Contraceptive options for perimenopausal women
By Ivy M. Alexander, MS, C-ANP
Adult Nurse Practitioner, Assistant Professor
Yale University School of Nursing
Adult and Family Nurse Practitioner Programs
New Haven, CT
Perimenopause is the time period preceding menopause. It lasts four years on average and can range from a few months to several years.1-3 Symptoms may begin as early as the mid-30s but are more common in the later 30s and early 40s. Characteristic symptoms are multiple and affect each woman differently. Symptoms can include changes in menstrual patterns, vasomotor instability, psychological and cognitive changes, sleep disturbances, vulvovaginal problems, somatic symptoms, and sexual problems.1-3
Contraception during perimenopause continues to be an important issue. Although fertility is reduced,1,2 pregnancy remains a real possibility for about 50% of patients.1 Perimeno pausal women experience a high rate of unintended pregnancies (77%) — second only to adolescents 13 to 144 — and thus experience a higher proportion of abortion.2,4 Pregnancy after age 35 also carries risks, such as higher rates of spontaneous abortion and miscarriage, increased maternal mortality, and greater incidence of chromosomal abnormalities.1 Careful evaluation for appropriate contraception is important. Consider these options:
• Combined OCs. Hormonal contraceptives include combined oral contraceptive pills (COC) and progestin-only pills, implants, and injections. With recent data demonstrating that age is not a contraindication to COC use, COCs provide a good contraceptive option for perimenopausal women who do not smoke or have hypertension, diabetes, or cardiovascular risks. Current low- dose COCs are safer than older, higher-dose prep arations and do not significantly impact the lipid profile.1 In healthy nonsmokers, the risks for myo cardial infarction, stroke, or thromboembolism are low.1,2 Recent studies suggest that COC use may not impact breast cancer incidence.1,5
Noncontraceptive benefits include reduced perimenopausal symptoms, decreased endometrial and ovarian cancer risk, increased bone density, reduction in benign breast disease, improved cycle control, and potential reduction of menorrhagia and fibroid size and pain.1,2,5,6
Because women taking COCs continue to cycle, diagnosing menopause can be difficult. Some recommend that women cease COC use after age 50 to evaluate follicle-stimulating hormone (FSH) levels. These women must be cautioned about the remaining possibility of pregnancy and need for alternate contraception.1,2 If regular cycling resumes, or FSH levels remain low, COC use can be restarted. Alternately, a woman can continue on COCs and have FSH levels evaluated annually at the end of the pill-free week.7 Although FSH levels may not fully increase by the end of the pill-free week, remaining on COCs does not pose a risk for a healthy woman. When a single elevated FSH is seen, future ovulation is still a possibility and appropriate contraceptive counseling is needed.1,2
• Progestin-only methods. Progestin-only pills, injections, and implants offer an alternative for perimenopausal women who smoke or have cardiovascular risks.1,2 While they afford some protection against ovarian and endometrial cancer and bone loss, these methods do not offer the benefits of estrogen replacement and can increase menstrual irregularity, already a problem among many perimenopausal women. Specific recommendations for identifying menopause when using these formulations are not widely available.2 With injections, the long and unpredictable return to regular menstruation can make identification difficult. (See Contraceptive Technology Update, December 1998, p. 160, for details on use of injections during perimenopause.) In women using implants, evaluating for menopause after scheduled removal is reasonable.2 Due to the long duration of action, injections and implants are not recommended for women interested in future pregnancy.2
• Barrier methods and IUDs. Barrier methods have lower overall efficacy than COCs but have the added benefit of greater protection against sexually transmitted diseases (STDs).1,2 Because perimenopausal women have reduced fertility, the failure rate for these methods is slightly lower than among younger women.1,2 Even so, barrier methods often are not recommended for women who have not used them previously. If they are used, the addition of spermicidal preparations can enhance effectiveness and help women with vaginal dryness.
Intrauterine devices (IUDs) represent another birth control option; in fact, the Copper T-380 offers contraceptive effectiveness equal to that of surgical sterilization.2 Menopause is easily identified since the IUD does not mask menstrual cessation.2 The most notable problem associated with the IUD is the possibility of heavier or longer bleeding. Hormone-containing IUDs can reduce bleeding through a local suppressive effect on the endometrium.1,2 While the Progestasert IUD (Alza, Palo Alto, CA) needs to be replaced annually, it represents a good option for women with menorrhagia who are not COC candidates.
• Periodic abstinence. Periodic abstinence becomes less effective due to perimenopausal cycle irregularity. However, using additional indicators of ovulation (mucous changes and basal body temperature) can improve effectiveness. Education regarding cycle changes, reduced days when intercourse is permitted, and the decreased reliability of this method during perimenopause is important.1,2 Women who have used this method may continue to find it effective; however, it is generally not recommended as a new method due to low efficacy, perimenopause cycle irregularity, and lack of STD protection.
• Surgical sterilization. Surgical sterilization, available for both women and men, is used by about 50% of women over age 30 and about 15% of partners.2 Regret is less common with increasing age, but potentially reversible methods are always preferable.1,2 Although extremely effective, sterilization is generally not easy to reverse and does not afford protection against STDs.
Counseling about options, potential benefits, and side effects for each choice is necessary for women to select a safe and effective method. Careful attention to personal and family health history, individual preferences, previous experiences, and any wishes for future fertility should guide the selection process.
References
1. Shabaan MM. The perimenopause and contraception. Maturitas 1996; 23:181-192.
2. Westhoff C. Contraception at age 35 years and older. Clin Obstet Gynecol 1998; 41:951-957.
3. Nachtigall LE. The symptoms of perimenopause. Clin Obstet Gynecol 1998; 41:921-927.
4. Forrest JD. Epidemiology of unintended pregnancy and contraceptive use. Am J Obstet Gynecol 1994; 170:1,485-1,489.
5. Tzingounis V, Cardamikis E, Ginopoulos P, et al. Incidence of benign and malignant breast disorders in women taking hormones (contraceptive pill or hormonal replacement therapy). Anticancer Res 1996; 16:3,997-4,000.
6. DeCherney A. Bone-sparing properties of oral contraceptives. Am J Obstet Gynecol 1996; 171:15-20.
7. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th ed. New York City: Ardent Media; 1998.
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