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Decisions about contraception for women with underlying medical problems can be complicated. Although several studies have shown that the use of hormonal contraceptives is safe and effective in healthy women, there are much fewer data concerning their use in women with medical problems. In some women, drugs taken for certain chronic conditions may alter the effectiveness of hormonal contraceptives; in such cases, pregnancy may be especially risky for the mother and fetus. The American College of Obstetricians and Gynecologists (ACOG) reviewed the evidence on the use of hormonal contraceptives in women with underlying medical conditions.
Women with Cardiovascular Risk Factors
ACOG addressed the use of combination oral contraceptives and other forms of hormonal contraception in women with hypertension, dyslipidemia, and diabetes; women who smoke or are obese; and women older than 35 years.
HYPERTENSION
Studies have shown that the use of oral contraceptives (including newer agents) increases blood pressure by as much as 8 mm Hg systolic and 6 mm Hg diastolic. However, depot medroxyprogesterone acetate (DMPA; Depo-Provera) does not significantly affect blood pressure. Some studies have reported increases in the risk of vascular events in women taking combination estrogen/progestin contraceptives. Because of the increased risk of myocardial infarction (MI) and stroke in women with hypertension, and the likelihood of additional risks associated with hormonal contraceptives, the decision to use combination hormonal contraceptives in these women should be weighed against the risk of adverse pregnancy outcomes associated with hypertension.
In women with well-controlled and monitored hypertension who are 35 years or younger, a trial of combination contraceptives may be appropriate as long as the patient is otherwise healthy, shows no signs of end-organ vascular disease, and does not smoke. If blood pressure remains well controlled several months after the trial is started, combination contraceptives may be continued. Progestin-only contraceptives and the levonorgestrel-releasing intrauterine system (Mirena) are appropriate options in women with hypertension.
DYSLIPIDEMIA
The estrogen component of combination oral contraceptives enhances removal of low-density lipoprotein (LDL) cholesterol and increases levels of high-density lipoprotein (HDL) cholesterol. Oral estrogen also increases triglyceride levels, but in women with both increased HDL and decreased LDL levels, this moderate increase in triglyceride levels does not increase the risk of atherogenesis. The progestin component of combination oral contraceptives antagonizes these...