Consider prescribing OCs for perimenopause use
A 45-year-old woman comes to you with complaints of night sweats, insomnia, and menstrual headaches, with menses coming every three weeks. She stopped smoking cigarettes six months ago after 25 years of use, and her family medical history includes osteoporosis, hypertension, and hypercholesterolemia. Her blood pressure is normal. Her cholesterol profile reveals a high-density lipoprotein (HDL) reading of 34 mg/DL and a low-density lipoprotein (LDL) reading of 150 mg/dL. A bone density measurement indicates osteopenia. Physically, she is thin and otherwise healthy, and her gynecological exam is normal. What is your approach?
Consider use of low-dose (20-35 mcg estrogen) oral contraceptives (OCs), advise contraceptive experts. For the perimenopausal patient, OCs have a number of advantages over hormone replacement.1 Benefits include effective contraception (if so needed), regular menses, treatment of menorrhagia and/or dysmenorrhea, reduction in vasomotor symptoms, higher bone density and fewer fractures, and prevention of ovarian and endometrial cancers.2
"In my practice, I am following an increasing number of perimenopausal women, many of whom do not need contraception, on OCs," says Andrew Kaunitz, MD, professor and assistant chair in the OB/GYN department at the Univer sity of Florida Health Science Center in Jackson ville. "In this particular patient, use of an OC formulated with norgestimate or desogestrel might be particularly appropriate to improve her lipoprotein parameters."
OCs used during the transition years offer a reliable form of birth control, a feature not afforded through hormone replacement therapy (HRT). Women in the perimenopause can benefit from pregnancy prevention. The abortion rate among women age 40 and above is exceeded only by that of teen-agers.3
Past fears impact use
The hesitation to use OCs in older women goes back to the mid 1980s, when OCs were not approved by the federal Food and Drug Admin istration (FDA) for women over age 35, recalls Leon Speroff, MD, professor of OB/GYN at Oregon Health Sciences University in Portland. Speroff, who then served as chair of the Gynecol ogic Practice Committee for the Washington, DC-based American College of Obstetricians and Gynecologists (ACOG), invited FDA officials to an ACOG committee meeting to hear the physicians’ opinion that low-dose pills were safe for healthy nonsmoking women. As a result, the FDA removed the age limit, despite the fact that the judgment was not yet supported by data, he says.
"Subsequent epidemiological data confirmed that low-dose pills are safe for healthy women, especially if [they are] nonsmoking with normal blood pressures," he says. "Yet there continues to be this fear, especially among internists and family practitioners."
The warnings against OC use by women over 35 were widely taught for a decade, says 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.
Those "contraindications" were based on the observed association between use of early, higher-dose OC and an increased risk of heart attack and stroke, notes Stewart. Later, more definitive research found that the increased risk observed was mainly related to smoking rather than just age, but many women and their clinicians had heard the warnings many times over the decade and continued practice based on the older data.
By reducing bone turnover acceleration and possibly enhancing bone mass, low-dose OCs can reduce the risk for future osteoporosis.4 Kaunitz points to a recently published study indicating that women who use the pill can reduce their risk of postmenopausal fractures.5
A history of OC use was assessed in 1,327 cases of hip fracture and 3,312 randomly selected controls in a Swedish population-based case-control study of women ages 50 to 81. Compared with women who had never used OCs, use of OCs after 40 was associated with a significantly decreased risk of hip fracture; in contrast, use before 30 did not significantly reduce risk, while those who used OCs between ages 30 and 40 experienced an intermediately reduced hip fracture risk.
One caveat of the study is that most past use of OCs involved older pills with a dose of estrogen higher than OCs in contemporary use, says Kaunitz. Nonetheless, it provides strong evidence that in the decade prior to menopause, use of combination OCs can reduce risk of fractures decades later in life, he says.
Women in the perimenopause group also could expect effective contraception protection from consistent condom use or consistent barrier method use as well as intrauterine device or contraceptive implant use, Stewart says. OCs mute the hormonal swings during the menstrual cycle, she notes. For many women approaching menopause, those swings are unpleasant and often associated with side effects such as less-regular bleeding patterns or premenstrual syndrome, she observes.
In assessing candidacy for OC use, smoking is an important risk factor. Pill use by smokers over age 35 is contraindicated, says Kaunitz. Use progestin-only pills, intrauterine devices, or barrier contraceptives for birth control in this population, he suggests. (How do you make the transition from OCs to HRT? Physicians share their approaches in "Ask the Experts," p. 33.)
References
1. Sulak PJ. Oral contraceptives: Therapeutic uses and quality-of-life benefits — Case presentations. Contraception 1999; 59:35S-38S.
2. Kaunitz AM. Oral contraceptive use by perimeno pausal women: An evidence-based approach. Presented at the Contraceptive Technology Quest for Excellence Conference. Atlanta; October 1999.
3. Mishell DR Jr., Stenchever MA, Droegemueller W, et al. Comprehensive Gynecology, 3rd ed. St. Louis: Mosby-Year Book; 1997, pp. 405, 532-533.
4. Association of Reproductive Health Professionals. Women’s health in the perimenopause: An integrated approach. Clinical Proceedings 1999; December:3.
5. Michaelsson K, Baron JA, Farahmand BY, et al. Oral contraceptive use and risk of hip fracture: A case-control study. Lancet 1999; 353:1,481-1,484.
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