Oral Contraceptive Pills and Hypertension: A Review of Current Evidence and Recommendations

Abstract

Oral contraceptive pills (OCPs) have been used as effective and popular forms of contraception since the middle of the last century. By 2019, over 150 million reproductive-aged individuals were using OCPs to prevent unintended pregnancies worldwide. Safety concerns regarding the effects of OCPs on blood pressure were reported soon after these pills gained approval. Although OCP doses were subsequently reduced, epidemiologic evidence continued to support a smaller, but significant association between OCPs and hypertension. Given the rising prevalence of hypertension, as well as the adverse effects of cumulative exposure to blood pressure elevations on cardiovascular disease risk, understanding the nature of the association between OCPs and hypertension is important for clinicians and patients to assess the risks and benefits of use, and make individualized decisions regarding contraception. Therefore, this review summarizes the current and historical evidence describing the association between OCP use and blood pressure elevations. Specifically, it identifies the pathophysiologic mechanisms linking OCPs to hypertension risk, describes the magnitude of the association between OCPs and blood pressure elevations, and distinguishes the effects of various OCP types on blood pressure. Finally, it describes current recommendations regarding hypertension and OCP use, as well as identifies strategies, such as over-the-counter OCP prescribing, to safely and equitably improve access to oral contraception.

Keywords: blood pressure; contraceptives, oral; estrogens; hypertension; progestins.

Figure 1.

Summary of estrogens and progestins used in oral contraceptive pills. Natural estrogens and lower doses of synthetic estrogens are associated with lower blood pressure elevations. Drospirenone has blood pressure lowering effects.

Figure 2.

Mechanisms through which estrogens in oral contraceptive pills may increase blood pressure. This diagram illustrates the renin-angiotensin-aldosterone system and shows the potential sites of action for estrogens, including through increased hepatic production of angiotensinogen, impaired negative feedback regulation of renin, altered regulation of antidiuretic hormone release via resetting of osmoreceptors, and impaired baroreceptor regulation. Figure created with BioRender.com.