Contraception: Hormonal contraception and blood pressure

INTRODUCTION — Hormonal contraceptives contain estrogens and/or progestins that can impact the cardiovascular system, including effects on blood pressure. These effects depend, in part, upon the drug, dose, and route of delivery, and they are particularly important when considering treatment options for individuals with underlying hypertensive disorders.

This topic will review our approach to the management of hormonal contraception for individuals with hypertension, as well as the management of individuals who develop an elevation in blood pressure after initiating hormonal contraception. Of note, this content does not apply to estrogen-containing hormone therapy for menopause. Overview discussions of contraception selection and menopausal hormone therapy can be found elsewhere. (See "Contraception: Counseling and selection" and "Menopausal hormone therapy: Benefits and risks" and "Menopausal hormone therapy and cardiovascular risk".)

In this topic, when discussing study results, we will use the term "women" as it is used in the studies presented. We recognize that not all genetic females or people who use contraception identify as women, and we encourage the reader to consider the specific counseling and treatment needs of transgender and gender nonbinary individuals.

DEFINITION AND DIAGNOSIS OF HYPERTENSION — Proper blood pressure measurement technique and interpretation is essential in the diagnosis and management of hypertension.

Definition of hypertension — There is not universal agreement as to the definition of hypertension. For this document, we use systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg. Our rationale is that data specific to females with systolic pressure 130 to 139 mmHg or diastolic pressure 80 to 89 mmHg, and the impact of contraception on blood pressure in this group, are lacking. While using a cutoff of 130/80 as the definition may be important for other cardiovascular outcomes, for the purposes of contraceptive selection, we and other organizations believe that individuals with Stage I hypertension, as described below, should not be denied contraceptive options based solely on blood pressure measurements until data specific to this group are available [1-3]. The definition of hypertension is presented in detail separately. (See "Overview of hypertension in adults", section on 'Definitions'.)

●Blood pressure ≥130/80 – The following definitions and staging system for hypertension were suggested in 2017 by the American College of Cardiology/American Heart Association (ACC/AHA) (table 1) [4]:

•Normal blood pressure – Systolic <120 mmHg and diastolic <80 mmHg

•Elevated blood pressure – Systolic 120 to 129 mmHg and diastolic <80 mmHg

•Hypertension:

-Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg

-Stage 2 – Systolic at least 140 mmHg or diastolic at least 90 mmHg

If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the stage. In clinical practice, patients who are taking medications for hypertension are usually defined as having hypertension, specifically "treated hypertension," regardless of their observed blood pressure.

●Blood pressure ≥140/90 – European guidance and guidelines from the American Academy of Family Physicians, the American College of Physicians, and the American College of Obstetricians and Gynecologists differ from that of the ACC/AHA (table 2) [4-8]. The European Society of Cardiology and European Society of Hypertension define hypertension, using office-based blood pressure, as a systolic pressure ≥140 mmHg or diastolic pressure ≥90 mmHg [6,8,9].

Diagnosing hypertension — Making the diagnosis of hypertension requires the integration of multiple blood pressure readings, the use of appropriate blood pressure measurement technique (table 3 and table 4), and also the use of blood pressure measurements made outside of the usual office setting (out-of-office blood pressure measurement) (algorithm 1). This is discussed in detail elsewhere. (See "Overview of hypertension in adults", section on 'Making the diagnosis of hypertension'.)

EFFECT OF EXOGENOUS ESTROGENS AND PROGESTINS ON BLOOD PRESSURE

Estrogens

Impact on blood pressure — Some individuals who take products with pharmacologic levels of estrogen (ie, contraceptives) may experience increases in blood pressure. The blood pressure effect is dose dependent. Products with physiologic levels of estrogen, such as hormone therapy for menopause, do not increase blood pressure. (See 'Menopausal hormone therapy' below.)

Based on data from users of combined estrogen-progestin oral contraceptive (COC) pills, any rise in blood pressure while taking COCs is usually mild, although some individuals may have more significant increases in blood pressure, and hypertensive emergencies may rarely occur [10,11]. Long-term use of COCs containing ethinyl estradiol and progestin at contemporary doses will slightly increase systemic blood pressure in most individuals, although the absolute increase is small and the development of overt hypertension is infrequent [10,12,13]. Most combined hormonal contraceptives contain ethinyl estradiol, but estradiol valerate, estradiol as a hemihydrate, and estetrol are also used (table 5); available data mostly reflect contraceptives containing ethinyl estradiol.

A 1996 prospective cohort study including 68,000 healthy nurses aged 25 to 42 years taking multiple types of COCs reported [10]:

●Among all users, the mean increases in systolic and diastolic blood pressure were small in adjusted analysis (0.7 mmHg, 95% CI 0.4-1.0; and 0.4 mmHg, 95% CI 0.2-0.6, respectively).

●In users of COCs containing ≤30 mcg ethinyl estradiol equivalents, the risk of developing hypertension remained greater for current users compared with never-users in adjusted analysis (relative risk 1.9, 95% CI 1.5-2.5).

●The risk of hypertension with COC use increased in a dose-dependent fashion across low (≤30 mcg ethinyl estradiol equivalents), medium (>30 to ≤50 mcg ethinyl estradiol equivalents), and high (>50 mcg ethinyl estradiol equivalents) dose pills.

By contrast, earlier COCs that contained at least 50 mcg of estrogen were reported to induce hypertension in approximately 5 percent of users [14-17]. Cessation of COCs typically leads to a return to an individual's baseline blood pressure within three months [14]. COCs that contain drospirenone, a progestin with antimineralocorticoid diuretic effects, appear to reduce the blood pressure elevating effect of estrogen (table 5) [18-20]. Detailed discussion of estrogen types and doses used in COCs is presented separately. (See "Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use", section on 'Estrogen'.)

The mechanisms responsible for the hypertensive effect of COCs are incompletely understood [21]. The renin-angiotensin system (RAS) may be involved since estrogen stimulates the hepatic production of renin substrate (angiotensinogen) [22], but the interaction among estrogen and progesterone and the RAS are complex. Activation of the sympathetic nervous system may also be involved. However, in a study comparing individuals taking combined hormonal contraception with non-users, no changes in muscle sympathetic nerve activity or systemic hemodynamics were reported [23].

Non-oral estrogen-containing contraceptives — Non-oral estrogen-progestin hormonal contraceptives include vaginal rings, transdermal contraceptive patches, and combined estrogen-progesterone injections (available outside of the United States and Canada). The effect of these agents on blood pressure may be more modest than with COCs, although available data are limited [24,25]. The impact of these methods on other cardiovascular risk factors appears to be similar to COCs. However, some data suggest an increased risk of venous thromboembolism (VTE) for users of combined estrogen-progestin contraceptive patches compared with users of lower-dose COCs (≤35 mcg ethinyl estradiol equivalents). This is reviewed in detail elsewhere:

●(See "Contraception: Hormonal contraceptive vaginal rings", section on 'Cardiovascular and thromboembolic events'.)

●(See "Contraception: Transdermal contraceptive patches", section on 'Risk of venous thrombotic events'.)

Impact on other cardiovascular risk factors — Combined estrogen-progestin contraceptives can increase the risk of thromboembolic events (both venous and arterial), myocardial infarction, and stroke, although the absolute risk remains low for most individuals. The risk of VTE events rises with increasing estrogen doses (table 6). These changes are reviewed in detail in related content:

●(See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Venous thromboembolism'.)

●(See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Myocardial infarction and stroke'.)

●(See "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Lipid changes and metabolic effects'.)

Progestins — Progestin-only contraceptives, from highest to lowest efficacy, include implants, levonorgestrel-releasing intrauterine devices (IUDs), depot medroxyprogesterone acetate (DMPA) injection, and progestin-only pills (POPs) (figure 1). While progestin-only contraceptives are generally not associated with elevations in blood pressure, some may impact other cardiovascular risks. These data are reviewed separately by formulation:

●(See "Contraception: Etonogestrel implant", section on 'Risk of thromboembolic event'.)

●(See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Cardiovascular and thromboembolic risk'.)

●(See "Contraception: Progestin-only pills (POPs)", section on 'Risks'.)

Nonhormonal contraceptives — Nonhormonal contraceptives do not impact blood pressure or other cardiovascular disease (CVD) risks. These options include the copper IUD, condoms (internal and external), and pericoital methods (ie, diaphragm, cervical cap, contraceptive sponge, and spermicide). Permanent contraception (eg, female or male sterilization procedures) may be an option for individuals who have completed childbearing and do not have other risk factors for poor surgical outcome. Efficacy varies by method (figure 1):

●(See "Intrauterine contraception: Background and device types", section on 'Copper IUD'.)

●(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 is presented in detail separately. (See "Contraception: Counseling and selection".)

Menopausal hormone therapy — Replacement doses of estrogen present in systemic menopausal hormone therapy are physiologic and have little clinically meaningful effect on blood pressure [26-29]. Transdermal estrogen preparations are associated with lower risk of hypertension compared with oral formulations [30]. The impact of menopausal hormone therapy on cardiovascular parameters is presented in detail separately. (See "Menopausal hormone therapy and cardiovascular risk", section on 'Blood pressure'.)

EVALUATION OF PATIENTS WITH HYPERTENSION

Assess other medical conditions and comorbidities — In patients with hypertension, additional medical conditions and comorbidities must also be taken into account when considering prescribing hormonal contraception (table 7) [31]. We, and other experts, use both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) comprehensive tables of medical conditions and personal characteristics that may affect contraceptive choice [1,2]. While the advisory documents are generally similar, clinicians should select whichever better fits their population. Summary tables can be found through the CDC's Summary Chart of US Medical Eligibility Criteria and the WHO Medical Eligibility Criteria for Contraceptive Use 2015.

Specific factors we consider when evaluating contraceptive options in individuals with hypertension include:

●Patient age (ie, <40 versus ≥40 years of age). Although the American College of Obstetrics and Gynecology (ACOG) guidelines suggest using age 35 as a criterion in considering the risk of hormonal contraception, others, such as the WHO and CDC, use age 40 [1,2,7].

●Use of tobacco products, including traditional cigarette or cigar smoking, e-cigarettes (ie, vaping), water pipes (ie, hookahs), and smokeless tobacco.

●Adequacy of blood pressure control.

●Other cardiovascular disease (CVD) risk factors:

•Hyperlipidemia

•Diabetes

•Obesity (body mass index [BMI] >30 kg/m²)

•Family history of premature CVD

•Physical inactivity

●The presence of CVD:

•Venous thromboembolism (VTE)

•Complicated valvular disease

•Ischemic heart disease

•Known thrombogenic variations

•Stroke

Compare with risks of pregnancy — When considering risks associated with hormonal contraceptives, the patient and clinician must balance potential risks against the risks of unintended pregnancy, the risks of pregnancy itself (eg, 10-fold greater risk of VTE (table 6)), and the greater risks of poor obstetric and neonatal outcomes for individuals with hypertension in pregnancy (eg, preterm delivery, small-for-gestational age). (See "Chronic hypertension in pregnancy: Prenatal and postpartum care", section on 'Risks of chronic hypertension in pregnancy'.)

Identify unacceptable risks to hormonal contraception — Based upon the CDC's Summary Chart of US Medical Eligibility Criteria and the WHO Medical Eligibility Criteria for Contraceptive Use 2015 Category 4 rating (unacceptable health risk [method not to be used]), combined hormonal contraception is not used in individuals with the following [1,2]:

●Uncontrolled hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)

●Age ≥35 years and smoking ≥15 cigarettes per day

●Multiple risk factors for arterial CVD (such as older age, smoking, diabetes, nephropathy, and hypertension)

●Acute VTE/pulmonary embolism (PE) or history of DVT/PE at high risk for recurrence and not on anticoagulation (see "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Venous thromboembolism' and "Contraception: Counseling for women with inherited thrombophilias", section on 'Personal history of venous thrombosis')

●Known ischemic heart disease

●History of stroke

●Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)

●Current breast cancer

●History of breast cancer (although there are some exceptions) (see "Approach to the patient following treatment for breast cancer", section on 'Contraception after breast cancer')

●Severe (decompensated) cirrhosis

●Hepatocellular adenoma or malignant hepatoma

●Migraine with aura (although there are limited exceptions) (see "Estrogen-associated migraine headache, including menstrual migraine")

●Diabetes mellitus of >20 years' duration, or diabetes mellitus of any duration complicated by diabetic nephropathy, retinopathy, or neuropathy

APPROACH TO CONTRACEPTION FOR INDIVIDUALS WITH HYPERTENSION

Counseling issues

Recognize need for counseling — Despite the risks associated with pregnancy in patients with hypertension, one database study of over 8000 individuals at risk for unintended pregnancy reported that 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) [32]. 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).

Adjust for medical comorbidities — We, and other experts, use the CDC's Summary Chart of US Medical Eligibility Criteria and the WHO Medical Eligibility Criteria for Contraceptive Use 2015 comprehensive tables of medical conditions and personal characteristics to help guide contraceptive choice [1,2]. In these documents, hypertension is defined as systolic >140 or diastolic >90 mmHg. While the advisory documents are generally similar, clinicians should select whichever better fits their population.

Controlled hypertension — Many individuals with hypertension can safely take hormonal contraception, even if they take antihypertensive medication, provided their blood pressure is controlled (ie, blood pressure <140/90 mm/Hg with medication). (See 'Definition of hypertension' above.)

In addition, they should be otherwise healthy and without additional CVD risk factors, continue on antihypertensive therapy (if applicable), and have their blood pressure well monitored [1,2,7]. One limitation of this guidance is that the WHO and CDC guidelines use a blood pressure cutoff of <140/90 mmHg and do not address individuals with stage 1 hypertension (130 to139 mmHg/80 to 89 mmHg) as a distinct treatment group. Until data specific to individuals with stage 1 hypertension are available, we continue to use the cutoff of 140/90 mmHg [7].

Age <40 years — Individuals who are <40 years of age with adequately controlled hypertension (ie, <140/90 mmHg), who are otherwise healthy, and who do not have other CVD risk factors or established CVD, may be offered any contraceptive method (figure 1) [7]. However, contraceptive selection must balance the patient's contraceptive goals, potential impact of the contraceptive on the patient's hypertensive disorder, contraceptive efficacy, and potential non-contraceptive benefits (eg, reduction of dysmenorrhea or treatment of endometriosis), among other variables. (See "Contraception: Counseling and selection".)

For patients with adequately controlled hypertension who have no absolute contraindication to hormonal contraception (see 'Identify unacceptable risks to hormonal contraception' above), we counsel patients that the lowest- to higher-risk hormonal methods include [1,2]:

●No restrictions – All levonorgestrel-releasing intrauterine devices (IUDs), progestin implants, and progestin-only pills (POPs).

●Advantages generally outweigh risks – Depot medroxyprogesterone acetate (DMPA).

●Risks of unclear magnitude – Combined estrogen-progestin contraceptives, including oral pills, transdermal patches, vaginal rings, and injections.

While both the WHO and the CDC label these medications with the statement "theoretical or proven risks usually outweigh the advantages," data specific to individuals with stage 1 hypertension (systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg) are lacking. Both the WHO and CDC define hypertension as systolic >140 mmHg and diastolic >90 mmHg. In our practice, otherwise healthy patients with elevated blood pressure, stage 1 hypertension, or pharmacologically treated hypertension <140/90 mmHg are potentially candidates for estrogen-containing contraceptives. Those who elect to use estrogen-progestin oral pills are prescribed pills containing 35 mcg of estrogen or less (table 5).

Blood pressure monitoring — Blood pressure checks are performed based on the type of contraceptive selected. Individuals who elect contraception that does not contain estrogen have their blood pressure repeated at routine visits. For individuals who elect combined estrogen-progestin contraception, we re-evaluate blood pressure two to four weeks after initiation, then at follow-up visits every six months; blood pressure evaluation can be performed through out-of-office or in-office measurement. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Our approach to measuring blood pressure'.)

If the patient's blood pressure increases significantly while on any hormonal contraception:

●We offer a different, non-estrogen hormonal contraceptive or a nonhormonal method (eg, copper IUD, condoms, pericoital contraceptives)

●After contraceptive switch, we monitor blood pressure to ensure a return to pretreatment values (typically within three months) [14]. If elevated blood pressure persists, further evaluation and treatment is warranted. (See "Initial evaluation of adults with hypertension" and "Choice of drug therapy in primary (essential) hypertension".)

Age ≥40 years — For individuals ≥40 years of age with adequately controlled hypertension (ie, <140/90 mmHg) who are otherwise healthy and without other CVD risk factors or CVD, and with no absolute contraindication to hormonal contraception, we suggest non-estrogen contraceptives, although estrogen-containing contraceptives may be appropriate in select patients. Contraindications to hormonal contraception are reviewed above. (See 'Identify unacceptable risks to hormonal contraception' above.)

Our approach includes the following [1,2,7]:

●No restrictions – All levonorgestrel-releasing IUDs, progestin implants, and POPs as well as all nonhormonal contraceptives. (See 'Nonhormonal contraceptives' above.)

●Advantages generally outweigh risks – Depot medroxyprogesterone acetate (DMPA).

While DMPA does not impact blood pressure, it may increase the risk of thromboembolic events and cause unfavorable changes in lipid metabolism. Based on these theoretical concerns, 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'.)

●Risks (theoretical or proven) generally outweigh benefits – Combined estrogen-progestin contraceptives, including oral pills, transdermal patches, vaginal rings, and injections.

Although there are limited data in this population, we generally do not prescribe these agents for such individuals because of the increased risk associated with multiple CVD risk factors (ie, older age and hypertension) and the availability of highly effective non-estrogen contraceptives [1,2]. In appropriately counseled patients, however, combined estrogen-progestin contraceptives may be used if alternative contraceptive options are not acceptable to the patient or if significant non-contraceptive benefits exist with use of combined hormonal contraception (eg, reduction of pelvic pain associated with endometriosis). Patients who elect to use estrogen-progestin oral pills should only be prescribed pills containing 35 mcg of estrogen or less (table 5).

Blood pressure monitoring — Blood pressure checks are performed based on the type of contraceptive selected. For individuals using progestin-only methods, we check blood pressure at routine visits. For the rare individual ≥40 years with controlled hypertension who starts combined estrogen-progestin contraception, we re-evaluate blood pressure in two to four weeks after initiation, then at follow-up visits every six months; blood pressure evaluation can be performed through out-of-office or in-office measurement. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Our approach to measuring blood pressure'.)

If blood pressure increases while on hormonal contraception:

●We discontinue hormonal agents, and offer nonhormonal contraceptive methods (eg, copper IUD, condoms, pericoital contraception).

●We monitor blood pressure to ensure return to pretreatment values (this typically occurs within three months) [14]. If elevated blood pressure persists, further evaluation and treatment is warranted. (See "Initial evaluation of adults with hypertension" and "Choice of drug therapy in primary (essential) hypertension".)

Uncontrolled hypertension — For individuals of any age with uncontrolled hypertension (blood pressure ≥140/90 mmHg, including those with blood pressure ≥160/100 mmHg), further evaluation and management of hypertension is warranted. (See "Treatment of resistant hypertension" and "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults" and "Choice of drug therapy in primary (essential) hypertension" and "Evaluation of secondary hypertension".)

For these patients, we take the following approach to contraceptive counseling regardless of age group [2,7]:

Choice of contraceptive

●No restrictions – All nonhormonal contraceptives are designated for use without restriction [2,7]. The nonhormonal copper IUD (copper 380 mm² IUD) does not impact blood pressure and is one of the most effective contraceptive options (figure 1). (See 'Nonhormonal contraceptives' above and "Intrauterine contraception: Background and device types".)

●Advantages generally outweigh risks – Progestin-only contraceptives can be used in select individuals with no other contraindications to progestins [1,2].

•The levonorgestrel-releasing IUDs, etonogestrel implant, and POPs are generally considered acceptable, even for patients with hypertension.

-(See "Intrauterine contraception: Background and device types".)

-(See "Contraception: Etonogestrel implant", section on 'Risk of thromboembolic event'.)

-(See "Contraception: Progestin-only pills (POPs)", section on 'Risks'.)

•Depot medroxyprogesterone acetate (DMPA) injection may be reasonably used in poorly controlled hypertensive individuals with no other cardiovascular risk factors and no history of stroke. DMPA injection does not impact blood pressure, but there are data suggesting it may contribute to or cause an unfavorable lipid profile and increase thromboembolic risk. However, the absolute risk of thromboembolic risk with DMPA injection is not known. (See "Depot medroxyprogesterone acetate (DMPA): Efficacy, side effects, metabolic impact, and benefits", section on 'Cardiovascular and thromboembolic risk'.)

●Risks (theoretical or proven) generally outweigh benefits – Estrogen-containing contraceptives, including oral pills, transdermal patches, vaginal rings, and injections, are generally avoided in individuals with blood pressure in the range of 130 to 159 mmHg/80 to 99 mmHg [1,2,7].

However, in some patients with blood pressure in the lower range of hypertension, combined estrogen-progestin contraceptives may be used if alternative contraceptive options are not acceptable to the patient or if significant non-contraceptive benefits exist with use of combined hormonal contraception. Such patients should only be prescribed pills containing 35 mcg of estrogen or less (table 5).

●Unacceptable risk – For patients with poorly controlled hypertension (ie, blood pressure ≥160/100 mmHg), we do not use combined estrogen-progestin contraceptives (oral pills, transdermal patches, vaginal rings, and injections) [1,2,7].

Blood pressure check — Repeat blood pressure checks are performed based on the type of contraceptive selected.

●For individuals using progestin-only methods, we check blood pressure at routine visits.

●For the rare individual ≥40 years with uncontrolled hypertension who starts combined estrogen-progestin contraception, we re-evaluate blood pressure in two to four weeks after initiation, then at follow-up visits every six months; blood pressure evaluation can be performed through out-of-office or in-office measurement. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Our approach to measuring blood pressure'.)

If blood pressure increases while on hormonal contraception (progestin-only or estrogen-containing):

●We discontinue hormonal agents and offer nonhormonal contraceptive methods (eg, copper IUD, condoms, pericoital contraception). (See "Intrauterine contraception: Background and device types", section on 'Copper IUD' and "Internal (formerly female) condoms" and "External (formerly male) condoms" and "Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge".)

●We monitor blood pressure to ensure return to pretreatment values (this typically occurs within three months) [14]. If elevated blood pressure persists, further evaluation and treatment, including evaluation of resistant hypertension, is warranted. (See "Initial evaluation of adults with hypertension" and "Choice of drug therapy in primary (essential) hypertension" and "Definition, risk factors, and evaluation of resistant hypertension" and "Treatment of resistant hypertension".)

INDIVIDUALS WITHOUT HYPERTENSION — This grouping includes patients with normal (systolic <120 mmHg and diastolic <80 mmHg) and elevated blood pressure (systolic 120 to 129 mmHg and diastolic <80 mmHg). (See 'Definition of hypertension' above.)

Risk of developing hypertension — For most individuals without hypertension (including those with normal blood pressure and elevated blood pressure) (table 1), the development of hypertension is unusual with contraceptives containing lower doses of estrogen (ie, ≤35 mcg estradiol or equivalent); the benefits of these agents generally outweigh the potential risk of medication-induced hypertension (table 5) [3,10]. Based on a study of estrogen-progestin oral contraceptive pills, the modest reported increases in the relative risk of hypertension with estrogen-containing contraceptives did not translate into increases in long-term overall mortality [33]. Hormonal contraception, including estrogen-containing products, can be offered from menarche until menopause in otherwise eligible individuals [1]. (See "Contraception: Counseling and selection" and "Combined estrogen-progestin contraception: Side effects and health concerns".)

Blood pressure monitoring — For individuals without hypertension and without CVD or CVD risk factors, routine blood pressure evaluation at annual follow-up visits is appropriate.

For individuals at higher risk of developing hypertension, such as individuals with a history of hypertension of pregnancy, we check blood pressure approximately three months after initiating estrogen-containing therapy. Blood pressure evaluation can be performed through out-of-office or in-office measurement. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Our approach to measuring blood pressure'.)

●If blood pressure becomes elevated while taking an estrogen-containing contraceptive, we typically discontinue it and offer non-estrogen containing hormonal contraceptive options, including a POP, a levonorgestrel-releasing IUD, or a progestin implant. (See "Contraception: Progestin-only pills (POPs)" and "Intrauterine contraception: Background and device types" and "Contraception: Etonogestrel implant".)

●If hypertension persists, we discontinue all hormonal agents, offer nonhormonal contraception (eg, copper IUD, diaphragm), and monitor blood pressure to ensure return to pretreatment values.

●If elevated blood pressure persists, further evaluation and management is warranted. (See "Initial evaluation of adults with hypertension" and "Overview of hypertension in adults".)

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

●Definition of hypertension for contraceptive purposes – When selecting contraception, individuals with hypertension are those with a systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg (table 1). While some organizations use a hypertension threshold of systolic ≥130 mmHg or diastolic ≥80 mmHg, data are lacking with regard to contraception and blood pressure in those with systolic pressure 130 to 139 mmHg or diastolic pressure 80 to 89 mmHg. (See 'Definition of hypertension' above.)

●Impact of hormones on blood pressure

•Estrogen-containing contraceptives – Pharmacologic levels of estrogen, such as those found in contraceptives (table 5), can increase blood pressure in some individuals. Physiologic levels of estrogen, such as those found in hormone therapy for menopause, do not impact blood pressure.

-Oral estrogens – Based on data from users of oral estrogen-progestin contraceptive pills, any rise in blood pressure while taking oral pills is usually mild, although some individuals may have more significant increases in blood pressure, and hypertensive emergencies may rarely occur. (See 'Impact on blood pressure' above.)

-Impact of non-oral estrogens – Non-oral estrogen-progestin hormonal contraceptives, including vaginal rings, transdermal contraceptive patches, and combined estrogen-progesterone injections (available outside of the United States and Canada) may have a more modest impact on blood pressure, although available data are limited. (See 'Impact on blood pressure' above.)

-Mechanism of action – The renin-angiotensin system (RAS) may be involved since estrogen stimulates the hepatic production of renin substrate (angiotensinogen). The sympathetic nervous system may also be activated. (See 'Impact on blood pressure' above.)

•Progestin-only contraceptives – Progestin-only contraceptives, which include implants, levonorgestrel-releasing intrauterine devices (IUDs), depot medroxyprogesterone acetate (DMPA) injection, and progestin-only pills (POP) (table 5), are generally not associated with elevations in blood pressure, although some may impact other cardiovascular risks. (See 'Progestins' above.)

●Patient assessment – For individuals who desire contraception, initial evaluation includes assessment of other medical conditions and comorbidities, including blood pressure measurement, comparison of risks of hormonal contraceptives with the risks of pregnancy itself, and identification of those with unacceptable risks for hormonal contraceptive methods. We, and other experts, use the Centers for Disease Control and Prevention (CDC)'s Summary Chart of US Medical Eligibility Criteria and the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use 2015 comprehensive tables of medical conditions and personal characteristics to help guide contraceptive choice. (See 'Evaluation of patients with hypertension' above.)

●Controlled hypertension – Many individuals with hypertension can safely take hormonal contraception, even if they take antihypertensive medication, provided their blood pressure is controlled (ie, blood pressure <140/90 mm/Hg with medication). (See 'Controlled hypertension' above.)

•<40 years – Individuals who are <40 years of age with adequately controlled hypertension (ie, <140/90 mmHg), who are otherwise healthy, and who do not have other cardiovascular disease (CVD) risk factors or established CVD, may be offered any contraceptive method. (See 'Age <40 years' above.)

•≥40 years – For individuals ≥40 years with controlled hypertension who desire hormonal contraception, we offer progestin-only contraceptives rather than estrogen-containing methods. These patients may use levonorgestrel-releasing IUDs, progestin implants, and POPs, in addition to all nonhormonal contraceptive methods, without restriction. The benefits of DMPA in this population are generally thought to outweigh the theoretical risks of thromboembolism and altered lipid profile. Combined estrogen-progestin contraceptives are generally avoided in these patients because of concerns for increased risk of thromboembolic events. However, select individuals in this group may be offered estrogen-containing contraceptives if they are expected to obtain additional benefits from these agents, provided they receive careful counseling and follow-up. (See 'Age ≥40 years' above.)

●Uncontrolled hypertension

•For individuals of any age with uncontrolled hypertension (blood pressure ≥140/90 mmHg, including those with poorly controlled hypertension [ie, blood pressure ≥160/100 mmHg]), further evaluation and management of hypertension is warranted.

•Individuals of any age with hypertension (blood pressure ≥140/90 mmHg, including those with poorly controlled hypertension [ie, blood pressure ≥160/100 mmHg]) may use any nonhormonal contraceptive without restriction. The nonhormonal copper IUD (copper 380 mm² IUD) does not impact blood pressure and is one of the most effective contraceptive options (figure 1). Other nonhormonal options include condoms (external or internal), diaphragms, and cervical caps.

•Individuals with uncontrolled hypertension (blood pressure ≥140/90 but ≤159/99 mmHg) who desire hormonal contraception are offered progestin-only contraceptives, including the levonorgestrel IUDs, or nonhormonal contraceptives, rather than estrogen-containing contraceptives. However, select individuals in this group may be offered estrogen-containing contraceptives if they have blood pressure in the lower end of this range, are expected to obtain additional benefits from estrogen-containing contraceptives, and receive careful counseling and follow-up.

•We do not use estrogen-containing contraceptives (oral pills, transdermal patches, vaginal rings, and injections) for individuals with poorly controlled hypertension (ie, blood pressure ≥160/100 mmHg) because of increased risk of cardiovascular event in these patients. (See 'Uncontrolled hypertension' above and "Combined estrogen-progestin contraception: Side effects and health concerns", section on 'Cardiovascular effects'.)

●Individuals without hypertension – For patients with normal (systolic <120 mmHg and diastolic <80 mmHg) and elevated blood pressure (systolic 120 to 129 mmHg and diastolic <80 mmHg) blood pressure, the development of hypertension is unusual with contraceptives containing lower doses of estrogen (ie, ≤35 mcg estradiol or equivalent); the benefits of these agents generally outweigh the potential risk of medication-induced hypertension. Routine blood pressure evaluation at annual follow-up visits is appropriate. (See 'Individuals without hypertension' above.)