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Introduction
The North American Menopause Society (NAMS) defines perimenopause as the time from the onset of menstrual changes and menopause-related symptoms until 1 year after cessation of menses [1]. This time is typically characterized by an increasing frequency of menstrual irregularity along with menopausal-related symptoms such as hot flashes, night sweats, sleep disruption, mood fluctuations and reduced libido. There is no set time for the onset or conclusion of the perimenopause, although it usually begins when a woman is in her 40s. As the time for this transition differs from woman to woman, so does its clinical presentation. What is common among all women during the perimenopause is a gradual reduction in, but not a complete loss of, the ability to conceive. Of interest is that the unintended pregnancy rate hovers around 40% in the USA for women over the age of 40 [2]. This is an unfortunate result of a convergence of erroneous beliefs. These include:
Pregnancy is nearly biologically impossible in sexually active women during the perimenopause.
The canard that women engage in little to no sexual activity during their 40s or 50s that would place them at risk of becoming pregnant.
Highly effective contraceptive methods are not needed and should not be used by perimenopausal women because of this as well as safety concerns.
What is accurate is that, by definition, perimenopausal women who are sexually active are exposed to the risk of becoming pregnant and there are no hormonal methods of contraception, regardless of their composition or mode of delivery, that are contraindicated solely on the basis of a woman’s age. In addition, such methods of contraception provide not only effective pregnancy prevention, but can also provide important non-contraceptive benefits for women during the perimenopause. To this end, we will present an overview of contraceptive methods amenable for use by women during the perimenopause and into the early years of menopause.
Contraceptive needs of the perimenopausal woman
As the perimenopause characterizes a transitional time in a woman’s reproductive life, her risk of pregnancy during this time is likewise characterized by that transition, which is directly related to reduced frequency and increased irregularity of ovulation. From ages 40–44, the chance of pregnancy in a sexually active woman not using contraception is estimated to be approximately 30% per year while that is further reduced to 10% per year in women aged 45–49 [3]. Increasing menstrual irregularity and menopausal symptoms reflect the reduced ovulatory frequency associated with the perimenopausal transition. The likelihood of pregnancy during this time is directly related to decreased ovulatory frequency, as well as coital frequency, male partner fertility and effectiveness of contraception used.
As frequency of ovulation diminishes, menstrual cycle length increases, although increasing length of the menstrual cycle does not necessarily indicate an anovulatory cycle; 25% of cycles greater than 50 days in length are ovulatory in nature, thus making increasing menstrual irregularity a poor predictor of fertility [4]. As there are no reliable predictors of fecundity in perimenopausal women, any woman who is sexually active with menstrual activity, but using no contraception, is exposed to a risk of pregnancy and contraception is advised if pregnancy is to be avoided. As a woman ages, her aging oocytes result in an increased likelihood of fetal aneuploidy (e.g., trisomy 21) and there is a consequent increase in spontaneous fetal loss and chromosomally abnormal offspring. In addition, increasing maternal age is also associated with an increased risk of adverse maternal obstetric outcomes. These may be exacerbated by a concomitant increase in comorbidities such as obesity, hypertension and diabetes. Accordingly, contraception in sexually active women during the perimenopause is important, not only to prevent pregnancy, but also to prevent the profound morbidity and mortality associated with pregnancy during the later stages of a woman’s reproductive life.
Contraceptive options during the perimenopause
When discussing contraceptive options for women during the perimenopause, it is again important to acknowledge that there are no age barriers to the use of any reversible method of contraception. Women who have decided that they no longer wish to become pregnant can choose from permanent methods of pregnancy prevention such as tubal sterilization, or a hysteroscopic tubal occlusion procedure such as the Essure™ system. For those women who may wish to conceive in the future or do not wish to undergo permanent sterilization, or may wish to avail themselves of the non-contraceptive benefits of certain reversible methods of contraception, the full array of contraceptive choices are potentially amenable for use (Table 21.1). However, while age itself does not rule out the use of any method of contraception, the onset of certain age-related conditions such as hypertension, diabetes, cancer and other cardiovascular conditions may preclude the use of certain methods of contraception, particularly those containing estrogen, because of concerns regarding safety. The effectiveness (typical use) of all methods of contraception are likely greater for women during the perimenopause because of the inherent decrease in fecundity associated with this stage in a woman’s reproductive life. This is best characterized by the current practice of assessing the effectiveness of a contraceptive regimen in women in clinical trials aged 18 through 35 years, but evaluating the safety of the regimen in women aged up to 45 years.
| Method | Failure rate (%:perfect/typical) | Drug delivery | Dosing regimen (label) |
|---|---|---|---|
| Male condom | 2/18 | None | Condom placed on penis prior to vaginal insertion and left on until ejaculation and removal from vagina. May be used concomitantly with vaginal spermicidal agent |
| Female condom | 5/21 | None | Vaginal placement of condom and left in situ until ejaculation and removal of penis. May be used concomitantly with vaginal spermicidal agent |
| Cervical cap | 6/12 | None | Device inserted prior to vaginal insertion and left in situ until ejaculation and removal from vagina. May be used concomitantly with vaginal spermicidal agent |
| Diaphragm | 6/12 | None | Device inserted prior to vaginal insertion and left in situ until ejaculation and removal from vagina. May be used concomitantly with vaginal spermicidal agent |
| Vaginal spermicide | 18/28 | None | Gel inserted prior to vaginal insertion of penis |
| IUD | 0.6/0.8 | Copper | Inserted at a time when pregnancy is not likely (e.g., menses). Left in situ for prescribed period of effectiveness. Removed and replaced if further contraception is desired |
Benefits of contraception
Aside from the prevention of pregnancy and its associated morbidities, certain hormonal contraceptive regimens can alleviate the increasing frequency and severity of the symptoms of menopause that are commonly experienced by women. In particular, regimens containing estrogen, regardless of the mode of delivery, can be effective in reducing symptoms of vasomotor instability including hot flashes and night sweats [5]. As these methods work by inhibiting ovulation, they can also be effective in regulating the menstrual irregularities characteristic of the perimenopause.
While progestin-only contraceptives do not contain estrogen and thus are unlikely to provide relief from the estrogen-dependent symptoms of vasomotor instability, they can be effective in managing irregular menstrual bleeding (Table 21.2). In particular, the levonorgestrel-containing intrauterine system (LNG-IUS: Mirena™) and the progestin-only pill (POP) containing 75 µg desogestrel (Cerazette™) may be effective in regulating menstrual bleeding, albeit by different mechanisms. The LNG-IUS exerts a mostly suppressive effect on the endometrium resulting in a relatively high frequency of amenorrhea after the first year of use. In addition, the LNG-IUS is effective for endometrial protection (off-label in the USA, but approved for 4 years in the UK) in women transitioning to menopausal hormone therapy. Conversely, the POP containing 75 mcg desogestrel (not available in the USA) effectively inhibits ovulation and exerts an inhibitory effect on the endometrium and a thickening of the cervical mucus, which is different from most POPs (those available in the USA) that contain a subinhibitory dose of progestin which fails to consistently inhibit ovulation, but exert their contraceptive effect mostly by local mechanisms of endometrial suppression and cervical mucus thickening. While these POPs would clearly provide effective contraception to a perimenopausal woman, they would likely not provide relief for the menstrual irregularity experienced by these women.
| Method | Failure rate (%:perfect/typical) | Drug delivery | Dosing regimen (label) |
|---|---|---|---|
| Oral contraceptives | 0.3/9 | Oral | Daily ingestion of pill; most regimens are continuous use in nature |
| Injectables | 0.2/6 | IM/SC | Intramuscular or subcutaneous initiation for prescribed time period. Reinjection at end of the time period if continued contraception is desired |
| Subdermal implant | 0.05/0.05 | Subdermal | Subdermal placement of implant system and left in situ for prescribed period of effectiveness. Removed at end of time period and replaced if continued contraception is desired |
| Intrauterine contraceptive LNG-IUS2 | 0.2/0.2 | LNG3 | Inserted at a time when pregnancy is not likely (e.g., menses). Left in situ for prescribed period of effectiveness. Removed and replaced if further contraception is desired |
1 All methods are typically started at the start of or during a normal menstrual bleed, a time at which a woman is most likely to not be pregnant, and allows for best temporal management of contraception. Discontinuation of all methods should be done at the conclusion of a usage cycle, except in cases of medical emergencies (e.g., cardiovascular event such as myocardial infarction). Source: Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates Jr W, Kowal D, Policar MS (eds). Contraceptive Technology, Twentieth Revised Edition. Valley Stream, NY: Ardent Media; 2013, pp. 69–76.
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