How to make the switch from OC use to HRT
When should providers help women make the transition from oral contraceptive (OC) use to hormone replacement therapy (HRT)? The following approaches are offered by Andrew Kaunitz, MD, professor and assistant chair in the OB/GYN department at the University of Florida Health Science Center in Jacksonville; Leon Speroff, MD, professor of OB/GYN at Oregon Health Sciences University in Portland; and Felicia Stewart, MD, adjunct professor in the Center for Reproductive Health Research and Policy of the department of OB/GYN and reproductive services at the University of California at San Francisco.
Although many providers recommend checking follicle-stimulating hormone (FSH) levels to determine when OC users have become meno pausal, Kaunitz says he does not believe that practice is useful. His approach is based on the following three observations:
• In perimenopausal-age women, FSH levels can be elevated one month and suppressed the next month. In this age group, therefore, a single elevated FSH does not reliably document that contraception is no longer needed.
• Sex steroids in OC tablets suppress FSH blood levels for far longer than seven days after the last OC tablet is ingested, which means that checking an FSH on the fifth to seventh day of the pill-free interval is not useful.
• Given that the median age of menopause in nonsmoking women is 52-plus years, that means 50% of 52-year-old OC users are not yet meno pausal. By age 55, however, the great majority of women are menopausal.
Kaunitz’s practice in older reproductive-age women doing well on OCs is to continue them on pills until they are in their mid-50s, then switching them to HRT, if they desire, without any lab testing or hormone-free days. He says this practice represents an evidence-based, patient-friendly, and cost-effective approach to the OC/HRT transition.
Speroff’s practice is to begin at age 50 to measure the patient’s FSH on Friday of the pill-free week. When it is greater than 20, he switches the patient to a regular postmenopausal regimen. Because of the variability in FSH levels, Speroff says such an approach does not work for all women, but for most, it does. He believes it is the only practical method outside empirically going to age 55 or 56.
Stewart discusses transition options with the patient and lets her select the approach that seems to best fit her needs. If hormonal swings are among the reasons she is using OCs, then the decision to continue pills until the patient is quite certain to be past menopause is fine; she then can switch to hormone therapy at age 53, 54, or 55, says Stewart. Otherwise, the patient can switch to another method such as a diaphragm, or stop OC use intermittently to check the FSH level and decide about initiating hormone therapy when the level is elevated.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content