New starts of the Pill —What’s your approach?
What is the accepted practice for checking blood pressure following initial starts on oral contraceptives? Following are observations from two members of the Contraceptive Technology Update Editorial Advisory Board, David Archer, MD, professor of obstetrics and gynecology and director of the Clinical Research Center at the Eastern Virginia Medical Center in Norfolk, and Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville.
Question: Have there been any recent surveys to see how many clinicians do rechecks (blood pressure) with initial starts on oral contraceptives? Since we are using lower and lower estrogen pills, is there still a need for close follow-up to check blood pressure, particularly in healthy college-age young adults?
Archer: Increased blood pressure in oral contraceptive users is rare. It appears to only occur in women who have an exaggerated response of the renin-angiotensin system from the steroids. All women are at risk since there is no way to predict who will have a significant elevation in blood pressure. Re-evaluation of blood pressure at three months is recommended. Significant changes > 140/90 should be monitored and, if persistent, oral contraceptives should be discontinued. If the increase in blood pressure is due to the oral contraceptive, it should have returned to normal within three months. Obviously, a nonsteroidal method of contraception should be used while following the patient.
Kaunitz: I continue to encourage patients starting any new hormonal or intrauterine method to return for a follow-up visit between four to 12 weeks post-initiation. Although the follow-up visit may represent an inconvenience for some patients, it provides a useful opportunity to review compliance and side effect issues. Accordingly, a brief follow-up visit can prevent premature contraceptive discontinuation, which enhances the likelihood of long-term successful contraceptive use. In the case of combination (estrogen-progestin) contraceptives (oral, patch, ring), the follow-up visit also provides an opportunity to check blood pressure, which in a few users, may rise in response to contraceptive initiation. Regarding follow-up after combination OC initiation, the World Health Organization recommends an annual follow-up visit, and indicates there are added benefits to a three-month follow-up contact.1
1. World Health Organization. Selected Practice Recommendations for Contraceptive Use. Geneva; 2002.