Hormonal contraceptive use and new-onset heart failure

Background: Heart failure in young adults is uncommon and typically reflects underlying myocardial vulnerability rather than primary cardiomyopathy. Estrogen-containing oral contraceptive pills (OCPs) are widely used and generally considered safe, though their hemodynamic and metabolic effects in high-risk phenotypes remain incompletely understood.

Case: A 22-year-old woman with class II obesity (BMI 36) and no known cardiac history presented with acute decompensated congestive heart failure, manifesting as progressive dyspnea, orthopnea, and peripheral edema. She denied recent viral illness, pregnancy, substance use, or family history of cardiomyopathy. She reported self-directed use of over-the-counter estrogen-containing OCPs for approximately one year without prior medical evaluation.

On admission, she was tachycardic with mildly elevated blood pressure. Laboratory studies demonstrated elevated natriuretic peptides with normal troponin and inflammatory markers. Transthoracic echocardiography revealed a reduced left ventricular ejection fraction of approximately 30–35% with global hypokinesis, mild left ventricular dilation, secondary functional mitral regurgitation, and elevated filling pressures. Coronary disease and pulmonary embolism were excluded.

The patient was treated with intravenous diuresis and guideline-directed medical therapy for heart failure with reduced ejection fraction, with rapid symptomatic improvement. Estrogen-containing OCPs were discontinued during hospitalization.

Conclusion: This case does not suggest a causal relationship between estrogen-containing OCPs and cardiomyopathy. Rather, it raises the hypothesis that estrogen exposure may act as a hemodynamic, neurohormonal, or metabolic stressor capable of unmasking previously compensated myocardial dysfunction, particularly in the setting of obesity. Potential mechanisms include estrogen-mediated activation of the renin–angiotensin–aldosterone system, sodium and fluid retention, blood pressure instability, and interaction with cardiometabolic stress. Current guidelines address contraceptive safety in women with established cardiovascular disease but do not consider hormonal exposure as a modifier of incident heart failure risk. This case highlights a potential gap in sex-specific heart failure risk assessment and warrants further investigation.

Dr. Affan Irfan, a non-invasive cardiologist specializing in prevention. He holds a PhD in Cardiovascular Physiology from the University of Louisville, KY. Dr. Irfan has worked on research projects in estimating risk biases in guidelines, acute myocardial infarction diagnoses, and cardiac prevention. He is currently at the Cardiovascular Division of Mayo Clinic Health System and Rochester, USA.