Hormones and the Heart: Understanding Birth Control and HRT Options

The birth control pill is one of the most prescribed drugs, taken by millions of women. However, for women with high blood pressure or a history of blood clots, the pill isn’t an option.

“The estrogen in birth control pills can make blood more prone to clotting, especially in women already at risk for a heart attack, stroke or blood clots,” explains Maria Shaker, MD, an OB/GYN at University Hospitals. “So certain cardiovascular conditions really change the conversation around what we can safely prescribe.”

These same risks also apply to women considering hormone replacement therapy (HRT) to manage the symptoms of perimenopause. Fortunately, with evidence-based guidance, women can make informed decisions that support both their reproductive and cardiovascular health.

Heart-Friendly Birth Control

In general, contraceptives that contain estrogen are not recommended for women with hypertension, a history of blood clots or heart failure related to a previous pregnancy, known as peripartum cardiomyopathy.

According to Dr. Shaker, even women who are successfully managing their high blood pressure are at greater risk. “For someone with hypertension, even if it’s adequately controlled, the risks of hormonal contraceptives containing estrogen outweigh the benefits. So, we usually steer clear of estrogen in those cases.”

Instead of estrogen, safer contraceptive alternatives include progestin-only methods, such as the progestin IUD, implant, injection or pill. For those who prefer non-hormonal contraception, Dr. Shaker points to options like the copper IUD or a non-hormonal gel that can be used with intercourse.

“These are great options for pregnancy prevention without increasing cardiovascular risk,” she says.

Heart-Friendly Menopause Care

During perimenopause, many women experience symptoms like hot flashes, night sweats, brain fog, vaginal dryness or disrupted sleep as a result of declining hormone levels.

For many women, HRT is a safe and effective option, but it depends heavily on personal health history. “We base our recommendations on each patient’s health history,” explains Dr. Shaker. “And we consult with cardiologists and internists when needed. It’s all about shared decision-making.”

Estrogen pills are one option for managing menopause symptoms, but an estrogen patch may be a safer option for everyone, including some women with higher cardiovascular risk. “Recent studies suggest that estrogen patches don’t significantly increase the risk for blood clots” says Dr. Shaker. “For patients with menopause symptoms and a history of clotting disorders, that may be a safer option.”

When estrogen is not advised, there are newer therapies on the market such as fezolinetant, a non-hormonal treatment that treats symptoms like hot flashes. Additionally, vaginal estrogen is available for women with symptoms such as vaginal pain or dryness, even if they can’t safely take estrogen via pill or patch.

Other non-hormonal options for managing perimenopausal symptoms include medications such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), which can reduce hot flashes and help with sleep.

Planning for a Safe Pregnancy

For women with cardiovascular conditions who are considering pregnancy, pre-conception planning is essential. Pregnancy significantly stresses the cardiovascular system, so women with pre-existing cardiovascular risks face higher chances of serious complications, both for themselves and their babies. For example, blood volume increases by roughly half during pregnancy, which can overwhelm a heart that’s already under stress.

Even well-controlled high blood pressure increases the risk of complications like preeclampsia, and more serious heart conditions require close collaboration between specialties.

“Some women will need referral to maternal fetal medicine, especially if they’ve had peripartum cardiomyopathy or have pulmonary hypertension,” says Dr. Shaker. “We work closely with cardiologists, pulmonologists and high-risk OBs to ensure a safe pregnancy plan.”

More Awareness – and Options

Dr. Shaker notes a growing awareness, especially around perimenopause, and more options for patients thanks to social media and public figures. “Patients are asking more questions, and we still need a great deal more research to help us understand at a deeper level how women with cardiovascular risk respond to medications,” she says. “However, pharmaceutical companies are beginning to respond with new solutions.”

With those solutions and close support and planning from their doctors, Dr. Shaker adds, “most women with cardiovascular risk factors can safely manage their reproductive and menopausal health.”

Related Links

At University Hospitals, our wide network of OBGYN physicians have the training and expertise to help women with cardiovascular conditions navigate contraception, pregnancy and menopause management. Learn more about UH OB/GYN and Women’s Health Services.