Contraception in perimenopause: practice points for GPs

By Lina Safro

Menopause is always a retrospective diagnosis in a woman who is not using hormonal contraception, and is confirmed after 12 months of amenorrhoea. The presence of the symptoms of menopause cannot be used as a reliable predictor of infertility (1), nor is there a biological marker that defines the precise moment of cessation of fertility in perimenopause (2).

For women over the age of 50, fertility is very unlikely to return after 12 months of amenorrhea and contraception can be stopped at that point. For women younger than 50, the return of fertile ovulation is more likely, therefore contraception should be used for two years after the last menstrual period. The available data suggest that fewer than 1 in 100 women conceive over the age of 50 and most women reach the age of natural infertility at 55, when contraception can be stopped (3).

For sexually-active women who wish to stop using reliable contraception earlier than recommended, the possibility and potential risks of an unintended pregnancy in this age group should be discussed as part of the midlife consultation.

For women using hormonal methods of contraception, amenorrhoea around the time of perimenopause can be difficult to interpret because it may be associated with the method itself. For women using combined hormonal contraception, FSH measurement is not useful due to the negative feedback effect of oestrogen on FSH.

For women over the age of 50 with at least 12 months of amenorrhoea, if progestogen-only contraception is being used, a single measurement of FSH is recommended as a baseline indicator of fertility status. If FSH is greater than 30 IU/ml, contraception is required for another 12 months. If FSH is below 30 IU/ml at baseline, reliable contraception should be used and FSH measured 12 months later.

Contraceptive choice throughout life is determined by several factors including medical eligibility, side effects, affordability and potential non-contraceptive benefits. Contraceptive options may become limited in perimenopause due to an increased risk of comorbidities after the age of 40 (4). Common symptoms of perimenopause such as heavy menstrual bleeding, mood swings and breast tenderness can also influence contraceptive choice.

The UK Medical Eligibility Criteria (UKMEC) provides a safety-based framework for contraceptive prescribing (5). The MEC definitions adapted from the UK Faculty of Sexual and Reproductive Healthcare are summarised in the table below.

MEC 1	A condition for which there is no restriction for the use of the method
MEC 2	A condition where the advantages of using the method generally outweigh the theoretical or proven risk
MEC 3	A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/ or referral to a specialist contraceptive provider
MEC 4	A condition that represents an unacceptable health risk if the method is used

While no method of contraception is contraindicated on the basis of age alone, the use of oestrogen-containing oral contraception, the vaginal ring and depot medroxyprogesterone acetate (DMPA) is not recommended in women over 50 (6).

The long-acting reversible contraceptives (LARC) top the list of effective options for medically eligible women at any reproductive stage.

Levonogestrel IUS (Mirena IUD) provides effective contraception for 5 years with the added benefit of reducing menstrual bleeding and dysmenorrhea (7). Women whose Mirena IUD is inserted at age 45 or older can use it for contraception for longer than 5 years until it’s no longer required (off-label extended use). It can also be used for endometrial protection in women who use menopausal hormonal therapy (MHT), however in this situation the IUD must be changed after 5 years as there’s no recommendation for extended use (8).

The copper IUD (Load 375, Copper TT380 Short or Copper TT380 Standard) provides a hormone-free option for women with MEC contraindications to hormonal contraception. From the age of 40 at insertion, any copper IUD approved for use in Australia can be left in place until menopause (off-label extended use) (9). The copper IUD can increase menstrual blood loss, which limits its use in perimenopausal women experiencing heavy menstrual bleeding.

The contraceptive implant (Implanon NXT) has few contraindications and does not adversely affect bone density (10). The main disadvantage of the implant is unscheduled bleeding which can occur in 20% of users, and should be investigated in this age group to exclude endometrial hyperplasia and carcinoma. Contraceptive implants cannot be used for endometrial protection by women using MHT.

The progestogen-only pill (Minipill) is a low-dose oral option with no known significant health risks (11). However, as with the implant, irregular bleeding can occur, prompting investigations to rule out endometrial hyperplasia and carcinoma. The progestogen-only pill cannot be used to protect the endometrium as part of an MHT regimen.

Other less effective contraceptive options which can be acceptable due to lower background fertility include barrier methods (male and female). Emergency contraception (pill and Copper IUD) is also available up to 5 days of unprotected sexual intercourse. Fertility awareness methods (FAM) are not generally recommended in the perimenopausal group due to irregular cycles. Permanent methods (male and female) involving surgery can have a higher risk-to-benefit ratio due to low background fertility at this reproductive stage.

Practice points:

• Amenorrhoea in women using hormonal contraception is not a reliable indicator of menopause
• A single FSH level can be used to diagnose menopause in women aged at least 50 with amenorrhea using progestogen-only methods
• MHT is not contraceptive
• The contraceptive implant and IUDs have few contraindications for use in perimenopausal women
• Copper IUDs can have extended use in women aged 40 years or older at the time of insertion
• Hormonal IUD can have extended use for contraception in women aged 45 years older at the time of insertion
• Combined hormonal methods and DMPA are not recommended for use beyond the age of 50
• UK MEC provides the safety framework for contraceptive prescribing https://www.fsrh.org/ukmec

References

1. https://bpac.org.nz/BT/2013/February/docs/best_tests_feb2013_reproductive_hormones_pages_12-22.pdf
2. Trussell J, Wilson C. Sterility in a population with natural fertility. Population Studies 2010; 39 (2):269–86
3. Faculty of Sexual and Reproductive Healthcare. FSRH Guideline Contraception for women aged over 40 years. 2017. Available online at: www. fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-forwomen-aged-over-40-years-2017/ (accessed November 2019)
4. Allen R, Cwiak C, Kaunitz A. Contraception in women over 40 years of age CMAJ 2013 Apr 16; 185(7): 565–573.
5. Faculty of Sexual and Reproductive Healthcare. UK medical eligibility criteria for contraceptive use (UKMEC). Available online at: www.fsrh.org/standardsand-guidance/documents/ukmec-2016/ (accessed November 2019)
6. Weill A, Dalichampt M, Raguideau F, et al. Low dose oestrogen combined oral contraception and risk of pulmonary embolism, stroke, and myocardial infarction in five million French women: cohort study. BMJ Clinical Research Ed 2016; 353:i2002
7. Imai A, Matsunami K, Takagi H, Ichigo S. Levonorgestrel-releasing intrauterine device used for dysmenorrhea: five-year literature review. Clin Exp Obstet Gynecol 2014; 4: 495-498
8. https://www.menopause.org.au/hp/information-sheets/280-contraception
9. Harvey C, McNamee K, Stewart M. A practical guide to contraception Part 2: Long-acting reversible method. Medicine Today 2013; 14(8):39-51
10. Villas‑Boas J, Vilodre LC, Malerba H, Pontremoli Salcedo M, Foresti Jimenez M, El Beitune P. Metabolic safety of the etonogestrel contraceptive implant in healthy women over a 3‑year period. Eur J Obstet Gynecol Reprod Biol 2016; 202:51–54
11. McNamee K, Bateson D, Murdoch J. Contraception for women aged 50 years and over. MedicineToday Vol 20, Number 12 (due to be published in Dec 2019)