22 September, 2014 

In their recent review, Hardman and Gebbie provide a great service to colleagues who face questions on the need for contraception in the perimenopause [1]. The manuscript is very practical, giving a little background and mainly focusing on various options for contraception, and their advantages or side-effects. The authors also present an algorithm for a multitude of perimenopausal situations. Here is the review Abstract:

'Perimenopausal women have low fertility but must still be advised to use contraception until natural sterility is reached if they are sexually active. Patterns of contraceptive use vary in different countries world-wide. Long-acting, reversible contraceptive methods offer reliable contraception that may be an alternative to sterilization. Hormonal methods confer significant non-contraceptive benefits, and each individual woman should weigh up the benefits and risks of a particular method. No method of contraception is contraindicated by age alone, although combined hormonal contraception and injectable progestogens are not recommended for women over the age of 50 years. The intrauterine system has particular advantages as a low-dose method of effective hormonal contraception, which also offers control of menstrual dysfunction and endometrial protection in women requiring estrogen replacement. Condoms are recommended for personal protection against sexually transmitted infections in new relationships. Standard hormone replacement therapy is not a method of contraception.'

Comment

The main question to answer is, 'When can a perimenopausal woman stop taking contraception'. The authors, correctly, state that a spontaneous pregnancy in women over 50 years old is rare. They also explain the UK principles for perimenopausal contraception. I believe that the limit at which to discontinue the progestogen-only pill, barrier methods or non-hormonal intrauterine device of 55 years is rather high. My advice is to stop using these methods already at the age of 52 years, but it is certainly a matter of personal opinion.

Non-reversible, female sterilization is still the most important contraceptive method in many countries. Table 2 in the review by Hardman and Gebbie shows data from the Population Reference Bureau giving sterilization figures for married women aged 15–49 years in various countries; hence, the frequency of use by perimenopausal women must generally be remarkably high. (As to Japan, the figure of 43% is an obvious mistake; when I checked the same source, the correct figure is 3%.) Therefore, regarding perimenopausal contraception, the statistics should preferably give data for women of 40–49 years. For example, in the USA, since 2002, about half of women aged 40–49 years have undergone sterilization [2]. Skewing this picture are the high numbers of hysterectomies in relation to sterilizations in many countries. In some countries, for tradition or religious reasons, hysterectomy may unfortunately be used for contraceptive purposes. In the USA, about 600,000 hysterectomies, 500,000 female sterilizations and 700,000 vasectomies are performed annually. In the UK, a little less than 30,000 hysterectomies are performed annually, while in England the annual number of sterilizations are decreasing and are in the range of 7500 per year. Hysterectomized women are not in need of contraception, but sometimes they may be included in statistics of married women who do not use contraception. During the last decade, the number of sterilizations has decreased in many countries (UK -74%, Finland -70%). It is obvious that the increased use of intrauterine systems may be an important factor behind this decrease, but it is very difficult to confirm this quantitatively.

The most useful sections of Hardman and Gebbie's review are the chapters dealing with the benefits and side-effects of various contraceptive methods. The use of combined hormonal contraception until the age of 50 years is acceptable if the user has good general health with no contraindications, including smoking and being overweight. In all cases, low-dose combined oral contraceptives should be prescribed (preferably with 10–20 µg of ethinylestradiol), since the risks of venous thromboembolism increase with increasing doses of ethinylestradiol [3]. Also the use of long cycles of 3–6–12 months could be considered [4]. Still with these doses of ethinylestradiol, the estrogenic potency is remarkable higher than when using standard oral doses of estradiol in hormone replacement therapy (HRT). Ethinylestradiol may, in fact, be ten times more potent than estradiol or conjugated estrogens [5].

The section focusing on progestin-only contraception correctly emphasizes the safety of these methods in comparison to combined hormonal contraception. Further, when progestin-only contraception is used, the symptoms of the climacteric become detectable once they occur. When selecting the mini-pill, one has to keep in mind that only the pill containing 75 µg of desogestrel inhibits ovulation efficiently and offers the most efficient contraception [6]. The great benefits to the user of the intrauterine system (IUS) are well presented. Once menopausal symptoms start, the IUS offers an option to continue using it as a part of HRT. If a woman has an IUS (Mirena), releasing 20 µg levonorgestrel daily for contraception, I advice her to continue its use up to 7 years [7]. With Mirena in situ, she can add any type of systemic estrogen replacement therapy, if there is a need to treat climacteric symptoms, generally without bleeding disturbances. The newer IUS releasing 14 µg of levonorgestrel (Jaydess) has only come to the market recently, but I believe that the older IUS will be preferred for perimenopausal contraception.

Risto Erkkola
Department of Obstetrics and Gynecology, University Central Hospital, Turku, Finland

References

1. Hardman SM, Gebbie AE. The contraception needs of the perimenopausal woman. Best Practice Res Clin Obstet Gynaecol 2014;28:903-15
http://www.ncbi.nlm.nih.gov/pubmed/24990143
2. Jones J, Mosher W, Daniels K. Division of Vital Statistics. Current contraceptive use in the United States, 2006–2010, and Changes in patterns of use since 1995. National Health Statistic Reports, Number 60, 2012 October 18
http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf
3. Lidegaard Ø, Edström B, Kreiner S. Oral contraceptives and venous thromboembolism: five-year national case-control study. Contraception 2002;65:187-96
http://www.ncbi.nlm.nih.gov/pubmed/11929640
4. Edelman AB, Gallo MF, Jensen JT, Nichols MD, Grimes DA. Continuous or extended cycle versus cyclic use of combined oral contraceptives for contraception. Cochrane Database System Rev 2005(3), Art. No: CD004695
http://www.ncbi.nlm.nih.gov/pubmed/16034942
5. Mandel FP, Geola FL, Lu JK, et al. Biologic effects of various doses of ethinyl estradiol in postmenopausal women. Obstet Gynecol 1982;59:673-9
http://www.ncbi.nlm.nih.gov/pubmed/6281707
6. Erkkola R, Landgren BM. Role of progestins in contraception. Acta Obstet Gynecol Scand 2005;84:207-16
http://www.ncbi.nlm.nih.gov/pubmed/15715527
7. Erkkola R. Recent advances in hormonal contraception. Curr Opin Obstet Gynecol 2007;19:547-53
http://www.ncbi.nlm.nih.gov/pubmed/18007132