‘See this as your role’: Contraceptive counseling vital in cardiology care
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RANCHO PALOS VERDES, Calif. — Cardiologists should address contraceptive use during every visit for reproductive-age women with CV risk, according to a speaker.
Cardiologists may not recognize the importance of discussing contraceptive methods with women during a visit; however, it is crucial to discuss the risks and benefits of various methods for women with complex medical conditions, Rachel Perry, MD, MPH, associate professor of obstetrics and gynecology in the division of family planning at the University of California (UCI), Irvine, and director of the UCI Health Women’s Options Center, said during a presentation at the Cardiometabolic Health Congress (CMHC) Women’s Cardiometabolic Health and Wellness Masterclass.
“OB/GYNs and primary care may seem like the first choice [to discuss contraception] because we have more time to do this kind of counseling, but some patients do not come to see us,” Perry said during a presentation. “It is important that if you are taking care of reproductive-age women, that you also see this as your role, particularly if pregnancy would be detrimental to a woman’s CV health. There are states where, if a woman has an unintended pregnancy, abortion would not even be an option right now. Then this takes on even more weight.”
Considerations for women with CV risk
When choosing a contraceptive method for a woman at CV risk, clinicians should consider whether a method could affect BP, volume status, blood glucose or lipid profile, as well as whether the method has thrombogenic potential or affects metabolism of other medications. Highly effective methods of birth control include IUDs, such as a copper IUD that releases progestin for several years, contraceptive implant or sterilization via tubal ligation. Other methods include combined oral contraceptives, such as the pill, the patch, a progestin-only pill or hormonal vaginal contraceptive ring. Barrier methods such as condoms should always be recommended when protection against STIs is a consideration, Perry said.
“When you have a patient where pregnancy would be detrimental to cardiac health, you want to emphasize method efficacy,” Perry said. “I love when specialists send me a patient for a family planning consult and the patient comes says to me, ‘My cardiologist feels using condoms is not enough and recommended I consider an IUD.’ I love that you are her trusted physician and suggested a highly effective method and she comes to the visit with me and already has an idea of what she wants to use. Remember the power that you have of helping your patients choose a good method.”
Synthetic estrogens such as ethinyl estradiol, used in the pill, patch and vaginal ring, can increase BP by increasing angiotensin and activating the renin-angiotensin system. On average, combined oral contraception will increase systolic BP by 8 mm Hg and diastolic BP by 6 mm Hg, Perry said during the presentation.
“This is dose-dependent and increases with age and BMI,” Perry said. “I teach my residents that the one aspect of the physical exam that you need to do before you prescribe contraception is to measure the BP.”
Venous thromboembolism risk increases up to fivefold in combined oral contraception users, stroke risk is doubled and highest during the first year of use and risk for MI is also increased, Perry said.
“It is important to keep in mind for otherwise healthy patients the absolute risks are otherwise very low,” Perry said. “These are still safe medications. Even for those at higher risk, the risks with contraception are lower than the risks of pregnancy.”
Progestin-only methods, such as the progestin-only pill, levonorgestrel IUD or subdermal contraceptive implant, are safer and have less contraindications than estrogen, Perry said, noting there are moderately unfavorable effects on lipid profile due to hypoestrogenic effects, such as a decline in HDL. Patients may also experience an increase in insulin resistance and some weight gain, she said.
Weighing risks and benefits
CDC medical eligibility criteria for contraception, available as an app for smartphones, is the best resource for clinicians considering methods for a patient with a CV condition, Perry said, adding that clinicians should consider that any risks with contraceptive methods are typically lower that risks that come with pregnancy.
She said for a patient with moderate or adequately treated hypertension, combined hormonal contraceptives should be avoided, or the patient should use the lowest possible dose if no other method is acceptable. For those with severe hypertension or vascular disease, combined hormonal contraception is contraindicated, she said.
For patients with diabetes without vascular disease, all contraceptive methods are acceptable, Perry said. For those with diabetes and vascular disease such as retinopathy or neuropathy, combined oral contraceptives are contraindicated. All methods are acceptable for those with a history of gestational diabetes. Combined oral contraceptives are also contraindicated for those with ischemic heart disease.
“Sometimes it is a little more subtle; a patient may have many risk factors or a combination of risk factors where combined oral contraception becomes higher risk,” Perry said. These can include age older than 35 years, smoking, diabetes, hypertension, low HDL, high LDL or high triglycerides.
Contraception in perimenopause
In healthy women, combined oral contraception can be safe until age 50 to 55 years and also offers noncontraceptive benefits in perimenopause, Perry said. For this age group, combined oral contraception has been shown to prevent and treat vasomotor symptoms and is associated with increased bone mineral density. Depot medroxyprogesterone acetate (DMPA) injections decrease bone mineral density in a transitory manner and should be used “with caution” during perimenopause, Perry said.
“As cycles decrease, most cycles do become anovulatory, but there is still a small chance of conception,” Perry said.
There is no consensus on when to discontinue a contraceptive method, she said, noting if there is no CV risk, combined oral contraceptive methods can be continued up to age 55 years.
“Often what we do is stop the [hormonal] method and switch to an alternative nonhormonal method and then see if she is amenorrheic,” Perry said.
Shared decision-making matters
Clinicians should use a shared decision-making model when discussing contraception options based on what a patient may want, Perry said. Some contraceptive methods have different bleeding profiles — a patient may prefer to have a monthly period to ensure they are not pregnant, for example — or may offer more flexibility in use vs. a device implanted for many years, Perry said. The CDC, Planned Parenthood and websites like www.bedsider.org offer comprehensive and patient-friendly lists of available contraceptive options outlining the risks and benefits of each. These resources can be shared with patients so they can also review options on their own time, Perry said.
“This is more of a give-and-take between you and the patient,” Perry said. “You want to emphasize the most effective method, but you also want to honor her autonomy, knowing patient values about contraception can differ from ours.”
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Perry R. Choosing wisely: Contraception in women with cardiovascular risk. Presented at: CMHC Women’s Cardiometabolic Health and Wellness Masterclass; Sept. 9-11, 2022; Rancho Palos Verdes, California
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