Is hormonal contraception right for your perimenopausal patient?
In healthy patients, combination OCs and other hormonal methods have a lot to offer—as long as you’re mindful of risks in selected subgroups.
IN THIS ARTICLE
Kaunitz: One randomized trial found that OC use increases bone mineral density (BMD) in women of older reproductive age.34 And a population-based, case-control trial from Sweden found a 25% reduction in the risk of hip fracture among postmenopausal women who had a history of OC use. The reduction in risk was even greater when the women had used OCs in their 40s or for an extended duration.35
The Women’s Health Initiative found no reduction in the risk of fracture among previous users of OCs, but failed to stratify women by the age at which they used OCs.
OBG Management: Are any hormonal contraceptives associated with bone loss?
Kaunitz: Yes. Use of intramuscular DMPA (150 mg) or subcutaneous DMPA (104 mg) is linked to a loss of BMD. The good news is that BMD recovers after discontinuation of the drug, even in women who begin to use it after 40 years of age.29,36 However, we lack data on the risk of fracture among postmenopausal women with a history of DMPA use.
OCs may ease hot flushes and other menopausal symptoms
OBG Management: Is there any evidence that use of combination OCs by perimenopausal women relieves vasomotor symptoms?
Kaunitz: Yes, but the number of studies demonstrating this association so far has been limited. One small double-blind trial randomly assigned women to use of an OC containing 20 μg of estradiol or to placebo.37 Although the number and severity of symptoms diminished by about 50% in those taking the OC, the difference was not statistically significant.
A prospective observational study found that 90% of perimenopausal women experienced complete relief after taking an OC containing 30 μg of ethinyl estradiol, compared with only 40% of nonusers.38
OBG Management: What about other forms of hormonal contraception? Are any effective against vasomotor symptoms?
Kaunitz: One interesting option is to use menopausal doses of estrogen to treat vasomotor symptoms along with an LNG-IUS to prevent endometrial hyperplasia and provide contraception, if needed. This combination produced substantial improvement in a trial involving perimenopausal women who were experiencing vasomotor symptoms.39 Most of the women became amenorrheic, and there was no endometrial hyperplasia.
DMPA in contraceptive dosages also has relieved vasomotor symptoms in menopausal women, compared with placebo.40
OBG Management: What about women who experience vasomotor symptoms during the 7 placebo days of a 28-pill cycle? What options do they have?
Kaunitz: Some physicians either switch to a 24/4 OC formulation (Yaz or Lo-Estrin 24), an extended OC formulation with no placebo days (Seasonique), a continuous OC formulation (Lybrel), or simply prescribe pills from a traditional 21/7 pack in a continuous fashion so as to eliminate the hormone-free interval. However, this strategy has been studied to only a limited degree.
At what age should an OC be discontinued?
OBG Management: Perimenopausal women are, obviously, going to become menopausal at some point. How do you know when that transition occurs if they are taking OCs?
Kaunitz: It turns out that testing is not useful in this clinical setting. Some people have advocated measuring the follicle-stimulating hormone (FSH) level, but this strategy is unreliable. An elevated FSH level—thought to be indicative of menopause—has been found in older ovulatory women,41 and a depressed FSH level has been found in postmenopausal women for weeks after discontinuation of OCs.42
Rather than use this imperfect science to try and predict the point of menopause, I recommend discontinuing OCs once the woman has attained age 55, arbitrarily assuming that she is menopausal at this age. I use the same approach for women using other hormonal contraceptives.8,43
