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Contraception Issues Complex in Perimenopause : With many birth-control options available, women older than 40 tend to prefer long-term methods.


 

ATLANTA — Women in perimenopause have unique issues that should be considered when developing a contraceptive plan, Dr. Miriam Zieman said at a conference on contraceptive technology that was sponsored by Contemporary Forums.

Older women are generally less fertile and thus their bodies may be more forgiving in terms of contraceptive efficacy. However, perimenopausal women often still ovulate for several years and thus the potential for pregnancy exists. In fact, the abortion ratio (number of abortions per 1000 live births) is high in women over 40.

To more easily gauge progress through perimenopause, women should keep a menstrual diary of any bleeding or spotting that occurs. “Taking an accurate menstrual history is so important to our diagnosis during these ages,” said Dr. Zieman of Emory University, Atlanta.

Comorbidities, including hypertension, heart disease, and obesity, are more common in older women. These conditions can affect the choice of contraception, because the risks associated with contraception generally increase with age. In general, though, “combination contraceptives can be safely used by lean, healthy, nonsmoking women until menopause,” Dr. Zieman said.

Because women older than 40 are often finished with childbearing, they tend to prefer long-term contraceptive methods. Indeed, data from the Centers for Disease Control and Prevention show that tubal sterilization is the most common contraceptive method in women aged 35–39 and 40–44.

Dr. Zieman suggested that intrauterine devices should be considered more frequently, as they are reversible, less risky than sterilization, and safe for most women. IUDs can also be used in a broader range of women, including those with contraindications to estrogen-containing hormonal contraception. Women with venous thromboembolism, arterial vascular disease, and acute liver disease; women who smoke; and those with migraine are all candidates for the copper IUD, and most can use the levonorgestrel system. For specific information, see the World Health Organization medical eligibility criteria at http://www.who.int/reproductive-health/publications/mec/iuds.html

For women without contraindications, combination oral contraceptives may be a good option, as they provide noncontraceptive benefits, such as improving menorrhagia, reducing vasomotor symptoms, and reducing the risk of endometrial and ovarian cancers.

Progesterone-only pills may be more appropriate choices for women with estrogen-contraindicating comorbidities such as hypertension.

Depot medroxyprogesterone acetate (DMPA) would be another good progestin-only option for perimenopausal women not planning to have more children. Women with hypertension can use DMPA as long as their blood pressure is controlled below 160/100, according to the World Health Organization guidelines.

When using methods that interfere with menstruation, the decision of when to stop contraception because of suspected menopause is arbitrary.

Follicle-stimulating hormone testing is not a reliable indicator of potential fertility in women older than 45 years. Moreover, in women using oral contraception, FSH testing cannot sensitively predict menopause on day 7 of the pill-free interval.

Dr. Zieman suggested that a woman may consider discontinuing oral contraceptives at age 50, while continuing to protect herself from pregnancy, in order to evaluate her menstrual status. Alternatively, she may want to continue them until age 55, at which point she has likely entered menopause.

The safety of continuing oral contraception through that age is not fully understood, and decisions should be made on an individual basis, taking into account how the woman feels about continuing with pills, she said.

Dr. Zieman has received honoraria from or consulted for Ortho, Barr, Berlex, Organon, and Wyeth.

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