Oral contraceptives--induced hypertension--nine years later

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

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.

Resistant Hypertension: Diagnosis and Management

Resistant hypertension is defined as high blood pressure requiring 3 or more medications for adequate control or controlled blood pressure requiring 4 or more medications. Considering the growing prevalence of hypertension and the strong link with cardiovascular disease, it is vital to understand the causes and treatment of resistant hypertension. This review article starts with an overview of the prevalence and little-known pathophysiology of resistant hypertension. Afterward, we discuss the evaluation and management of suspected secondary resistant hypertension in 2 broad categories: pseudoresistant hypertension and true resistant hypertension. Strategies for the identification and management of pseudoresistant hypertension are addressed. In addition, causes of true resistant hypertension, such as obstructive sleep apnea, primary aldosteronism, and renal artery stenosis, are examined along with their respective treatments. Finally, treatment of resistant hypertension is reviewed including pharmacologic treatments and novel procedural interventions for resistant hypertension. Overall, the review hopes to provide practitioners with a cohesive approach for the diagnosis and treatment of resistant hypertension.

CODA: Integrating multi-level context-oriented directed associations for analysis of drug effects

In silico network-based methods have shown promising results in the field of drug development. Yet, most of networks used in the previous research have not included context information even though biological associations actually do appear in the specific contexts. Here, we reconstruct an anatomical context-specific network by assigning contexts to biological associations using protein expression data and scientific literature. Furthermore, we employ the context-specific network for the analysis of drug effects with a proximity measure between drug targets and diseases. Distinct from previous context-specific networks, intercellular associations and phenomic level entities such as biological processes are included in our network to represent the human body. It is observed that performances in inferring drug-disease associations are increased by adding context information and phenomic level entities. In particular, hypertension, a disease related to multiple organs and associated with several phenomic level entities, is analyzed in detail to investigate how our network facilitates the inference of drug-disease associations. Our results indicate that the inclusion of context information, intercellular associations, and phenomic level entities can contribute towards a better prediction of drug-disease associations and provide detailed insight into understanding of how drugs affect diseases in the human body.

Adverse effects of drugs on the kidney

The number of drugs presently marketed is countless, their prescription is relentlessly growing, such that the likelihood of adverse effects is strikingly increasing. As many drugs are cleared by the body through kidney excretion, renal adverse events are likely. In this review we shall concisely describe the pathophysiologic mechanisms of renal damage by drugs, the different clinical presentations outlining renal toxicity in the course of pharmacologic treatment, and the main offending agents.

Angiotensin-converting enzyme and angiotensinogen gene polymorphisms are non-randomly distributed in oral contraceptive-induced hypertension

OBJECTIVES AND METHODS

Oral contraceptives (OC) usage increases serum angiotensinogen levels to three to five times normal and about 5% of these women develop arterial hypertension. The genetic contribution to this susceptibility to OC-induced hypertension is poorly understood. We have analyzed the genotypes of 149 hypertensive and 101 normotensive women using oral contraceptives, for three genetic polymorphisms in genes of the renin-angiotensin system: an insertion/deletion (I/ D) in the angiotensin converting enzyme (ACE) gene, the T235M polymorphism of the angiotensinogen gene (AGT) and a point mutation in its promoter.

RESULTS

After cessation of oral contraception the mean arterial pressures of the hypertensive women were separable into two non-overlapping groups; 88 of the women remained hypertensive and 61 returned to normal blood pressure. Both groups of hypertensive women had a similarly higher frequency of hypertensive relatives than the normotensive women, but were otherwise similar. The 235T allele of AGT was significantly increased in frequency in the 61 oral contraceptive-inducible hypertensive women compared with the controls and the 88 women that remained hypertensive. The ACE I/D genotypes were similarly distributed within the three groups of women, but were distinctly non-random in the oral contraceptive-induced hypertensive women when they were also classified by AGT genotype.

CONCLUSION

This statistical interaction of genotype frequencies suggests that the genetic basis of susceptibility to OC-induced hypertension is complex.

Rapid non-genomic activation of cytosolic cyclic AMP-dependent protein kinase activity and [Ca(2+)](i) by 17beta-oestradiol in female rat distal colon

1. In this study, the effect of 17beta-oestradiol on adenosine 3' : 5'-cyclic monophosphate (cyclic AMP)-dependent protein kinase (PKA) activity was investigated. 2. Rapid (within 15 min) activation of basal PKA activity was observed in cytosolic fractions by 17beta-oestradiol but not by 17alpha-oestradiol, progesterone or testosterone. This stimulation was abolished by the specific PKA inhibitor PKI but not by the classical oestrogen receptor antagonist tamoxifen. 3. 17beta-Oestradiol did not stimulate basal PKA activity in membrane fractions or in cytosolic fractions from male rats. 4. The increase in cytosolic PKA activity was indirect as (i) it was inhibited by the adenylyl cyclase inhibitor SQ22536, (ii) it was mimicked by forskolin and (iii) 17beta-oestradiol did not cause a stimulation of basal PKA activity in either type I or type II commercially available PKA holoenzymes. 5. Protein kinase Cdelta (PKCdelta) was directly activated by 17beta-oestradiol. The specific PKC inhibitor, bisindolylmaleimide I (GF 109203X), abolished the 6. 17beta-oestradiol-induced PKA activation. 17beta-Oestradiol stimulate an increase in free intracellular calcium ion concentration ([Ca(2+)](i)) in isolated female but not male rat colonic crypts. This was inhibited by verapamil, nifedipine and zero extracellular [Ca(2+)] but unaffected by tamoxifen. 17alpha-Oestradiol, testosterone and progesterone failed to increase [Ca(2+)](i). 7. PKC and PKA inhibitors abolished the 17beta-oestradiol-induced increase in [Ca(2+)](i). 8. These results demonstrate the existence of a novel 17beta-oestradiol-specific PKA and Ca(2+) signalling pathway, which is both sex steroid- and gender-specific, in rat distal colonic epithelium.

Effect of desogestrel-containing oral contraceptives on vascular reactivity and catecholamine levels

The modifications induced by new oral contraceptives (OC) on blood pressure, great vessel vascular reactivity by color Doppler, and catecholamine levels were investigated. Young healthy women not taking OC (n = 22; controls) or receiving, for > or = 6 months, OC containing desogestrel with either 30 micrograms (n = 14) or 20 micrograms of EE (n = 8) were enrolled. Blood pressure measured at rest in supine position was similar between controls and OC users. The pulsatility index (PI), an indirect index of resistance to blood flow, of axillary artery was significantly higher (p < 0.05) in 30 micrograms than in 20 micrograms EE OC users or controls. A similar trend, albeit not significant, was observed for the internal carotid artery PI. Norepinephrine (p < 0.01) and dopamine (p < 0.05) but not epinephrine levels, were lower in 30 micrograms EE OC users than in 20 micrograms EE OC users or controls. Thus, both 20 micrograms and 30 micrograms EE OC had no negative effect on blood pressure, but the 30 micrograms EE OC tended to increase great vessel resistance to blood flow, independently of catecholamine levels.

Clinical and metabolic features of desogestrel: a new oral contraceptive preparation

Desogestrel is a highly selective gonane progestin. A monophasic formulation containing 150 micrograms of desogestrel and 30 micrograms of ethinyl estradiol has recently been approved as an oral contraceptive (OC) in the United States. Although desogestrel-containing formulations are new to the United States, they have been the most widely prescribed OCs in Europe for almost 10 years. An extensive literature demonstrates that desogestrel-containing preparations are safe, effective, and well tolerated by most women. In light of desogestrel's high selectivity, low affinity for androgen receptors, and lack of interference with the increase in sex hormone-binding globulin, desogestrel-containing OCs may be particularly appropriate for women with androgen-induced skin disorders because of their high selectivity. Several European studies have found significant improvement or almost complete resolution of previously existing acne. Desogestrel provides excellent cycle control, no major impact on weight, minimal or no adverse effects on blood pressure, statistically significant increases in high-density lipoprotein cholesterol with low-density lipoprotein cholesterol usually unchanged or reduced, and little effect on glucose tolerance or insulin resistance.

Combined oral contraception with desogestrel/ethinyl estradiol: tolerability profile

Since their introduction nearly 30 years ago, oral contraceptives have been widely researched regarding their contraceptive and noncontraceptive effects. With proper usage, oral contraceptives provide highly effective contraception. In addition, oral contraceptives confer significant noncontraceptive health benefits, including prevention of ovarian and endometrial cancer and reduction in the incidence of pelvic inflammatory disease, endometriosis, benign breast disease, and dysmenorrhea, among others. Today's low-dose oral contraceptives have an improved safety profile when contrasted with their early higher dose counterparts. Yet oral contraceptive use continues to be associated with a variety of minor side effects, which range from menstrual changes such as breakthrough bleeding, spotting, or amenorrhea, to androgenic effects, including weight gain and acne. These androgenic effects are important factors in patient discontinuation of oral contraceptives. Progestins with increased selectivity have the potential to cause fewer androgenic side effects while retaining appropriate progestin suppression of the endometrium and hypophyseal-pituitary-ovarian axis. A combination oral contraceptive (30 micrograms of ethinyl estradiol with 150 micrograms of desogestrel) has been evaluated extensively by European investigators. This literature suggests that a low-dose oral contraceptive formulated with the selective progestin desogestrel offers a favorable profile of reduced androgenic side effects while retaining the cycle control associated with low-dose oral contraceptives currently marketed in the United States.

Comparative metabolic study of percutaneous versus oral micronized 17 beta-oestradiol in replacement therapy

The aim of this study was to compare the metabolic effects of two presentations of 17 beta-oestradiol (E2) which are of recognized effectiveness in the prevention of post-menopausal bone loss, one being administered via the oral and the other via the percutaneous route. During this prospective, randomized study, 32 patients were treated for 2 mth with either 2 mg/day of oral micronized E2 (n = 16) or 1.5-3 mg/day of percutaneous E2 (n = 16). Both regimens proved efficacious, since significant increases in oestrone (E1) and E2 concentrations ranging up to mid-follicular values were observed. In the percutaneous-treatment group we noted a significant decrease in triglycerides (TG), without any significant changes in high-density lipoprotein cholesterol (HDL-C) or low-density lipoprotein cholesterol (LDL-C). In the oral-treatment group, we saw no significant increase in HDL-C, although significant increases were observed in body weight, TG, plasma renin substrate (PRS) and sex-hormone-binding globulin (SHBG) as well as significant decreases in antithrombin III (AT III) activity and antigen. All of these metabolic variations led us to the conclusion that oral E2 at the dose established as effective in preventing post-menopausal osteoporosis may, even when micronized, alter certain metabolic and haemostatic parameters in a population characterized by increases in cardiovascular risk factors and morbidity. Oral oestrogen replacement therapy should therefore continue to be used only in carefully selected patients and be strictly followed up by systematic checks on a series of metabolic criteria.

Low-dose oral contraception and blood pressure in women with a past history of elevated blood pressure

Sixty-one women with a past history of elevated blood pressure (high-risk group) associated with oral contraceptive use (27 patients), unknown etiology (17 patients), or preeclampsia (17 patients) used a low-dose oral contraceptive containing 0.4 mg of norethindrone and 35 micrograms of ethinyl estradiol for 3 to 24 months. The highest blood pressures recorded in the past were 141.0 +/- 14.9 (mean +/- SD) mm Hg systolic and 98.3 +/- 8.0 diastolic. Sixty-one women without a past history of elevated blood pressure (low-risk group), selected from a pool of 616 low-risk patients, were matched with the high-risk group for race, initial age, initial body weight, duration of use, history of smoking, and family history of hypertension. The blood pressures in the high-risk group before and after oral contraceptive therapy were significantly higher than those in the low-risk group. Despite these differences, the mean systolic and diastolic blood pressures in these two groups of women using the low-dose oral contraceptive did not rise when compared with their own baseline blood pressures. Five high-risk patients (8.2%) discontinued therapy because of the redevelopment of hypertension; however, blood pressures at discontinuance were comparable to the previous highest blood pressures.

The renin-angiotensin system and total body sodium and potassium in hypertensive women taking oestrogen-progestagen oral contraceptives

Measurements of total body sodium and potassium, and of components of the renin-angiotensin-aldosterone system, were made in a group of women who developed hypertension while taking oestrogen-progestagen oral contraceptives. The results were compared with similar measurements made in age-matched women with essential hypertension. Total body sodium and potassium were normal in both groups. Plasma renin-substrate was significantly elevated in the women taking oral contraceptives, while concentrations of active renin were similar and normal in both groups. Thus plasma angiotensin II was significantly elevated in the pill users; overall the product of renin and renin substrate concentrations correlated significantly with angiotensin II. The rise in plasma angiotensin II in conjunction with normal total body sodium could therefore contribute to the increase in blood pressure induced by oestrogen-progestagen oral contraceptives.

Plasmatic and vascular factors of the hemostatic system in rats receiving an estrogen-progestogen combination

Treatment of rats for 10 estral cycles with an estrogen-progestogen combination giving 100% infertility triggered a vascular response characterized by increased prostacyclin activity in arterial walls and increased systolic blood pressure. In contrast, plasma fibrinolytic activity and physiological coagulation inhibitors as well as vascular fibrinolytic activity were not changed by this treatment. The same rats tended to have shorter occlusion times of an aortic prosthesis, and could represent a useful model to study the blood-vessel-wall interplay during oral contraceptive treatment.

Haemodynamic and hormonal effects of short-term oestradiol treatment in postmenopausal women

Haemodynamic changes during a 3-wk treatment with oestradiol valerianate (2 mg/day orally) were studied in 12 postmenopausal women by isotope 113Inm radiocardiography. Systolic blood pressure measured in the supine position decreased during oestradiol treatment by 3% (P less than 0.05) and the diastolic blood pressure decreased by 4% (P less than 0.01). The heart rate decreased by 15% (P less than 0.001). Blood volume increased during oestrogen treatment by 5% (P less than 0.05) whereas cardiac output decreased by 9% (P less than 0.05). Stroke volume increased by 13% (P less than 0.001) due to concomitant decrease in heart rate. Changes in plasma oestrone and oestradiol concentrations during oestradiol valerianate substitution showed a positive correlation with the changes of blood volume.

Catechol-O-methyltransferase activity in erythrocytes of women taking oral contraceptive steroids

We have measured catechol-O-methyltransferase (COMT) activity in erythrocytes (red blood cells, RBCs) obtained from 64 women taking oral contraceptives steroids and compared these values with those found in RBCs obtained from 73 women using nonsteroidal contraceptives. The COMT activity in the RBCs of women taking oral contraceptives steroids and of women not taking contraceptive steroids was 9.1 +/- 0.28 (mean and standard error) and 8.8 +/- 0.26 nmoles 2-methoxyestrone X ml-1 RBC X hr-1, respectively. This difference in the COMT activity in RBCs from these two groups of women was not statistically significant. This finding differs from that of others who found that COMT activity in RBCs of women taking oral contraceptive steroids was greater than that of women not taking such drugs.

Oral and intrauterine contraception: a 1978 risk assessment

This report reviews the current literature on the various risks associated with the use of oral contraceptives and intrauterine contraceptive devices. Reports on oral contraceptives from large prospective studies are not beginning to supplement the detailed reports resulting from earlier case-control studies. These studies suggest that in Western societies there is an increase in the incidence of a variety of circulatory diseases, with an increased risk of death. With intrauterine contraceptive devices it now has been fairly well documented that there is an increased risk of pelvic inflammatory disease. After reviewing and assessing the risks of both methods in some detail and comparing these risks to the benefits, the resultant conclusion is that the benefits continue to outweigh the risks for both methods, except for older women who choose oral contraceptives and also are heavy smokers.

Contraceptive efficacy determination by postcoital testing

A new vaginal contraceptive method that offers the ease of use with none of the potentially harmful physiologic effects of hormonal contraception was subjected to direct in vivo tests of its efficacy in immobilizing spermatozoa and preventing their entry into the cervical canal. The new contraceptive, a small avoid only 2.8 cm long and 1.4 cm wide, is easily inserted into the vagina without the need for special applicators. It offers protection through the delivery of a highly effective spermicide by the effervescent formation of foam that disperses over the uterine opening. In the trials, no motile spermatozoa could be found in any samples obtained from the vagina, the os externum, or the cervical canal immediately after intercouse protected with the new agent. In no case were any sperm, even immotile sperm, observed in the cervical canal. By contrast, examination of 30 samples obtained immediately after coitus protected with another contraceptive agent (used as a control) revealed motile spermatozao in the cervical canal in nine cases, and propulsive motility was seen on five occasions. The new contraceptive proved highly effective in preventing conception.