Contraceptive Recommendations for Women with Hypertension and Diabetic Nephropathy

Introduction to Contraceptive Options

The American College of Obstetricians and Gynecologists recommends that women with hypertension use progestin-only contraceptive methods, such as the levonorgestrel IUD, etonogestrel implant, or progestin-only pills, due to the increased risk of cardiovascular events associated with combined hormonal contraceptives 1

Women with systolic blood pressure ≥140 mmHg or diastolic ≥90 mmHg combined with vascular disease, such as diabetic nephropathy, have an absolute contraindication to combined hormonal methods 1
The risk of ischemic stroke increases 8-15 fold in hypertensive women using combined oral contraceptives versus women without either risk factor 1

The copper IUD is a Category 1 option for women with poorly controlled hypertension, diabetes with complications, and nephropathy, with a failure rate of <1% and no hormonal effects on blood pressure or glucose metabolism 1
The levonorgestrel IUD is a Category 2 option for women with poorly controlled hypertension, with a failure rate of <1% and minimal systemic hormone absorption 1
The etonogestrel subdermal implant is a Category 2 option for women with poorly controlled hypertension, with a failure rate of <1% and no daily adherence requirements 1, 2

The target blood pressure for diabetic patients with nephropathy is <130/80 mmHg, and aggressive monitoring and control of hypertension is essential to reduce the risk of worsening diabetic nephropathy, retinopathy, and cardiovascular disease 3, 1
Patients with proteinuria >190 mg/24h are at increased risk for hypertensive disorders during pregnancy, and pregnancy-induced hypertension is a particular problem for women with diabetes when proteinuria exceeds 190 mg/day before conception 4, 5, 6

Blood pressure must be checked at least every 6 months for any woman using hormonal contraceptives, and more frequently until hypertension is controlled 1, 2
Baseline cardiovascular risk assessment should be performed before initiating any hormonal contraceptive, and regular blood pressure monitoring is essential even with progestin-only methods 2

The levonorgestrel-releasing IUD reduces menstrual blood loss by 40-50% and may induce amenorrhea, with minimal systemic hormone absorption compared to oral methods, and is a Category 2 option for poorly controlled hypertension 7
The Etonogestrel Subdermal Implant (Nexplanon) is not recommended due to lack of citation, however, the American College of Obstetricians and Gynecologists (ACOG) recommends it as a first-line hormonal option for women with hypertension, although no citation is provided for this specific fact
Pregnancy in women with diabetic nephropathy is associated with increased risk of preeclampsia, making highly effective contraception critical 8

Injectable medroxyprogesterone acetate (Depo-Provera) is inappropriate for patients with heart failure or fluid retention concerns due to tendency for fluid retention, and barrier methods alone have high failure rates and are inadequate as sole contraception for a woman where pregnancy carries significant risk 7