The following are 10 points to remember about contraception and cardiovascular disease:

1. Improvements in the treatment of congenital heart disease, have increased the number of female patients living to puberty and childbearing years. Thus, careful planning related to pregnancy for those on cardiac medications and/or with complex cardiac disease is essential. Large population-based studies have observed median age of menarche to be 12-13 years of age, and age of first sexual intercourse to be around the age of 17. Therefore, early discussions of contraceptives, in particular for girls with complex congenital heart disease, are recommended. The authors of this review recommend an individualized approach, which incorporates use of cardiac medications, risk related to heart disease, and the patient’s wishes.
2. Several types of contraception are available. These include barrier, calendar, and withdrawal methods, all of which are considered insufficient due to the respective failure rates. However, condoms do protect against sexually transmitted disease and can be used in conjunction with other contraceptive methods.
3. Combined estrogen and progesterone or progesterone-only contraceptives are two other types of contraception. Combined estrogen-progesterone includes tablets, vaginal rings, injections, or transdermal patches. Variations in types of progestin and type and dose of estrogen are available. Estrogens increase risk for venous thrombus and therefore are not generally recommended for women with heart disease. Some medications, for example Bosentan (used in pulmonary hypertension), decrease the effectiveness of these contraceptive methods.
4. Progesterone-only methods do not appear to increase the risk for venous thrombosis, but most have limited efficacy and may need to be used in combination with another type of contraceptive method. Subdermal implants can be used for longer periods of time (i.e., years). Intrauterine devices are also used for years. These devices may carry an increased risk for infection in the first several months after implantation. The authors suggest consideration of antibiotic prophylaxis among high-risk women. Tubal ligation and tubal stents are considered irreversible forms of sterilization. In many situations, progesterone-only methods may offer the best option for long-term contraception with lower risks.
5. Last, emergency contraception may be considered for cases of unprotected intercourse. These include a single dose of either Levonogestrel (which delays ovulation), Mifeprostone (progesterone receptor modulator), or Ulipristal (both are progesterone receptor modulators). These are thought to be generally safe in women with heart disease. An interaction between warfarin and high-dose Levonogestrel may exist; therefore, monitoring of international normalized ratio (INR) is recommended.
6. To date, there is scarce evidence related to effectiveness and adverse effects of contraception types among women with heart disease. Among women with reduced systolic function, there is no absolute contraindication to any specific form of contraception. The authors do suggest that contraceptive steroid hormone, such as in combinations of estrogen and progesterone, may be less preferable given their increased risk for thrombosis.
7. For women with heart disease who are anticoagulated, increases in menstrual bleeding may not be insignificant. Estrogen and progestin can potentiate Coumadin; this monitoring of the INR carefully is essential. An additional concern is thrombotic risk. The authors of this review suggest that progesterone-only methods may be preferable over combination therapies.
8. In women with arrhythmias, consideration of cardiac medications in relation to teratogenic potential is one issue. For use of contraception, most types are effective; however, the thrombotic potential of therapies such as combinations of estrogen and progesterone may be a concern among women with arrhythmias such as atrial fibrillation.
9. Among women with complex heart problems including pulmonary hypertension, several concerns exist. Intrauterine devices when implanted require cardiovascular monitoring often with anesthesia back up. Tubal ligation via hysteroscopic insertion of tubal stents may be preferable, as opposed to more invasive methods. Methods that carry increased thrombotic risk may also not be suitable in these high-risk women.
10. The authors of this excellent review conclude by strongly recommending early, personalized approaches to contraception in women with heart disease. Consideration of what heart medications are used as well as the type and severity of the heart problem should be considered as well. Input from the patient, obstetrician, and cardiovascular specialist are recommended.

Keywords: Antibiotic Prophylaxis, Anticoagulants, Condoms, Contraception, Contraception, Postcoital, Contraceptive Devices, Contraceptives, Oral, Estrogens, Heart Defects, Congenital, Hypertension, Pulmonary, International Normalized Ratio, Intrauterine Devices, Levonorgestrel, Menarche, Norpregnadienes, Ovulation, Pregnancy, Primary Prevention, Progesterone, Progestins, Receptors, Progesterone, Sexually Transmitted Diseases, Stents, Sterilization, Tubal, Sulfonamides, Thrombosis, Venous Thrombosis, Warfarin

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