Contraceptive Options for Women With Heart Disease, Obesity, Hypertension, or Diabetes
In this video, Anum Minhas, MD, MHS, discusses recommendations for contraceptives in women with heart disease, obesity, high blood pressure, or diabetes in a cardiology setting, including dependable resources that clinicians can reference when managing patients with these risk factors.
Additional Resources:
Lindley KJ, Bairey Merz CN, Davis MB, Madden T, Park K, Bello NA; American College of Cardiology Cardiovascular Disease in Women Committee and the Cardio-Obstetrics Work Group. Contraception and reproductive planning for women with cardiovascular disease: JACC focus seminar 5/5. J Am Coll Cardiol. 2021;77(14):1823-1834. doi:10.1016/j.jacc.2021.02.025
ACOG Practice Bulletin No. 206 Summary: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2019;133(2):396-399. doi:10.1097/AOG.0000000000003073
TRANSCRIPTION:
Anum Minhas, MD, MHS: Hi, I'm Dr Anum Minhas, and I'm a cardiologist at Johns Hopkins University with expertise in cardiovascular care for women.
Consultant360: Please describe a situation where hormonal contraception in women of childbearing years might be discussed with patients in your cardiology practice.
Dr Minhas: For me as a cardiologist, this comes up in the setting of patients that have preexisting cardiovascular disease. So, for instance, for patients that have cardiomyopathy, or ischemic heart disease, and they're now desiring to use contraception to prevent pregnancy.
And then the second case in which this comes up in my practice very frequently would be women who have cardiovascular risk factors, such as hypertension obesity, or diabetes, or who smoke and are interested in contraception.
C360: What contraceptives are recommended for women with heart disease?
Dr Minhas: So, when we talk about contraception, I think it's nice to think about it in three tiers. The first would be implantable contraception. For instance, things like IUDs or intrauterine devices that are used for contraception, like the copper IUD for instance. And then we have contraception that would be birth control pills, for instance, like oral contraceptives. That would be the second main category of contraceptives to think about. And then you have the barrier methods of contraception. So, that would be like condoms, for instance, that could be used for contraception.
When we're thinking about contraception, in particular, oral contraception, and combined hormone therapy, such as combined contraceptives include progesterone and estrogen together. Estrogens are known to be associated with increased thromboembolism risk. So, in patients who are at high risk for thromboembolism, contraceptives that use estrogen, particularly oral estrogen, are advised against. So, for instance, a patient who has had a DVT or who has had a PE, would of course be at high risk for having a future event. In those patients, a combined hormonal contraceptive and OCP that has estrogen and progesterone would not be recommended.
Additionally, in women who have ischemic heart disease. So even though the risk of oral combined hormonal contraceptives primarily comes from an increase of venous thromboembolism, in women that have ischemic heart disease in general, combined hormonal contraceptives are not advised.
And then similarly, women that have an increased risk of forming thromboembolism, such as women that have newly diagnosed cardiomyopathy, particularly with an ejection fraction of less than 35%, those patients, as we know, are at increased risk of having LV thrombus formation, for instance, and those patients would be advised against using combined hormonal contraceptives.
C360: What contraceptives are recommended for women with other risk factors, such as high BMI, high blood pressure, or diabetes?
The American College of Obstetrics and Gynecology puts out practice bulletins, which recommend how clinicians should think about gynecologic and obstetric conditions. One of these is the ACOG practice bulletin number 206, which is the use of hormonal contraception in women with coexisting medical conditions. And I think this is a fantastic document for all clinicians, including cardiologists, to be aware of, because it covers conditions that are cardiovascular, so for instance, risk factors. This practice bulletin advises that in women who have blood pressure, a systolic blood pressure of 140 to 159, or above 160, or diastolic blood pressure of 90 or greater, combined hormonal contraceptives should not be used unless there is no other appropriate method. Particularly in women that have more severe hypertension, so systolic blood pressure above 160, or diastolic blood pressure above 100, with vascular disease or without vascular disease, they should not use any combined hormonal contraceptive because the risk is too great for them to develop a venous thromboembolism.
Now when it comes to obesity, the question comes up, is contraception equally effective in women who are obese compared to women who are not obese? Most data tell us that contraception is effective in women who are obese and that they can choose any form of contraception that is appropriate for them, with no clear contraindications to using combined hormone therapies. Now I will give the caveat that obesity itself is known to increase the risk of thromboembolism, and pregnancy itself is known to increase the risk of thromboembolism. So, when we study the additional risk of thromboembolism in the setting of using an oral contraceptive that includes estrogen, on top of the risk that is already there from obesity, that risk is very low, it's on the lower side. So, in general, most of the risk for obese women comes from the obesity itself and not from the oral contraceptive itself, which is why the American College of Obstetrics and Gynecology does not advise against using combination contraception for women who have obesity.
Now in terms of diabetes, when we think about diabetes and contraception, it's helpful to think about the duration of diabetes. So, women who have uncomplicated diabetes, and who have had diabetes for less than 20 years, can choose combined hormonal contraceptives, and that is appropriate per the ACOG guidelines. But in women who have had diabetes for more than 20 years, or who have evidence of microvascular disease such as retinopathy, nephropathy, or neuropathy, combined oral contraceptives are contraindicated, and they're advised against using combined hormonal contraceptives. Now for most women, unless they have an extremely high risk for thromboembolism, if they are not advised a combined hormonal contraceptive, so again that would be estrogen plus progesterone, they can still have contraception that is progestin-only. So, there are tablets that can be taken that would be progesterone only, and there are also implantable devices that can be used that would be progesterone only.
In general, for any women with cardiovascular disease or risk factors, intrauterine devices or IUDs can be used safely. That would be the recommendation for women who have pre-existing heart disease, especially if pregnancy would carry a high risk to the mother and then potentially a fetus and the woman wants to avoid pregnancy altogether. IUDs have the strongest data for efficacy short of procedures that would involve sterility.
C360: Please provide a case presentation of a patient at risk for thromboembolism in need of contraception. Using shared decision-making, what method of contraception was recommended for this patient?
I have a patient in my practice who unfortunately had a CABG at a very, very young age. So she had a CABG in her mid-20s after having a STEMI, and was found to have multivassel coronary artery disease. Now, this patient was very interested in pregnancy and was able to successfully become pregnant and was able to deliver her baby. And now, because she's still of reproductive age, she asked what she could do in terms of contraceptives. So, we discussed potentially long-term options such as an IUD, which would provide contraception for multiple years. However, the patient stated that she was interested in having another baby in the next three years. She also did not like the idea of having an IUD placed and asked if there were any oral options that she could have to avoid that. So, we discussed the potential risks of thromboembolism that are recognized with combined oral contraceptives and the potential lower risk associated with a progestin-only pill that she could take. And she ended up electing to use a progestin-only contraceptive method that would be oral. And she is planning to become pregnant a second time in the next two years. So, this was the best fit for her, both in terms of her wishes and then also medically knowing that this would offer a lower risk for thromboembolic disease.