A 34-year-old woman, gravida 1 para 1, comes to the clinic for evaluation of her contraceptive method. For the past 8 months, the patient has experienced unpredictable bleeding since having a subdermal progestin implant placed and requests its removal. She previously used combined oral contraceptives and would like to return to that method. The patient has primary hypertension that was diagnosed last year and has been well controlled with hydrochlorothiazide. She takes no other medications and has no allergies. Her father and brother have type 2 diabetes mellitus. The patient does not use tobacco, alcohol, or illicit drugs. BMI is 24 kg/m². Blood pressure is 130/75 mm Hg. Physical examination is normal. Combination oral contraceptives increase the patient's risk of which of the following?

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11ec25c8_d261_e31c_bc81_99bfda2ffa2e_MD0003_00 Combination estrogen/progestin oral contraceptive pills (OCPs) have risks and benefits that should be discussed with patients prior to starting therapy. Although most women have no blood pressure changes, a risk of OCP use is hypertension due to increased angiotensinogen synthesis by estrogen during hepatic first-pass metabolism. Therefore, women who have controlled hypertension may take combination OCPs with close blood pressure monitoring to ensure ongoing control. An additional side effect of OCPs is an increased risk of thromboembolism due to the hypercoagulable properties of estrogen. Women with uncontrolled hypertension, end-organ damage, or are age >35 and use tobacco should not be placed on combination OCPs. The compounding of these factors results in an increased risk of myocardial infarction and stroke. The elimination of a modifiable risk factor, such as OCP use, can decrease the overall risk of these conditions for this patient population. > (Choice A) OCPs decrease the risk of benign breast disease, particularly fibroadenoma and fibrocystic breast disease. A history of benign breast disease or family history of breast cancer is not a contraindication to OCP use. (Choices B and C) OCPs reduce the risk of endometrial and ovarian cancer. The decreased risk of endometrial cancer is due to progestin, which counteracts estrogen's effect on endometrial proliferation. The decreased risk of ovarian cancer is attributed to chronic suppression of ovulation. (Choice D) OCP use has been associated with glucose intolerance and increased insulin resistance in some studies, but it has not been directly linked to the development of type 2 diabetes mellitus. Educational objective: Combination oral contraceptive pills (OCPs) can worsen hypertension. Patients with well-controlled hypertension may use OCPs but should have their blood pressure monitored. OCPs reduce the risk of endometrial and ovarian cancer. References: Blood pressure effects of the oral contraceptive and postmenopausal hormone therapies. (http://www.ncbi.nlm.nih.gov/pubmed/21565676) Blood pressure measurement prior to initiating hormonal contraception: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23063336)

A 34-Year-Old Woman, Gravida 1 Para 1, Comes to the Clinic