Cahpter 20 – Contraception for the Perimenopausal Woman




Abstract




The World Health Organization (WHO) defines menopause as the permanent cessation of menstruation due to loss of ovarian follicular activity [1]. It is a retrospective diagnosis, which can only be made with certainty after 12 months of spontaneous amenorrhoea. The average age of menopause in UK women is 51 [2].





Cahpter 20 Contraception for the Perimenopausal Woman


Paula Briggs and Nicola Kersey


The World Health Organization (WHO) defines menopause as the permanent cessation of menstruation due to loss of ovarian follicular activity [1]. It is a retrospective diagnosis, which can only be made with certainty after 12 months of spontaneous amenorrhoea. The average age of menopause in UK women is 51 [2].


The perimenopause (or menopause transition) is the time leading up to the menopause and lasts until 1 year after the final menstrual period [1]. It usually begins with menstrual changes during which the menstrual cycle may shorten or lengthen and women often experience heavier bleeding. Other associated menopause-related symptoms may include vasomotor symptoms (hot flushes, night sweats), effect on mood, sleep disturbance, arthralgia, myalgia, symptoms of urogenital atrophy and loss of libido. The perimenopause typically starts in the mid forties and lasts 4–5 years [3], although this is variable.


There is a reduction in fertility with age, with a sharp decline in the late thirties. Despite this, until the postmenopause a woman is still at risk of pregnancy and requires effective contraception. Over the course of a year of unprotected sexual intercourse, the risk of pregnancy in a woman aged 40–44 years is 10–20 per cent and 12 per cent at 45–49 years, with the chance of pregnancy after the age of 50 being small [4].


There is a correlation between advancing age and an increase in peri-natal mortality and morbidity, as well as a higher incidence of miscarriage and ectopic pregnancy [5]. Women over 40 have the highest rates of spontaneous abortion compared to live births, with 28 per cent of pregnancies in this age group ending in abortion [6].


Women may not appreciate the fact that they are still at risk of pregnancy as they get older, or wrongly believe that menopausal hormone therapy (MHT) is effective as contraception, highlighting the need for appropriate counselling. It is also important to consider that some older women may still be hoping to conceive. The perimenopause is an important time to review contraceptive needs, to ensure the contraceptive method choice has the lowest risks whilst conferring the most benefit.



Contraception and MHT


MHT inhibits ovulation only in approximately 40 per cent of women, and thus cannot be relied upon for contraception [7]. Therefore, contraception is still required in woman taking MHT. Progestogen-only contraception (POC) and non-hormonal methods can be safely used alongside MHT. The Mirena intrauterine system (IUS) can be used for both contraception and endometrial protection with estrogen as MHT. However, other progestogen-only methods (including alternative intrauterine systems to the Mirena) are not licensed for endometrial protection.



Diagnosing the Menopause and Stopping Contraception


Diagnosis is usually based on a woman’s symptoms and age, rather than relying on blood tests (gonadotrophin levels). However, use of hormonal contraception affects the natural menstrual cycle, and therefore symptoms including abnormal bleeding patterns cannot be used to determine the menopause. Some women experience menopause-related symptoms with progestogen-only injectable contraception, due to its hypoestrogenic effect. UK guidelines from the National Institute of Clinical Excellence (NICE) advise that women using non-hormonal methods of contraception may stop after 2 years of amenorrhoea if under 50 and 1 year if over 50 [8].



Follicle-Stimulating Hormone


The blood test follicle-stimulating hormone (FSH) is not recommended routinely for women over 45 as levels often fluctuate in the menopause transition. However, women taking hormonal contraception may wish to know when they are able to cease use [4, 8]. Women using Combined Hormonal Contraception would need to stop this 6 weeks before checking FSH. If FSH levels are to be used, two separate measurements should be taken 6 weeks apart. If both results are over 30 IU/L then contraception may be stopped after a further 2 years in women under 50 and 1 year in women over the age of 50 [4]. For women using high-dose injectable progestogens, FSH levels may be less accurate [8].


For women under the age of 50, any method of contraception can be used or continued depending upon eligibility. For women who wish to continue with contraception over the age of 50, either a non-hormonal or POC method is recommended and both can be safely continued until 55 years (Table 20.1).




Table 20.1 The UK Faculty of Sexual and Reproductive Health (FSRH) recommendations for women over 50

























Method Recommendation
Progestogen-only pill and implant If amenorrhoeic for 12 months or more:


  1. If two FSH levels taken 6 weeks apart are >30 IU/L, it is safe to stop POP after one further year. If not amenorrhoiec, continue until 55 years.

Progestogen-only intrauterine system (if fitted at the age of 45 years or older)

If amenorrhoeic for 12 months or more:




  1. If two FSH levels taken 6 weeks apart are >30 IU/L, it is safe to remove IUS after 1 further year in women over 50 and 2 years in women under the age of 50.

DMPAa


  • Switch to a non-hormonal method and cease this after 2 years of amenorrhoea, OR



  • Switch to an alternative progestogen-only method and follow the advice for the method.

CHC (COC, patch, ring)a


  • Switch to a non-hormonal method and cease this after 2 years of amenorrhoea, OR



  • Switch to a progestogen-only method and follow the advice for the method.

Non-hormonal methods (copper IUD and barrier methods) Stop after 1 year of amenorrhoea if >50.


Note. From [8].




a These methods are generally not recommended over the age of 50 years.


Intrauterine devices are a potential source of infection and should eventually be removed.



Which Method of Contraception Is Best?


Whilst age alone does not completely contraindicate any contraceptive method, combined hormonal contraception (the pill, patch or vaginal ring) and progestogen-only injectables (Depo Provera or Sayana Press) are generally not recommended over 50 years of age [4]. It is important to consider any comorbidities when prescribing a contraceptive method, particularly as women get older. The risk of both venous thromboembolism (VTE) and arterial thromboembolism (ATE) increases with age as do common medical problems such as hypertension, diabetes, arrhythmias and hyperlipidaemia. Women should be advised of non-contraceptive benefits associated with their contraceptive method, which may help with perimenopausal symptoms, e.g. flushes, heavy menstrual bleeding.


The UK Medical Eligibility Criteria (UKMEC 2016) [9] is a useful method for assessing suitability of a contraceptive choice based on an individualized risk assessment (see Table 20.2).




Table 20.2 Definition of UK Medical Eligibility Criteria (UKMEC) categories for contraceptive use


















UK MEC 1 A condition for which there is no restriction for the use of the contraceptive method
UK MEC 2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks
UK MEC 3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method; the provision of the method requires expert clinical judgment and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable
UK MEC 4 A condition which represents an unacceptable health risk if the contraceptive method is used


Note. From [9].



Contraceptive Options



Combined Hormonal Contraception (CHC)


CHC acts to inhibit ovulation. It is 99 per cent effective if used as directed and is available in oral (tablet), transdermal (patch) and transvaginal (vaginal ring) delivery routes, which are all equally effective [11].


Age alone does not contraindicate CHC; however, risk of cardiovascular comorbidities increase with age, which can influence suitability. CHC is generally not recommended over the age of 50 [4, 9].


Since the early 1960s when the ‘pill’ first came to market, the dose of estrogen in combined oral contraception (COC) has reduced significantly, and different progestogens with unique features have improved tolerability (mostly in relation to hormonal side effects) of COC.



Benefits

There are many non-contraceptive benefits of CHC (Table 20.3). CHC can alleviate the perimenopausal symptoms of hot flushes and night sweats. CHC offers good cycle control and therefore can improve irregular and heavy menstrual bleeding (HMB) and premenstrual syndrome, more common around the menopause transition (Table 20.4). Only one COC (estradiol valerate/dienogest [Qlaira]) is currently licensed for treatment of HMB in women who require contraception, with no structural abnormality; however, NICE recommendations include use of all COC for HMB [12]. It is important to note that HMB must first be investigated based on an individualized risk assessment before initiating treatment with CHC.




Table 20.3 Non-contraceptive benefits of contraceptive methods
















Vasomotor symptoms




  • Combined hormonal contraception (the pill, patch or vaginal ring).



  • Extended regimes are more likely to be effective.


Osteoporosis




  • Combined hormonal contraception may increase bone mineral density (BMD).



  • Depot medroxyprogesterone acetate (DMPA) may reduce BMD.


Menstrual pain, bleeding and irregularity




  • Combined hormonal contraception (CHC) may relieve symptoms.



  • Some progestogen-only methods may help or they may cause problematic bleeding.


Menstrual pain




  • Progestogen-only contraception may reduce symptoms.


Heavy Menstrual Bleeding




  • LNG-IUS is highly effective in reducing menstrual bleeding and can induce amenorrhoea.



  • DMPA and CHC are also recommended treatments for HMB.



Note. Adapted from NICE CKS Contraception Assessment [10].




Table 20.4 Non-contraceptive benefits of CHC (FSRH CHC)




















Non-contraceptive benefits of CHC
Reduction in heavy menstrual bleeding
Reduction in menstrual pain
Good cycle control
Reduction in symptoms of endometriosis, PMS and PCOS
Reduced risk of endometrial and ovarian cancers
Possible positive effect on bone health, helping to maintain BMD in the perimenopause

Women have traditionally been advised to take CHC for 21 days with a hormone-free interval (HFI) of 7 days. Continuous and extended regimens (Table 20.5) have been shown to be more effective at conferring the non-contraceptive benefits listed in Table 20.4 and reduce hormone withdrawal symptoms during the HFI. Despite being outside of product licence, evidence has demonstrated these regimens as being safe and effective and they are recommended by the UK Faculty of Sexual and Reproductive Health (FSRH). There may, however, be associated problematic bleeding [4].




Table 20.5 Continuous and extended regimens










Tailored Regimens




  • Women may prefer to use CHC with fewer, shorter or no hormone-free intervals (HFI).



  • Tailored regimens include



  • Extended regimens




    1. Fewer HFIs, timing can be fixed or flexible




  • Continuous regimens




    1. No HFI



Multiphasic Regimens




  • These COCs, e.g. Qlaira, contain varying doses of the hormones estrogen and progestogen.


There is a reduced risk of endometrial and ovarian cancers in women using CHC. This effect lasts for decades after ceasing CHC, and longer-term use is associated with a greater reduction in risk [4]. There is some evidence that CHC has a positive effect on bone health [13].



Risks

Despite the potential benefits of CHC for perimenopausal woman, there are also serious health risks related to the use of contraceptive methods containing estrogen. CHC is associated with an increased risk of venous thromboembolism (VTE) and arterial thromboembolism (ATE) (e.g. myocardial infarction, stroke). VTE risk whilst using CHC is 5–12/10 000 women per year of use compared to non-CHC users, whose risk is 2/10 000 per year [14].


A woman over the age of 40 is more likely to have a higher baseline risk for these conditions, due to the increasing likelihood of comorbidities such as hypertension, raised BMI and diabetes that occur with advancing age [4].


Over 50, women should stop CHC and use alternative contraception if required.


UK MEC 2016 classify CHC as category 3 for women with ‘multiple risk factors’ and age is a relevant risk factor.


UK MEC also advises the following for women over 35 years who smoke:




  • 15 or more cigarettes per day = UK MEC 4



  • Less than 15 cigarettes per day = UK MEC 3


Some studies have demonstrated a slight increased risk of breast cancer in women taking COC compared to women not taking COC, with the risk decreasing after cessation [15].


Another downside of CHC is user dependency, which reduces the effectiveness of the method when ‘typical user failure rates’ are considered. With perfect use, the failure rate of the combined pill is less than 1 per cent. However, typical user failure rate is 9 per cent. In perimenopausal women this needs to be balanced against declining fertility [16].


When prescribing the COC, current recommendations suggest using a pill with the lowest dose of estrogen (such as 20 mcg ethinyl estradiol and levonorgestrel 100 mcg) to minimize VTE/ATE risk [17].


Recent evidence [18] has shown that Qlaira, a combined pill containing estradiol valerate and dienogest (anti-androgenic) in a quadraphasic regime, is associated with a lower risk of VTE/ATE. Studies comparing sexual function in women using Qlaira compared with women using a pill containing an androgenic progestogen show similar results. Although not considered a first-line pill, Qlaira has specific potential benefits for women in the menopause transition.

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Sep 9, 2020 | Posted by in GYNECOLOGY | Comments Off on Cahpter 20 – Contraception for the Perimenopausal Woman
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