Contraception Options for Patients with Diabetes, Hypertension, and Dyslipidemia

Contraindications for Combined Hormonal Contraceptives

The U.S. Medical Eligibility Criteria (U.S. MEC) recommends that women with complicated diabetes should not use combined hormonal contraceptives, depending on the severity of the condition 1, 2
Women with severe hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥100 mm Hg) should not use combined hormonal contraceptives (U.S. MEC 4) 2, 3
Women with less severe hypertension (systolic pressure 140-159 mm Hg or diastolic pressure 90-99 mm Hg) or adequately controlled hypertension generally should not use combined hormonal contraceptives (U.S. MEC 3) 2, 3
Some women with hyperlipidemias generally should not use combined hormonal contraceptives (U.S. MEC 2/3, depending on the type and severity of the hyperlipidemia and presence of other cardiovascular risk factors) 1, 4
Combined oral contraceptives in women with dyslipidemia significantly increase the risk of myocardial infarction (OR 25, 95% CI 6 to 109) 5
Combined oral contraceptives in women with hypertension significantly increase the risk of myocardial infarction (OR range 6 to 68) 5

Non-hormonal copper IUDs are a first-line contraceptive option due to their safety profile and minimal impact on metabolic parameters, with no effect on glucose metabolism, lipid profiles, or blood pressure 5, 4, 6
Levonorgestrel-releasing IUDs have minimal systemic hormonal effects and may cause slight changes in body composition, but are generally well-tolerated 6

Blood pressure should be measured before initiating combined hormonal contraceptives if they are being considered despite risks, according to the U.S. Medical Eligibility Criteria 2, 3
Weight (BMI) measurement is not needed to determine medical eligibility for any contraceptive methods, as all methods can be used among women with obesity (U.S. MEC 1) or generally can be used (U.S. MEC 2) 1, 7
Glucose and lipid screening before initiation of hormonal contraceptives is not necessary according to CDC guidelines, but should be monitored in women with pre-existing diabetes and dyslipidemia 4, 8
For women with diabetes using hormonal methods, regular monitoring of glycemic control is recommended, according to the American Diabetes Association 9

When choosing glucose-lowering medications for people with type 2 diabetes and contraceptive methods, consider potential interactions and prioritize medications with beneficial effects on weight, according to the American Diabetes Association 9
For women with diabetes requiring obesity pharmacotherapy, reliable contraception is essential as many weight loss medications are contraindicated in pregnancy, according to the American Diabetes Association 9

Women with dyslipidemia using combined oral contraceptives have a 25-fold increased risk of myocardial infarction (OR 25, 95% CI 6 to 109) compared to non-users, according to the American College of Obstetricians and Gynecologists guidelines 10
Combined hormonal contraceptives increase the risk of both ischemic and hemorrhagic stroke, with risk amplified in women with multiple cardiovascular risk factors, as reported by the British Medical Journal 10
Current users of combined oral contraceptives show an increased risk of arteriothrombotic events compared to non-current users, as stated by the National Institute for Health and Care Excellence 10
Progestin-only pills show no association with increased risk of myocardial infarction or stroke, unlike combined oral contraceptives, according to the American Heart Association 10

In breastfeeding women, progestin-only oral contraceptives and depot medroxyprogesterone acetate were associated with a two- to threefold increase in diabetes risk, so these should be used with caution during breastfeeding, as recommended by the American Diabetes Association 11
Review of current glycemic control (HbA1c) and lipid panel values is essential before initiating any hormonal contraceptive, as suggested by the American Association of Clinical Endocrinologists 12
Monitor lipid panel annually as recommended for all patients with type 2 diabetes, according to the American Diabetes Association 12

Oral contraceptive pills for treatment of polycystic ovary syndrome are not contraindicated in women with type 2 diabetes who lack other cardiovascular risk factors, as stated by the Endocrine Society 12
However, women with multiple cardiovascular risk factors (T2DM + hypertriglyceridemia + dyslipidemia) require careful consideration of contraceptive options, as recommended by the American College of Cardiology 13