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Use contraception management tips for women approaching menopause
Contraception plays key part in health planning during transition
Your next patient is a recently divorced 48-year-old mother of two. Her menstrual periods have become somewhat irregular, and she reports occasional hot flashes and night sweats. Her ex-husband had a vasectomy. She has used condoms with her current boyfriend. What options are available that will address her specific needs?
Perimenopause is the time of transition from normal ovulatory cycles to menopause, with menstrual irregularity as the key marker.1 No one symptom or test is accurate enough by itself to make a definitive diagnosis. Clinicians should diagnose perimenopause based on menstrual history and age without relying on laboratory test results.2
Mean cycle length in the last four years prior to menopause for healthy U.S. women has been reported as 30.48, 35.02, 45.15, and 80.22 days.3 However, contrary to prevailing opinions, women in the late-menopausal transition group see significantly higher menstrual blood loss after an ovulatory cycle than an anovulatory cycle, recent research indicates.4
According to the Washington, DC-based Association of Reproductive Health Professionals, most women in their early to mid 40s still ovulate regularly and are at risk for pregnancy.5 This is evidenced by the latest analysis of U.S. birth trends; the preliminary birth rate for women ages 40-44 in 2008 increased 4%, to 9.9 births per 1,000 women, the highest rate since 1967. The rates for women ages 45-49 years also increased in 2008 from 0.6 births per 1,000 in 2007 to 0.7.6
Older maternal age is associated with relatively higher risks of perinatal mortality/morbidity.7 Medical risks associated with pregnancy in older women include gestational diabetes and pregnancy-induced hypertension.7 To avoid unintended pregnancy and its complications, contraception is an important part of health planning.
Weigh benefits, risks
What are some of the benefits of using hormonal contraception in women during the "transition years" prior to menopause?
Hormonal contraception provides excellent protection from unintended pregnancy, notes Nikki Zite, MD, MPH, assistant professor in the Department of Obstetrics and Gynecology in the University of Tennessee Graduate School of Medicine in Knoxville. Zite will present on contraceptive management for women in the transition years during the October 2010 Contraceptive Technology Quest for Excellence conference in Atlanta.
This protection is extremely important to emphasize to women who might believe they are no longer fertile, says Zite. Fifty-one percent of pregnancies to women over age 40 are unintended, and 60% of pregnancies in women over 40 are terminated.8
Hormonal methods of contraception offer numerous non-contraceptive health benefits, such as a decrease in risk of ovarian and endometrial cancer, says Zite. A benefit unique to a "transition years" female is relief from some of the symptoms she is experiencing due to hormonal changes, observes Zite.
"Hormonal contraception can regulate the cycle irregularities that occur as the ovaries less consistently produce follicles and treat the perimenopausal mood issues that often bother women," says Zite.
What conditions may preclude the use of hormonal contraception in women in this age range? Most of the contraindications to the use of hormonal contraception exist regardless of age; however, some of the conditions that are contraindications, such as poorly controlled hypertension, are usually more common as women age, says Zite. Women over age 35 who are smokers, regardless of how much they report they smoke, should be advised against estrogen-containing contraceptive options, states Zite. Progestin-only hormonal methods remain safe and effective options for smokers over age 35, she notes.
What are the options?
The copper-bearing intrauterine device (ParaGard IUD, Teva Women's Health) provides convenient and excellent long-term pregnancy prevention without hormones. For perimenopausal women with heavy menstrual bleeding, the levonorgestrel intrauterine system (Mirena LNG IUS, Bayer HealthCare Pharmaceuticals, Wayne, NJ) provides effective contraception, as well as prevents erratic perimenopausal bleeding. The Food and Drug Administration gave approval in October 2009 for use of the Mirena for heavy menstrual bleeding in women who desire contraception.
The LNG IUS is the most effective medical treatment of heavy menstrual bleeding. In clinical trials, 85% of women with idiopathic heavy menstrual blood had normalization of menses. Women had a 71% reduction in median blood loss by six months. Longer use of the method is associated with increasing rates of amenorrhea.9 By five years of use, 50% of users had no spotting or bleeding.
How about use of the contraceptive injection [depot medroxyprogesterone acetate (DMPA), Depo Provera, Pfizer, New York City; Medroxyprogesterone Acetate Injectable Suspension, USP, Teva Pharmaceuticals USA, North Wales, PA]? Use of DMPA in women ages 18-45 is classed by the US Medical Eligibility Criteria for Contraceptive Use as a "1," a condition for which there is no restriction for the use of the contraceptive method.10 Use in women above age 45 is classed as a "2," a condition for which the advantages of using the method generally outweigh the theoretical or proven risks.10
Most studies have found that women lose bone mineral density (BMD) while using DMPA, but regain BMD after discontinuing the method, the criteria note. However, it is not known whether adult women with long duration of DMPA use can regain BMD to baseline levels before entering menopause, it states. The relation between DMPA-associated changes in BMD during the reproductive years and future fracture risk is unknown.10
For perimenopausal women who have contraindications to the pharmacologic doses of estrogen in combined hormonal methods, progestin-only pills may also be considered for contraception.11
Pill, patch, or ring?
Low-dose birth control pills represent another possible option for women during perimenopause. Low-dose combined oral contraceptives (OCs) can correct irregular bleeding, help with hot flashes and night sweats, and reduce the risk of ovarian and uterine cancer. Low-dose pills, as well as the contraceptive patch (Ortho Evra, Ortho Women's Health and Urology, Raritan, NJ) and the contraceptive vaginal ring (NuvaRing, Merck & Co., Whitehouse Station, NJ) are appropriate options for healthy, nonsmoking, nonobese perimenopausal women.11
How long can women take the Pill? According to information presented at the 2010 Contraceptive Technology conference, combined oral contraceptives may be used up until age 50.12
What about the risk for breast cancer? Many of your patients may overestimate their risk for breast cancer. In a 2009 national survey, 40% of women ages 35 to 75 estimated that a 40-year-old's chance of developing breast cancer over the next decade is 20% to 50%. The real risk is 1.4%, according to the National Cancer Institute.13
In the wake of the Women's Health Initiative (WHI) studies, women might be confused by information they hear about hormones. According to Contraceptive Technology, healthy reproductive-aged women are not affected by low-dose OCs because they already are exposed to endogenous hormones.11
Exactly when is menopause?
According to Contraceptive Technology, menopause can be diagnosed in women in the following circumstances:1
The median age of menopause is 51.3 years, according to Contraceptive Technology. Approximately 1% of women undergo menopause before age 40; 2% of women still are not menopausal at age 55, it says. Menopause before 30 can be associated with chromosomal abnormalities. A genetic evaluation is indicated, according to Contraceptive Technology. Premature menopause (less than 40 years old) and early menopause (less than 45 years old) are strongly influenced by family history; however, age of menopause does not follow a clear familial pattern and therefore is not predictable, it says.