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Contraception Corner

Contraception in the Perimenopausal Woman

Barbara Clark, RN, MSN, MPH; Kirtly Parker Jones, MD

Perimenopausal women need contraception as much as younger women, and they can choose from the same menu of options. However, prudent selection is ultimately determined by their unique priorities and needs. During the 5 to 7 years before menopause, women undergo many changes due to fluctuating and waning estrogen levels. Women may have shortened or lengthened cycles, heavier bleeding, intermenstrual spotting, dysmenorrhea, and worsening of premenstrual symptoms. In addition, perimenopausal women may also experience the onset of vasomotor symptoms, including hot flashes, night sweats, and sleep disturbances. Preventing osteoporosis and gynecologic cancers can become a concern as well.

However, perimenopausal women continue to be sexually active. According to the Study of Women ês Health Across the Nation,1,2 there are no differences between premenopausal and perimenopausal women with regard to sexual desire, satisfaction, arousal, physical pleasure, or the importance of sex. As women age, the likelihood of pregnancy decreases and the risk of miscarriage increases, but the potential consequences of an unplanned pregnancy after age 40 years are significant.3 Contraception is still required during perimenopause; one survey found that 51% of pregnancies occurring among women aged 40 years and older during 1994 were unintended, of which 65% resulted in abortion.4

Perimenopausal women are also still at risk for human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and sexually transmitted infections (STIs). In the United States, HIV infection was among the four leading causes of death for black and Hispanic women aged 35 to 44 years in 2001. Overall, HIV infection was the fourth leading cause of death among all women aged 35 to 44 years.5

Perimenopausal women can choose from the same contraceptive methods that are available to younger women. However, some methods are better suited to this population than others.

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CONTRACEPTIVE CHOICES


Womenês contraceptive needs and desires change with age, especially at midlife. For example, the perimenopausal woman may choose oral contraceptives (OCs) for their noncontraceptive benefits, such as menstrual cycle control and osteoporosis prevention. As she is less likely to desire a future pregnancy, she may choose a long-acting contraceptive that is not readily reversible (eg, medroxyprogesterone acetate) or a permanent method (eg, sterilization). In fact, 50% of all women aged 40 to 44 years who practice contraception have been sterilized, and another 20% have a partner who has undergone vasectomy.6 Other factors influencing contraceptive choice include frequency of intercourse, route of administration, safety, effectiveness, need for protection against STIs and HIV/AIDS, lifestyle, behaviors (eg, cigarette smoking), and medical history. The contraceptive options discussed here all have high efficacy rates, except for barrier methods. They all have various advantages and disadvantages; a comparison is presented in the Table.

Table not available online

TABLE. Comparison of Contraceptives for Perimenopausal Women

Oral Contraceptives

Despite the well-documented noncontraceptive benefits of OCs, only 11% of US women aged 40 to 44 years and 4% of those aged 45 to 50 years reported using OCs.7 Women in this population may associate serious health risks with OCs.8 This was an accurate perception before 1991, when OCs were contraindicated in women aged 35 years and older. In the early 1990s, the US Food and Drug Administration (FDA) determined that this risk was confined to smokers, and that the age of the nonsmoking user was not related to cardiovascular risk.

The reduction in estrogen and progestin dosages over the past 30 years has led to a significant reduction in OC-related health risks, and most formulations now contain 20 to 35 mcg of ethinyl estradiol (EE). Indeed, combined (ie, estrogen/progestin) OCs have many noncontraceptive benefits as well. Women for whom estrogen is contraindicated can use a progestin-only pill, but these formulations confer no noncontraceptive advantages.

Dysmenorrhea and changes in the amount, duration, and frequency of menstrual flow are the most common reasons for women to seek medical attention during perimenopause. Oral contraceptives can improve such dysfunctional uterine bleeding,8 and may also help reduce the need for gynecologic surgery for benign menstrual conditions (eg, fibroids, dysfunctional bleeding). Rates of hysterectomy for these menstrual conditions peak among women in their 40s.9

Perimenopausal women may want to consider an extended OC regimen to help alleviate menstrual disturbances. This type of regimen significantly reduces bleeding episodes and the number of bleeding days. In 2003, the FDA approved a dedicated extended OC regimen whereby women take 84 days of active pills, followed by a 7-day pill-free interval to induce withdrawal bleeding.

During perimenopause, bone loss starts to accelerate because of decreasing estrogen levels: Peak bone mass is attained between ages 20 and 40 years and then decreases about 1% per year.10 Prospective studies of perimenopausal women have found that OCs can preserve bone mineral density. Vasomotor symptoms (eg, hot flashes, night sweats, vasomotor instability) affect approximately 85% of peri- menopausal women.13 According to prospective studies, OCs can relieve vasomotor symptoms in most women.14

Studies show that OCs can also significantly reduce the risk of gynecologic cancers. Specifically, OC use at any point in a womanês lifetime can decrease the risks of ovarian and endometrial cancers by up to 80% and by 40% to 50%, respectively.15,16 Furthermore, OCs may also protect against colon cancer17 and decrease the incidence of pelvic inflammatory disease.18

Condoms

Perimenopausal women are still at risk for HIV/AIDS and STIs. Other than abstinence, the male condom is the only method that protects against STIs. Women should be questioned and counseled about safe-sex practices, and the physician should not assume that older patients do not require advice about such precautions. To prevent pregnancy, condoms should be combined with another contraceptive method.

Sterilization

Female sterilization, the most common contraceptive method used by older women, provides permanent protection against pregnancy. It also may lower the risk of ovarian cancer and increase sexual spontaneity and satisfaction due to less anxiety about becoming pregnant.19,20

Female Barrier Methods

Female barrier methods, which include the diaphragm and cervical cap, have an average 85% efficacy rate. The advantages are that they do not require special medical care, except for a diaphragm fitting, and there are no side effects aside from an occasional allergic reaction to latex. Women should be cautioned that female barrier methods are often used incorrectly, leading to unintended pregnancy.

Periodic Abstinence

Perimenopausal women should not rely on the –rhythm method,” because the timing of ovulation becomes more difficult to predict during this period. Menstrual cycles are often erratic during peri-menopause, rendering charting—even by temperature—useless.

Depot Medroxyprogesterone Acetate Injection

For women who cannot use estrogen, quarterly depot medroxy-progesterone acetate injections are a good progestin-only option. Depot medroxyprogesterone acetate confers noncontraceptive benefits that include decreased cramping, bleeding, and anemia. As return to fertility is delayed, it may be contraindicated for perimenopausal women desiring future pregnancy.21

Intrauterine Contraception

Two forms of intrauterine contraception are available in the United States: the copper-T intrauterine device (IUD) and the levonor-gestrel-releasing intrauterine system (LNG-IUS). The LNG-IUS may be more suitable than the copper-T IUD for perimeno-pausal women because it reduces menstrual bleeding and dysmenorrhea, whereas the copper-T IUD may increase both conditions. Women using the LNG-IUS may have lighter periods, irregular light bleeding, or amenorrhea.22 The copper-T IUD is effective for up to 10 years, and the LNG-IUS for 5 years.

Implants

A single-rod implantable contraceptive will soon be available in the United States, providing protection for up to 3 years.23 This implant is a small, flexible, 40-mm by 2-mm rod that contains ethylene vinyl acetate impregnated with 68 mg of etonogestrel. For perimenopausal women who cannot use estrogen, who want long-term protection with rapid reversibility, and who want to control fluctuating hormone levels, this may be an attractive option. As with all progestin-only methods, there are noncontraceptive benefits and irregular vaginal bleeding is not uncommon.

Transdermal Contraceptive Patch

The transdermal contraceptive patch contains the progestin no-relgestromin and EE. A new patch is applied each week for 3 weeks (21 total days), and week 4 is patch-free. Perimenopausal women may desire this method because it is a simple, weekly approach that they can control, and it regulates menstrual bleeding.

Vaginal Ring

The vaginal ring releases a daily dose of estrogen and progestin. The patient removes it after 3 weeks for a 1-week break, and then inserts a new ring. Advantages to perimenopausal women are good menstrual cycle control, relief of vaginal dryness, and rapid reversibility. Because this is a new low-dose method, there is no long-term evidence yet as to whether it protects against bone loss or uterine and ovarian cancers.

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CONCLUSION

Women at midlife deserve a healthy and satisfying sex life—without fear of pregnancy and STIs. They also deserve to have as smooth a transition to meno-pause as possible. Easing menstrual disturbances, stabilizing hormonal levels, and helping to prevent long-term diseases are priorities. Physicians can help perimenopausal women choose the appropriate contraceptive by considering medical, personal, social, and sexual history; plans for future pregnancy; lifestyle; desire for sexual spontaneity; and cost—as well as efficacy and noncontraceptive benefits.

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Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, Va. Kirtly Parker Jones, MD, is professor and vice chair of Educational Affairs, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City.

References

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