Short-term   studies   have   been   suggested   that   combined   hormonal contraceptives may induce a mild rise in blood pressure ^(95,96,97).  In fact,  it seems that HCs induce hypertension in approximately 5% of users of high-dose pill that contains at least 50 μg estrogen and 1 to 4 mg progestin, however small increases in blood pressure have been reported even among users of modern low-dose formulations ^(7,97).

In fact, it seems that low-dose pill users have a 1.0 mm Hg rise in diastolic pressure,  which is statistically significant but clinically unimportant ⁽⁹⁹⁾.  In addition,  blood pressure differences between HC users and non users tend to increase with age.

Furthermore,  obesity,family history of hypertension and previous hypertensive disorders of pregnancy seem associated with an increase of blood pressure during hormonal contraceptive use ^(9,100). It is very likely that blood pressure undergoes physiologic variation depending on hormonal fluctuations ^(96,101,102).

Data on long- term and withdrawal effects of HC use on this outcome are, however, scarce. A recent prospective cohort study carried out on HC-users and past users aged 28-75 years, showed that hormonal contraceptives increase blood pressure,  and urinary albumin excretion (UAE)  and may be deleterious on urinary function in 6.3% of the users. Although stopping may result in correction of these effects.In fact, women who take HCs have an increased risk of developing new hypertension, which returns to baseline within 1 to 3 months of HC cessation ⁽¹⁰³⁾. Therefore,  some cases of irreversible hypertension, kidney failure and malignant nephrosclerosis have been reported ^(104,105).

Women with pre-existing hypertension who take HCs have an increased risk of stroke and myocardial   infarction   when   compared   with   hypertensive   women   who   do not ^(8,61,106). Women who smoke,  have an increased risk of hypertension (2 to 3 times) when take HCs. Smoking increases the risk of vascular damage by increasing   sympathetic   tone,  platelet   stickness   and   reactivity, free   radical production,  damage   of   endothelium,  and   by   surges   in   arterial   pressure.

Surprisingly,  this increased risk declines on quitting cigarettes within 2 to 3 months ⁽¹⁰⁷⁾. Blood pressure elevations are usually attributed to the estrogen, but there is evidence of a progestin role as well ^(102,103) The mechanism by which some HCs users develop hypertension is poorly understood,but it may be related to changes in the renin-angiotensin-aldosterone system ^(108,109) The raise of hypertension often associated with raise of weight is the consequence of increased fluid retention in women taking hormonal contraceptives,  especially if over 35 years.  Androgenic progestins accentuate sodium retention, which may play an important role ⁽¹¹⁰⁾. 

A short term study showed in women aged 35-39, treated with gestodene 75 mcg/ EE 20 mcg versus gestodene 60 mcg/ EE 15 mcg a non statistically significant mean increase of 4mmHg for systolic pressure and 2 mm Hg for diastolic pressure in the first group and corresponding increases of 3 and 2 mmHg in the second group ⁽¹¹⁰⁾. Among young women, HDL cholesterol levels decline and LDL levels increase among users relative nonusers of HCs.  On the other hand,old women treated with estrogens have more favorable lipid profiles than do women of the same age not receiving estrogen ⁽²⁶⁾.

Considering the role of renin-angiotensin-aldosterone system in the development of hypertension, it is possible to explain the absence of effects on hypertension exerted by progestins containing   HCs   with   antiandrogenic   properties   and,  particularly   of   the drospirenone, an aldosterone- derivative ^{(110,111,112)}.

Although the first problem is the HC prescription and following use with prevalence of uncontrolled hypertension ⁽¹¹³⁾. In fact, women with hypertension should be cautioned about the effects of estrogen-containing oral contraceptives which may cause a further elevation in systemic blood pressure. Women with hypertension are at increased risk for cardiovascular events.  HC users who did not have their blood pressure measured before initiating HC use were at higher risk for ischemic stroke and myocardial infarction,  but not for haemorrhagic stroke or VTE,  than HC users who did have their blood pressure measured ^(2,7,8).

In   the   meantime, in   order   to   evaluate   the   risk   factors   for   VTE   and cardiovascular   disease,  prior   to   the   prescription   of   combined   hormonal contraceptives a full clinical,  personal and family history, together with the measure of blood pressure and body mass index (BMI) may be advisable.

—
Rosa Sabatini and Giuseppe Loverro
Dept. Obstetrics and Gynecology,
General Hospital Policlinico-University of Bari, Italy
—

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