The author reports research support from Barr, Bayer, Medical Diagnostic Laboratories, Organon, and Warner-Chilcott. He serves as a speaker or consultant for Barr, Bayer, Johnson & Johnson, Merck, Noven, Organon, and Warner-Chilcott. He holds stock in Procter & Gamble, Quest, and Sanofi-Aventis.
CASE Perimenopausal complaints, and a request for contraception
At her annual visit, M.B., a healthy 48-year-old divorced woman, reports that her periods are increasingly erratic and that she has begun experiencing occasional hot flushes. Although her previous husband had a vasectomy, she has started to date and is concerned about contraception. A close friend became pregnant at the age of 46 and chose to have an abortion. M.B. hopes to avoid the same fate and asks specifically about birth control pills. Is this an appropriate option for her? What do you tell her?
Although only 11% of women 40 to 44 years old reported using oral contraceptives (OCs) in 2002 in the United States, that figure represents a 5% increase over 1995,1,2 and all indications are that the percentage is still rising.
In lean, nonsmoking, healthy perimenopausal women, OCs offer users not only effective contraception, but also benefits that include a reduction in heavy menstrual bleeding; regularization of the menstrual cycle; protection against ovarian, endometrial, and colorectal cancer; prevention of bone loss (with possible prevention of postmenopausal osteoporotic fractures); and some degree of relief from vasomotor symptoms. Although an increased risk of venous thromboembolism (VTE) is well documented in OC users, concerns also exist that use of the pill might increase the risk of myocardial infarction (MI), stroke, and breast cancer in older reproductive-age women.
To explore the range of hormonal contraceptive options and their risks and benefits in perimenopausal women in more depth, OBG Management recently caught up with Andrew M. Kaunitz, MD, an expert in both contraception and menopause and a member of the OBG Management Board of Editors. He describes and interprets the robust data in this field to answer our many questions—although he points out that perimenopausal women have been underrepresented in studies of OC use in particular and hormonal contraception in general.
Why hormonal contraception?
OBG Management: Why is effective contraception important in this age group? Aren’t perimenopausal women less fertile than younger women?
Kaunitz: Older women are less fecund, but irregular menstrual cycles make it difficult to predict when ovulation is occurring, making unplanned pregnancy a real possibility in sexually active women.
Pregnancy itself is fraught with risks in this age group. Pregnancy-related mortality among women 40 years or older in the United States is five times higher than among 25- to 29-year-olds. Older women are also more likely to have comorbidities such as hypertension and diabetes, further increasing the risks of pregnancy.3,4 In addition, perimenopausal women are more likely than any reproductive age group except adolescents to opt for induced abortion when they do become pregnant, with 304 abortions for every 1,000 live births in women 40 years or older in the United States.5
OBG Management: Why should a perimenopausal woman consider hormonal contraception?
Kaunitz: It is highly effective and offers a range of noncontraceptive benefits, and older women are more likely to use it properly, making contraceptive failure less likely than in younger patients.
Nor are combination OCs the only option for this age group. Progestin-only OCs, the levonorgestrel-releasing intrauterine system, the etonogestrel implant, and injectable depot medroxyprogesterone acetate (DMPA) are alternatives. Although the vaginal patch and ring have not been studied extensively, they may be appropriate in some instances. Until further data specific to these combination estrogen–progestin methods are available, let’s assume for our discussion that they carry the same risk–benefit profile as combination OCs.
OBG Management: What is the greatest risk of OC use in perimenopausal women?
Kaunitz: That would be VTE. The risk rises sharply after 39 years of age among users of combination OCs, with approximately 100 cases for every 100,000 person-years, compared with 25 cases for every 100,000 person-years among adolescents.6 This already elevated risk almost doubles among obese women older than 39 years.7 In these women, progestin-only or intrauterine contraceptives are better options than combination OCs.8