Contraception in Perimenopause: FAQ’s for the clinician.

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Contraception in Perimenopause: FAQ’s for the clinician.

Dr. Mandakini Parihar 

Contraceptive methods available include:

  • Intrauterine progesterone-only system
  • Progestogen-only pill (POP) – many women over 40 years of age develop amenorrhoea with this form of contraception
  • Progestogen implants
  • Depot progestogen injections
  • Combined oral contraceptive pill – FDA regulations now permit the use of the combined oral contraceptive pill to women at low-risk (non-smokers, no cardiovascular risk factors) up to the age of 50
  • Barrier methods
  • Conventional intrauterine devices
  • Natural methods

Questions:

 

  1. Can a woman aged 40 or above be given the combined oral contraceptive pill?

Answer: Women aged over 40 years can be advised that combined hormonal contraception can be used unless there are co-existing diseases or risk factors.

  1. If a 35 year old woman, who smoked when she was younger, but no longer smokes, can she be given Oral Contraceptive pill?

Answer: women aged >=35 years with no other risk factors who have stopped smoking more than a year ago may consider using combined hormonal contraception. The excess risk of MI associated with smoking falls significantly 1 year after stopping and is gone 3-4 years later, regardless of the amount smoked

  1. When is OCP completely contra-indicated in peri-menopausal years?

Answer: women aged over 40 years with cardiovascular disease, stroke or migraine (even without aura) and women above 35 years who are still smoking, should be advised against the use of combined hormonal contraception

  1. What age should women stop using contraceptives?

Answer:

Women in their forties are still potentially fertile, and pregnancy in this age group is attended by increased risks of maternal mortality, spontaneous abortion, fetal anomalies and perinatal mortality

women using combined contraception should be advised to switch to another suitable contraceptive method at the age of 55 years, if she is still menstruating. (when natural loss of fertility is assumed )

Contraceptives should be continued for one year after cessation of periods. FSH is not a reliable indicator of stoppage of ovarian function in women using combined hormones, even if measured during the hormone-free or oestrogen-free interval

  1. Why should “progestogen only” methods be used in peri-menopausal women?

Answer: Women in this age group are prone for medical disorders like Diabetes and hypertension. This increases the risk of venous thromoembolism (VTE) and ishchemic heart Disease(IHD) when using estrogen containing contraceptives. Hence, progesterone only methods should be encouraged.

  1. Can a woman with previous history of VTE or IHD be given Progesterone only contraceptives?

Answer:  Women with previous VTE or IHD can be advised that the benefits of using progestogen-only methods outweigh the risks

  1. If she is using an implant or POP as contraceptive, how long should it be continued?

Answer: women can be advised that a POP or implant can be continued until the age of 55 years when natural loss of fertility can be assumed. Alternatively, the woman can continue with the POP or implant and have FSH levels checked on two occasions 2 months apart, and if both levels are >30 IU/l this is suggestive of stoppage of ovarian function and can then stop using contraceptives.

  1. If a woman has a Mirena/ LNG- insertion at 45 years, when should she be asked to come back for removal?

Answer: women who have the intrauterine progesterone-only system inserted at age >=45 years for contraception or for the management of menorrhagia can be counseled about retaining the device for up to 7 years, safely without the risk of pregnancy.

  1. Can women needing estrogen replacement use LNG-IUS as part of HRT?

Answer: Women using estrogen replacement therapy may choose the intrauterine progesterone-only system to provide endometrial protection.

Questions and Answers compiled by:

Dr.Mandakini Parihar