Perimenopause

 

The goal of contraception should not only be to prevent pregnancy, but also to improve the user’s quality of life and to provide protection against preventable adverse health conditions, say Amanda Black and Anita Nelson in the newest edition of Contraceptive Technology.¹ A common example? Symptomatic endometriosis is frequently found in this age group, as are heavy and prolonged bleeding episodes. These symptoms may improve with the use of some forms of contraception while concurrently preventing an unintended pregnancy.²

What? Unintended pregnancies among mature women who in so many ways have their lives in control? Oh yes. In fact, the percentage of pregnancies that are unintended at this age is similar to or even higher than is found in younger age groups: almost half of unintended pregnancies during the perimenopause are terminated.³ Why so? Contraception appears to be used less consistently in this age group than earlier in life,⁴ possibly due to a lower perceived risk of pregnancy. But the chance of naturally occurring pregnancy is approximately 30% per year at age 40 to 44, decreasing to 10% per year during age 45 to 49, but certainly not zero.⁵ And remember, pregnancies in this age group are associated with higher risks of poor fetal and maternal outcomes.

When counseling your perimenopausal patients, recommend Black and Nelson, remember that “no contraceptive method is contraindicated on the basis of age alone.”^6,7  For individuals in their later reproductive years, contraindications to contraceptive methods include all those that apply to younger users, such as VTE, malignancy, and certain medications. However, additional medical conditions frequently develop with increasing age that may raise contraceptive risks, particularly for estrogen-containing methods. Conditions to consider in this category include hypertension, obesity, tobacco use, diabetes, migraine, and cardiovascular disease.

What to think about the various contraceptive methods for the perimenopausal patient? Permanent birth control methods such as tubal ligation, salpingectomy, or partner vasectomy may be an option, although the benefit-to-risk ratios for performing these procedures decrease steeply with age.

Implants deliver a progestin that can provide endometrial protection from the risks of unopposed estrogen associated with either anovulation or obesity, which are common problems in this age group.⁸ Extended use of the implant for up to 5 years’ total duration is very appropriate in this age group. But consider, those abnormal bleeding patterns may raise concerns about the possibility of an underlying pathology. In this context, the question would be: “how should one interpret abnormal bleeding, especially for users who have risk factors for endometrial hyperplasia?” Off-label, the implant provides adequate endometrial protection when estrogen therapies are being used to treat perimenopausal or postmenopausal symptoms.⁹

Levonorgestrel intrauterine systems (LNG-IUS) provide top-tier pregnancy protection and, depending upon the specific device, induce endometrial changes that address many uterine and bleeding problems that tend to develop during perimenopause. For off-label use as a source of endometrial protection from systemic estrogen therapy postmenopausally, even longer use may be considered.

Copper IUDs are highly effective, long-acting, reversible contraceptives, but they are associated with increased menstrual blood loss. Therefore, they may not be suitable in the setting of abnormal or heavy uterine bleeding, which is fairly common during the late reproductive years.

DMPA can be useful for treating many types of heavy menstrual bleeding (HMB), including leiomyoma-related or adenomyosis-related HMB in poor surgical candidates, although successful treatment of HMB is less likely with DMPA compared to the LNG-IUS.¹⁰ Additionally, DMPA alone has been shown to help reduce vasomotor symptoms in postmenopausal women.¹¹ Be aware that early unscheduled bleeding may discourage initiation of DMPA in this group. Consider whether the patient has other potential risk factors for osteoporosis that might increase liability risks.

Combined oral contraceptives (COCs) can be safely used by healthy patients without contraindications to estrogen until they reach menopause. However as patients get older, additional health issues may evolve that increase the risk of using an estrogen-containing contraceptive method. COCs provide effective contraception as well as good cycle control (with the possibility of amenorrhea), decreased blood loss, treatment of vasomotor symptoms, at least partial protection against bone loss, and reduction in the risks of several cancers. COCs can reduce irregular menstrual bleeding during the perimenopause and the reduce risk of endometrial hyperplasia associated with anovulatory cycling. COC users in their 40s or early 50s may not experience traditional symptoms of menopause while taking COCs. They will not experience menstrual irregularities or hot flashes, especially if COCs are used on an extended basis.

POPs are excellent options to use when transitioning patients in the late reproductive years from longer acting methods that commonly induce amenorrhea (DMPA, LNG-IUS) or from those methods that cause cyclic bleeding (pills, patches, rings). If there is a question about an individual’s menopausal status or whether she is still at risk for pregnancy when discontinuing one of the other contraceptive methods, switch the patient to POPs and look for absence of bleeding for at least 12 months to be sure that contraception is no longer needed.

Diaphragms (Caya) and, to some extent, the cervical cap (FemCap) rely on vaginal wall support to maintain their positioning. Patients with pelvic relaxation or significant urethral hypermobility may not be optimal candidates for these methods. Male condom use may be more challenging if the partner is older or suffers from erectile dysfunction. In this case, female condoms may be an option. Withdrawal may be appropriate in the perimenopause, especially if the couple is experienced using this method.

 

1] Black A, Nelson A. Contraception in the later reproductive years. In: Hatcher RA, Nelson A, Trussell J, et al. Contraceptive Technology. 21st edition. New York, NY: Ayer Company Publishers, Inc., 2018.
2] Van Heertum K, Liu J. Contraception and conception in mid-life: a review of the current literature. Women’s Midlife Health 2017;3:3.
3] Santoro N, Crawford SL, El Khoudary SR, et al. Menstrual cycle hormone changes in women traversing the menopause: Study of women’s health across the nation. J Clin Endocrinol Metab 2017;102:2218–29.
4] Black A, Yang Q, Wen SW, Lalonde A, Guilbert E, Fisher W. Contraceptive use by Canadian women of reproductive age: Results of a national survey. J Obstet Gynaecol Can 2009;31:627–40.
5] Avis NE, Brockwell S, Randolph JF, et al. Longitudinal changes in sexual functioning as women transition through menopause: results from the Study of Women’s Health Across the Nation. Menopause 2009;16:442–52
6] Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive use, 2016. Morbidity and Mortality Weekly Report (MMWR) 2016;65:1–103
7] World Health Organization. Medical eligibility criteria for contraceptive use. 5th Edition ed. Geneva, Switzerland 2015
8] Santoro N. Perimenopause: From research to practice. J Womens Health (Larchmt) 2016;25:332–9
9] Long ME, Faubion SS, MacLaughlin KL, Pruthi S, Casey PM. Contraception and hormonal management in the perimenopause. J Womens Health (Larchmt) 2015;24:3–10
10] Kucuk T, Ertan K. Continuous oral or intramuscular medroxyprogesterone acetate versus the levonorgestrel releasing intrauterine system in the treatment of perimenopausal menorrhagia: a randomized, prospective, controlled clinical trial in female smokers. Clin Exp Obstet Gynecol 2008;35:57–60
11] Bullock JL, Massey FM, Gambrell RD Jr. Use of medroxyprogesterone acetate to prevent menopausal symptoms. Obstet Gynecol 1975;46:165–8