Managing perimenopause: the case for OCs
Perimenopausal patients—and their physicians—often view oral contraceptives with suspicion, believing the pills too risky for older women. But, the author argues, the evidence proves just the opposite.
TABLE 1
Beneficial effects of perimenopausal OC use
| CONTRACEPTIVE ISSUES |
|
| BENIGN GYNECOLOGIC DISORDERS |
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| ESTROGEN DEFICIENCY SYMPTOMS/SEQUELAE |
|
| EFFECTS ON THE BREAST |
|
| CANCER PREVENTION |
|
| DIAGNOSTIC/THERAPEUTIC PROCEDURES |
|
Contraindications and other barriers to use
Contraindications to OC use—for women of all ages—include a history of myocardial infarction (MI), thromboembolism, stroke, breast cancer, or serious liver disease. Women over 35 who have risk factors for cardiovascular disease also should be discouraged from taking the pills. When in doubt, limit OC use among perimenopausal women to healthy nonsmokers.
There are a number of reasons perimenopausal women elect not to use OCs, and they need to be considered when counseling patients. For example, in some cases, cost may be an issue, while side effects discourage many other women. Fortunately, the low-dose formulations available today carry fewer side effects than in years past. They also may be administered in a number of different ways to further reduce the likelihood of adverse effects. For example, my colleagues and I found that some effects, e.g., headache, pelvic pain, breast tenderness, and bloating, occur more frequently during the 7 days when no pills are taken than during the 21 days when they are.26 Many Ob/Gyns now extend the “active” phase of OC regimens while reducing the pill-free interval. In fact, a formulation is now available that includes only 2 pill-free days (Mircette; Organon, Inc, West Orange, NJ), and an OC with 12 weeks of active pills is currently under investigation (Seasonale; Barr Labs, Pomona, NY).
This strategy may be advisable for all perimenopausal women who take OCs, which can be extended for 12 active weeks or longer, if necessary. (In one investigation, older women preferred menstruating every 3 months to never.27) In this regard, triphasic pills have no advantages over monophasic formulations. If a patient taking a triphasic OC wants to try continuous dosing, I generally switch her to a monophasic equivalent. If breakthrough bleeding occurs on a 20-mcg OC, I prescribe a 30-mcg formulation. Hopefully, further research will elucidate the best way of extending OC dosing.
It is important to advise new OC users that, while they are likely to experience at least 1 side effect, most ease spontaneously within 1 to 3 cycles. It also is important to probe for any unsubstantiated fears the patient may have about OC use (see sidebar), as misconceptions are common.
Misconceptions among women about oral contraceptive (OC) use persist, many of them associated with older formulations that contain higher doses of estrogen.
The top 5 myths include:
- The pill causes cancer. Many women believe OCs can cause cancer when, in fact, they lower the risk of endometrial and ovarian cancer. Although some recent research suggests a slightly elevated risk of breast cancer with the use of OCs, that increase may reflect the more intensive monitoring for cancer among women who are studied, or an increase in the diagnosis of local tumors (as opposed to systemic disease). Other research has found a decrease in the rate of metastatic breast disease with OC use.1,2
- I’ll gain weight. Another fear is significant weight gain. However, a recent analysis found similar weight gains among OC users and controls.3 In fact, in the initial 6 to 9 months of use, a new 30-mcg ethinyl estradiol formulation that contains drospirenone was found to be associated with weight loss—rather than a gain.4,5
- The pill is dangerous. As long as the patient is a healthy nonsmoker, the benefits of OC use greatly outnumber the risks.
- I’m too old to be on the pill. Many patients think of the pill primarily as an option for younger women, i.e., those in their teens and 20s. However, OC use often is of greatest benefit to perimenopausal women, as it stabilizes the menstrual cycle and helps prevent a range of pathologies.
- I’ve been on the pill too long. Patients may be reluctant to take the pill for more than a few years, believing it increases their risk of cancer and other ills. However, as mentioned above, OCs actually reduce the incidence of endometrial and ovarian cancer. Other long-term benefits include enhanced bone density and fewer fibrocystic changes in the breast.
—Patricia J. Sulak, MD
REFERENCES
1. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives: further results. Contraception. 1996;54(suppl):1S-106S.
2. Rosenberg L, Palmer JR, Rao RS, et al. Case-control study of oral contraceptive use and risk of breast cancer. Am J Epidemiol. 1996;143:25-37.
3. Redmond G, Godwin AJ, Olson W, Lippman JS. Use of placebo controls in an oral contraceptive trial: methodological issues and adverse event incidence. Contraception. 1999;60:81-85.
4. Parsey K, Pong A. An open-label, multicenter study to evaluate Yasmin, a low-dose combination oral contraceptive containing drospirenone, a new progestogen. Contraception. 2000;61:105-111.
5. Foidart JM, Wurrke W, Bouw GM, Gerlinger C, Heithecker R. A comparative investigation of contraceptive reliability, cycle control and tolerance of two monophasic oral contraceptives containing either drospirenone or desogestrel. Eur J Contracept Reprod Healthcare. 2000;5:124-134.
