these patients:
●Preferred – Patients with blood pressure ≥140/90 mmHg may use nonhormonal contraceptives, progestin-only pills, levonorgestrel-releasing IUDs, and etonogestrel implants [2,3,18].
●Less preferred – Though DMPA injection is generally avoided due to its association with thromboembolic events and unfavorable changes in lipid metabolism, it may be used in select patients after appropriate counseling regarding potentially increased thromboembolic risk. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Cardiovascular and thromboembolic risk'.)
●Methods to avoid – We avoid estrogen-containing contraceptives (eg, oral pills, transdermal patches, vaginal rings) as the additive CVD risks associated with exogenous estrogen are unacceptable in this patient population [3,18,19].
Although we avoid estrogen-containing contraceptives for most patients with uncontrolled hypertension, we do use them in rare circumstances, such as for a patient with blood pressure in the lower range of elevated blood pressure for whom the noncontraceptive benefits (eg, treatment of heavy menstrual bleeding, reduction of pelvic pain associated with endometriosis) outweigh the potential risks of the medication. In such patients, we prescribe estrogen-containing contraceptives using a shared decision-making approach after a discussion of the associated risks. If selected, we advise using pills containing ≤35 mcg of ethinyl estradiol (or equivalent) and prefer estrogens like estradiol valerate or estetrol (combined, if possible, with the progestins dienogest or drospirenone) (figure 1 and table 2).
Treated hypertension and/or intermediate or low CVD risk — For patients considering estrogen- or progestin-containing contraceptives, we define hypertension as ≥140 mmHg systolic or ≥90 mmHg diastolic, as above (see 'Blood pressure thresholds for contraceptive selection' above). In such individuals, if blood pressure is maintained below 140/90 mmHg through antihypertensive medication, diet, and lifestyle modifications, we offer contraceptive options based on whether the patient is older than 40 years of age as increasing age is an additional risk factor for elevated blood pressure and cardiovascular events. Our advice is consistent with the WHO and the CDC, though, in contrast, the American College of Obstetricians and Gynecologists guidelines suggest using the age of 35 [2,3,18].
For patients without hypertension who have intermediate or low cardiovascular disease (CVD) risk (eg, <20 percent 10-year ASCVD risk using a validated risk calculator (calculator 1)), we offer contraception using an age-based framework.
Age <40 years — Individuals who are <40 years of age may be offered any contraceptive method (figure 2). We provide counseling about potential risks and confirm they are otherwise healthy without additional risk factors for CVD (table 3) and have adequately controlled hypertension (eg, blood pressure <140/90 mmHg) [18].
We take the following approach to contraceptive counseling [2,3]:
●Preferred – We offer any nonhormonal contraceptive, progestin-only pills, levonorgestrel-releasing IUDs, etonogestrel implants, and DMPA [2,3,18]. While there are concerns that DMPA may increase venous thromboembolism risk, its use in patients <40 years is viewed as having benefits that generally outweigh the risk [2].
●Selective use – Estrogen-containing contraceptives, including oral pills, transdermal patches, and vaginal rings, can be used in select patients aged <40 years with controlled blood pressure using a shared decision-making approach. If the patient has additional cardiovascular risk factors (table 3) or a history of previous hypertension of pregnancy, we avoid estrogen-containing contraceptives, given the additive CVD risks associated with exogenous estrogen.
If selected, we use contraceptive pills that contain either 35 mcg or less of ethynyl estradiol or contain estradiol valerate or estetrol, ideally combined with a fourth-generation progestin like dienogest or drospirenone (figure 1 and table 2).
Age ≥40 years — For patients ≥40 years of age with adequately controlled blood pressure (ie, <140/90 mmHg) who are otherwise healthy and without CVD or other CVD risk factors (table 3), we suggest nonhormonal or progestin-only contraceptives.
We take the following approach to contraceptive counseling [3,18,19]:
●Preferred – These patients may use any nonhormonal contraceptive, progestin-only pills, levonorgestrel-releasing IUDs, or etonogestrel implants [2,3,18].
●Less preferred – While DMPA does not impact blood pressure, it may increase the risk of thromboembolic events and cause unfavorable changes in lipid metabolism. Therefore, DMPA is less preferred in this population, given the availability of alternate options. However, as outcome data for individuals ≥40 years and controlled hypertension are lacking, DMPA can be reasonably used in appropriately counseled patients. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Cardiovascular and thromboembolic risk'.)
●Selective use – Although there are limited data in this population, we generally do not prescribe estrogen-containing contraceptives for patients ≥40 years with hypertension because the increased CVD risks do not outweigh the potential benefit, especially given the availability of highly effective non-estrogen contraceptives [3,19].
In appropriately counseled patients, however, estrogen-containing contraceptives may be used if significant noncontraceptive benefits are gained with the use of estrogen-containing contraception (eg, treatment of heavy menstrual bleeding, reduction of pelvic pain associated with endometriosis). If selected, we advise using pills containing ≤35 mcg of ethinyl estradiol (or equivalent) and prefer estrogens like estradiol valerate or estetrol (combined, if possible, with the progestins dienogest or drospirenone) (figure 1 and table 2).
BLOOD PRESSURE MONITORING —
We monitor blood pressure based on the type of contraceptive selected. Patients with uncontrolled hypertension also warrant additional monitoring and follow-up for blood pressure management. (See "Hypertension in adults: Blood pressure measurement and diagnosis", section on 'Additional evaluation and follow-up'.)
Follow-up
●Non-estrogen contraceptives – For patients using non-estrogen contraceptives, including progestin-only methods, we check blood pressure at routine visits. Specific visits for blood pressure measurements are not indicated. Additional follow-up for established hypertension or other cardiovascular risk factors may be indicated, as discussed separately. (See "Hypertension in adults: Blood pressure measurement and diagnosis", section on 'Screening for hypertension'.)
●Estrogen-containing contraceptives
•Average risk of hypertension – Patients with normal blood pressure and average risk for developing hypertension should check their blood pressure four to eight weeks after initiation. This can be done through out-of-office (eg, self-measured) or in-office measurements. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Follow-up'.)
•Known hypertension or history of gestational hypertension – For patients with known hypertension or with a history of gestational hypertension, we check blood pressure in the office approximately two to four weeks after initiating estrogen-containing contraception. If blood pressure is <140/90 mmHg, subsequent blood pressure monitoring may be performed through out-of-office (eg, self-measured) or in-office measurement. (See "Hypertension in adults: Blood pressure measurement and diagnosis", section on 'Screening for hypertension'.)
Approach to elevated blood pressure — If blood pressure increases above 140/90 mmHg while on estrogen-containing contraception, we take the following steps:
●Discontinue the estrogen-containing contraception and offer either nonhormonal contraceptive methods (eg, copper intrauterine device [IUD], condoms, pericoital contraception) or progestin-only contraceptive options (eg, progestin-only pills, levonorgestrel-releasing IUDs, or etonogestrel implant) using a shared decision-making approach. (See 'Hypertension with blood pressure ≥140 mmHg systolic and/or ≥90 mmHg diastolic' above.)
●Monitor blood pressure every four to eight weeks to ensure a return to pretreatment values (this typically occurs within three months) [4].
●If elevated blood pressure persists, we discontinue all hormonal agents, including progestin-only contraceptives, and offer nonhormonal contraception. The patient should also be evaluated for a diagnosis of hypertension, either through a primary care or specialty referral. (See "Hypertension in adults: Blood pressure measurement and diagnosis".)
CONTRACEPTION AND VTE RISK —
The risk of venous thromboembolism (VTE) with various forms of contraception is presented in separate topic reviews:
●(See "Contraception: Etonogestrel implant" and "Contraception: Etonogestrel implant", section on 'Risk of thromboembolic event'.)
●(See "Contraception: Transdermal contraceptive patches", section on 'Risk of venous thrombotic events'.)
Contraception decision-making for patients with inherited thrombophilia or prior thrombotic event is also presented separately:
●(See "Contraception: Counseling regarding inherited thrombophilias".)
RESOURCES FOR CLINICIANS —
Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention maintain evidence-based recommendations for the use of contraceptive methods in the context of a range of medical conditions and personal characteristics. The WHO medical eligibility criteria for contraceptive use and the United States medical eligibility criteria for contraceptive use are freely available, are easy to use, and provide contraceptive prescribers with definitive guidance on safety across a broad range of conditions for different patient populations [2,3].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception" and "Society guideline links: Hypertension in adults".)
SUMMARY AND RECOMMENDATIONS
●Blood pressure thresholds for contraceptive selection – When selecting contraception, we use a blood pressure threshold of ≥140 mmHg systolic or ≥90 mmHg diastolic (table 4). While some organizations use a hypertension threshold of ≥130 mmHg systolic or ≥80 mmHg diastolic, data are lacking regarding hormonal contraception and blood pressure in those with systolic pressure 130 to 139 mmHg or diastolic pressure 80 to 89 mmHg. (See 'Blood pressure thresholds for contraceptive selection' above.)
●Impact of hormones on blood pressure – Contemporary estrogen-containing oral contraceptives generally use lower doses of ethinyl estradiol (≤35 mcg) or contain estrogens related to endogenous estrogens (table 2). These agents can lead to increases in blood pressure that are modest in most patients (figure 1) but may be clinically significant in those with hypertension or cardiovascular risk factors (table 3). Nonoral estrogen contraceptives, including vaginal rings, transdermal contraceptive patches, and estrogen-progesterone injections, have an even smaller impact on blood pressure, although available data are limited.
Progestin-only contraceptives, including progestin-only pills, levonorgestrel-releasing intrauterine devices (IUDs), etonogestrel implants, and the depot medroxyprogesterone acetate (DMPA) injection, are generally not associated with elevations in blood pressure, although DMPA may increase risk of venous thromboembolism and alter lipid metabolism. (See 'Impact of hormones on blood pressure' above.)
●Patient counseling – Contraceptive counseling should consider the patient's contraceptive goals; the potential impact of the contraceptive on the patient's medical conditions; medical risk of high-risk, unintended pregnancy; and potential noncontraceptive benefits (eg, treatment of heavy menstrual bleeding or endometriosis). (See 'Patient counseling' above.)
●Approach to contraceptive selection – Our approach varies by the patient's risk factors for cardiovascular disease (CVD), blood pressure, and age:
•Estrogen-containing contraceptives are associated with an increased risk of cardiovascular events, stroke, and elevated blood pressure. Therefore, these medications are contraindicated in patients at the highest risk of CVD, including:
-Patients with known CVD
-Patients with high CVD risk (≥20 percent 10-year atherosclerotic CVD risk using a validated risk calculator (calculator 1))
-Patients with blood pressure ≥140 mmHg systolic and/or ≥90 mmHg diastolic
Instead, we offer nonhormonal contraceptives (eg, the copper 380 mm2 IUD), progestin-only pills, levonorgestrel-releasing IUDs, or etonogestrel implants. We avoid DMPA injections in patients with known CVD due to its association with thromboembolic events and unfavorable changes in lipid metabolism, though it may be used in select patients with isolated elevated blood pressure after appropriate counseling. (See 'Patients with known CVD or high CVD risk' above and 'Hypertension with blood pressure ≥140 mmHg systolic and/or ≥90 mmHg diastolic' above.)
•For patients with intermediate or low CVD risk and/or hypertension with blood pressure <140/90 mmHg, we offer contraceptives using an age-based framework:
-Age ≥40 years – We suggest against the use of estrogen-containing contraceptives in patients with intermediate or low CVD risk and/or hypertension with blood pressure <140/90 mmHg and with age ≥40 (Grade 2C). The increased CVD risks of estrogen-containing contraceptives do not outweigh the potential benefit, given the availability of highly effective non-estrogen alternatives, including nonhormonal contraceptives (eg, the copper 380 mm2 IUD), progestin-only pills, levonorgestrel-releasing IUDs, or etonogestrel implants.
-Age <40 years – We counsel these patients about the potential risks of estrogen-containing contraceptives but do consider them a treatment option along with non-estrogen alternatives, including nonhormonal contraceptives (eg, the copper 380 mm2 IUD), progestin-only pills, levonorgestrel-releasing IUDs, or etonogestrel implants. For these patients, DMPA is another contraceptive option as its benefit generally outweighs the risk of thromboembolic events or changes in lipid metabolism in this age group. (See 'Treated hypertension and/or intermediate or low CVD risk' above.)
●Blood pressure monitoring – Repeat blood pressure checks are performed based on the type of contraceptive selected. (See 'Follow-up' above.)
If blood pressure increases above 140/90 mmHg after an estrogen-containing contraceptive is initiated, we discontinue the estrogen-containing contraception and offer either nonhormonal contraceptive methods (eg, the copper 380 mm2 IUD, condoms, pericoital contraception) or progestin-only contraceptive options (eg, progestin-only pills, levonorgestrel-releasing IUDs, or etonogestrel implant). Further monitoring and treatment are indicated if blood pressure remains elevated. (See 'Approach to elevated blood pressure' above.)
ACKNOWLEDGMENT —
We are saddened by the death of George Bakris, MD, who passed away in June 2024. UpToDate acknowledges Dr. Bakris's past work as a section editor for this topic.
