Five Common Conditions

Network: Winter 1999, Vol. 19, No. 2

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.

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

1. World Health Organization. The World Health Report 1998. Life in the 21st Century. A Vision for All. (Geneva: World Health Organization, 1998)45-58.
2. Cardiovascular disease and steroid hormone contraceptives. Progr Human Reprod Res 1998;(46):1-12.
3. Sullivan JM, Lobo RA. Considerations for contraception in women with cardiovascular disorders. Am J Obstet Gynecol 1993;168(6): 2006-11.
4. Beral V, Hermon C, Kay C, et al. Mortality associated with oral contraceptive use: 25 year follow up of cohort of 46,000 women from Royal College of General Practitioners' oral contraception study. BMJ 1999;318(7176):96-100.
5. Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives, results of an international, multicenter, case-control study, World Health Organization collaborative study of cardiovascular disease and steroid hormone contraception. Contraception 1998;57(5):315-24.
6. Sibai BM, Anderson GD. Pregnancy outcome of intensive therapy of severe hypertension in first trimester. Obstet Gynecol 1986; 67(4):517-22.
7. Sullivan.
8. The 1993 report of the Joint National Committee on detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1993;153(2):154-83.
9. World Health Organization Ad Hoc Diabetes Reporting Group. Diabetes and impaired glucose tolerance in women aged 20-39 years. World Health Stat Q 1992;45(4):321-27.
10. Skouby SO, Mølsted-Pedersen L, Kosonen A. Consequences of intrauterine contraception in diabetic women. Fertil Steril 1984;42(4):568-72; Kjos SL, Ballagh SA, La Cour M, et al. The Copper T 380A intrauterine device in women with type II diabetes mellitus. Obstet Gynecol 1994;84(6):1006-9; Petersen KR, Skouby SO, Jespersen J. Contraception guidance in women with pre-existing disturbances in carbohydrate metabolism. Eur J Contracept Reprod Health Care 1996;1(1):53-59.
11. Petersen.
12. Osegbe DN, Akinyanju O, Amaku EO. Fertility in males with sickle cell disease. Lancet 1981;2(8241):275-76; Modebe O, Ezeh UO. Effect of age on testicular function in adult males with sickle cell anemia. Fertil Steril 1995;63(4): 907-12; Agbaraji VO, Scott RB, Leto S, et al. Fertility studies in sickle cell disease: semen analysis in adult male patients. Int J Fertil 1988;33(5):347-52.
13. Howard RJ, Lillis C, Tuck SM. Contraceptives, counseling, and pregnancy in women with sickle cell disease. BMJ 1993;306(6894): 1735-37.
14. Tuck SM, Studd JWW. Pregnancy in sickle cell disease in the UK. Br J Obstet Gynaecol 1983;90(2):112-17.
15. De Ceulaer K, Gruber C, Hayes R, et al. Medroxyprogesterone acetate and homozygous sickle cell disease. Lancet 1982;2(8292):229-31.
16. Goldzieher JW, Zamah NM. Oral contraceptive side effects: where's the beef? Contraception 1995;52(6):327-35.
17. Lutcher CL, Harris P, Henderson PA, et al. A lack of morbidity from oral contraception in women with sickle cell anemia. Clin Res 1981;29:863A.
18. Lutcher CL, Milner PF. Contraceptive-induced vascular occlusive events in sickle cell disorders – fact or fiction? Clin Res 1986;34:217A.
19. Blumenstein BA, Douglas MB, Hall WD. Blood pressure changes and oral contraceptive use: a study of 2676 black women in the Southeastern United States. Am J Epidemiol 1980;112(4):539-52.
20. Ladipo OA, Falusi AG, Feldblum PJ, et al. Norplant use by women with sickle cell disease. Int J Gynecol Obstet 1993;41(1):85-87.
21. Klufio CA, Reid SE, Bruce-Tagoe AA, et al. Contraceptive use among women with sickle cell diseases, Accra, Ghana. Br J Fam Plann 1985;10(4):113-17.
22. Sillanpaa M. Changes in the prevalence of migraine and other headaches during the first seven school years. Headache 1983;23(1):15-19.
23. Vessey MP, McPherson K, Yeates D. Oral contraceptives and stroke in young women: associated risk factors. JAMA 1975;75:718.
24. International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8(suppl 7):1-96.
25. Lidegaard O. Oral contraceptives, pregnancy and the risk of cerebral thromboembolism: the influence of diabetes, hypertension, migraine and previous thrombotic disease. Br J Obstet Gynaecol 1995;102(2):153-59.
26. Mattson RH, Rebar RW. Contraceptive methods for women with neurologic disorders. Am J Obstet Gynecol 1993;168(6, Part 2):2027-32.
27. Sulak PJ, Cressman BE, Waldrop E, et al. Extending the duration of active oral contraceptive pills to manage hormone withdrawal symptoms. Obstet Gynecol 1997;89(2):179-83.
28. World Health Organization. Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Contraceptive Use. (Geneva: World Health Organization, 1996)58.
29. Mattson RH, Rebar RW. Contraceptive methods for women with neurologic disorders. AmJObstet Gynecol 1993;168(6):2030.
30. Mattson RH, Cramer JA, Darney PD, et al. Use of oral contraceptives in women with epilepsy. JAMA 1986;256(2):238-40.
31. Neinstein L. Contraception in women with special medical needs. Comp Ther 1998; 24(5):238.
32. Odlind V, Olsson SE. Enhanced metabolism of levonorgestrel during phenytoin treatment in a woman with Norplant implants. Contraception 1986;33(3):257-61; Neinstein.
33. Mattson RH, Cramer JA, Caldwell BV, et al. Treatment of seizures with medroxy-progesterone acetate: preliminary report. Neurology 1984;34(9):1255-58.

Click to select preferred language, if other than English:
French | Spanish.