Contraception in the perimenopause

The perimenopause is a stage of life when a woman has low fertility but still requires contraception. It is also a peak age for menstrual dysfunction and a time when menopausal symptoms may commence. All these factors impact on contraceptive choice. Combined oral contraception can be continued until the age of 50 years in women who are low risk and do not smoke. Progestogen-only methods have advantages for women who have risk factors for cardiovascular disease. An intrauterine device may exacerbate menstrual problems at this stage but the levonorgestrel releasing intrauterine system is highly effective in controlling perimenopausal menstrual dysfunction. Women should receive accurate individualised advice on how the risks and benefits of contraceptive methods relate to them and on when contraception can be safely discontinued. Hormone replacement therapy is not reliably contraceptive and women should be advised to continue with a contraceptive method until they have reached natural sterility.     

Contraception during perimenopause

Perimenopause marks the transition from normal ovulation to anovulation and ultimately to permanent loss of ovarian function. Fecundity, the average monthly probability of conception, declines by half as early as the mid-forties, however women during the perimenopause still need effective contraception. Issues arising at this period such as menstrual cycle abnormalities, vasomotor instability, the need for osteoporosis and cardiovascular disease prevention, as well as the increased risk of gynecological cancer, should be taken into consideration before the initiation of a specific method of contraception. Various contraceptive options may be offered to perimenopausal women, including oral contraceptives, tubal ligation, intrauterine devices, barrier methods, hormonal injectables and implants. Recently, new methods of contraception have been introduced presenting high efficacy rates and minor side-effects, such as the monthly injectable system, the contraceptive vaginal ring and the transdermal contraceptive system. However, these new methods have to be further tested in perimenopausal women, and more definite data are required to confirm their advantages as effective contraceptive alternatives in this specific age group. The use of the various contraceptive methods during perimenopause holds special benefits and risks that should be carefully balanced, after a thorough consultation and according to each woman's contraceptive needs.     

Contraception during perimenopause.

Perimenopause marks the transition from normal ovulation to anovulation and ultimately to permanent loss of ovarian function. Fecundity, the average monthly probability of conception, declines by half as early as the mid-forties, however women during the perimenopause still need effective contraception. Issues arising at this period such as menstrual cycle abnormalities, vasomotor instability, the need for osteoporosis and cardiovascular disease prevention, as well as the increased risk of gynecological cancer, should be taken into consideration before the initiation of a specific method of contraception. Various contraceptive options may be offered to perimenopausal women, including oral contraceptives, tubal ligation, intrauterine devices, barrier methods, hormonal injectables and implants. Recently, new methods of contraception have been introduced presenting high efficacy rates and minor side-effects, such as the monthly injectable system, the contraceptive vaginal ring and the transdermal contraceptive system. However, these new methods have to be further tested in perimenopausal women, and more definite data are required to confirm their advantages as effective contraceptive alternatives in this specific age group. The use of the various contraceptive methods during perimenopause holds special benefits and risks that should be carefully balanced, after a thorough consultation and according to each woman's contraceptive needs.     

In case of a request for contraception in the perimenopause; do's and don'ts

The mini pill is certainly the most appropriate contraceptive method during the perimenopausal period, while macropills and regular dose pills should not be considered. Hormonal contraception can be arrested for brief periods to be replaced by mechanical contraception. For no reason should a premenopausal woman go unprotected; the risk of sporadical ovulation during this period is too great.     

Contraception for the older woman: an update.

Although fertility declines with advancing age as the woman approaches the menopause, some risk of pregnancy persists, and effective contraception needs to be offered to avoid an unintended pregnancy. An older woman may have menstrual dysfunction or climacteric symptoms and these factors would need consideration when making the choice of contraception. Low-estrogen dose combined oral contraceptives may be prescribed to healthy non-smoking women up to about 50 years of age. The progestogen-only pill may be an appropriate option in an older woman with declining fertility. The copper intrauterine device is an optimal method for parous women free of pre-existing menstrual problems. The levonorgestrel-releasing intrauterine system is considered the contraceptive method of choice for perimenopausal women with menstrual dysfunction. The woman should be provided with individualized advice so that she has a choice between the newer, effective, largely safe, reversible methods and sterilization.     

Emergency contraception: the state of the art

Emergency contraception, otherwise known as post-coital contraception, is part of the continuum of contraceptive methods that women and couples can use for pregnancy prevention. Although emergency contraception should not be used as a regular, plan-ahead contraceptive method, it gives a woman one last-ditch effort to prevent unwanted pregnancy. This paper reviews the history of emergency contraception, the need for further studies, and results of studies conducted at the World Health Organization. Various methods used for emergency contraception are discussed, as well as their efficacies and side effects.     

Hormonale Kontrazeption in der Perimenopause

Perimenopause marks the transition from normal ovulation to anovulation. However, perimenopausal women may still be at risk for unintended pregnancy. Various contraceptive methods may be offered including oral contraceptives (OC), tubal ligation, intrauterine devices, barrier methods, hormonal injectables and implants. Furthermore, the contraceptive vaginal ring and the transdermal contraceptive system have been introduced recently. However, these new options have to be further investigated in perimenopausal women. Women should be informed that OC use until menopause or the mid-50s is both safe for healthy, non-smoking women and effective in easing perimenopausal symptoms. OC use during perimenopause can also help reduce risks of bone density loss, as well as endometrial, ovarian and colorectal cancer later in life.     

Impact of literacy on contraceptive practice in Indian perimenopausal women

Objectives

To study the contraceptive practices in perimenopausal women and to compare them between general population and staff nurses.

Methods

A questionnaire based study was done on 250 perimenopausal women (100 staff nurses and 150 women from general population) to evaluate the impact of literacy on the contraceptive choices among these women.

Results

Mean parity of the general population was more (3.2) as compared to the staff nurses (2.12) and this difference was statistically significant (p<0.001). Effect of literacy on reducing the parity was statistically significant (p=0.001) and was inversely related to it. Use of barrier method was more common in staff nurses as compared to general population (p<0.001). None of the women in either group were using oral contraceptive pills. Awareness about emergency contraception was more in staff nurses as compared to general population (p<0.001).

Conclusion

Intellectual status and literacy level has a definite role in using temporary methods of contraception more effectively. There is a need for creating awareness about emergency contraception among women more so amongst the general population     

Do contraceptive choices of Turkish married adolescents differ from those of older women?

OBJECTIVE: To compare contraceptive choices of Turkish married adolescents to those of women of reproductive age and perimenopausal women. METHODS: Demographic variables, fertility goals and contraceptive choices of adolescents (Group A, n = 95) were compared with those of women of reproductive age (Group B, n = 5224) and perimenopausal women (Group C, n = 2208). RESULTS: All women in the study group were married and had delivered at least once. A past history of voluntary terminations of pregnancy (TOPs) was reported often, although significantly less so by adolescents (43.1%) than by women belonging to the other two groups (66.5 and 77.4%, respectively). The percentage of women who applied no contraception was significantly higher in Group A (p < 0.05). The rate of use of withdrawal, oral contraceptives and intrauterine devices did not differ significantly between the three groups. The percentage of women who were indecisive about future pregnancy or wanted to have more children was greatest in Group A (87.4, 46.9 and 25.7%, respectively; p < 0.05). CONCLUSION: The distribution of contraceptive methods used was similar among the three age groups, but the absence of contraception was most frequent in the adolescent group. The adolescents we assessed, being married and having delivered at least once, are a highly selected group and not representative of adolescents in general. Nevertheless, their contraceptive choices did not differ from those of older women. The incidence of TOPs among them was quite high. Minimization of the frequent neglect of application of contraceptive measures by adolescents requires improvement of family planning services for this age group.     

Postpartum contraception

Fertility and sexual activity can resume shortly after childbirth therefore the early initiation of effective postpartum contraception is important to prevent an unintended pregnancy. An inter-pregnancy interval of at least 12 months is recommended to reduce the risk of obstetric and neonatal complications. Most methods of contraception can be safely initiated immediately after childbirth, including the most effective long-acting methods such as the implant and intrauterine contraception. The antenatal period presents a unique opportunity to counsel women about the full range of contraceptive options so that the method chosen by the woman can be initiated after delivery. This reduces the need for additional postnatal visits to discuss and provide contraception, which may be difficult for mothers to attend. Maternity care providers are ideally placed to deliver a postpartum contraceptive service and should receive appropriate training to ensure knowledge and skills in this area are maintained.     

Contraception at 40

During forty, fertility decreases but the risk of spontaneous pregnancy is not negligible, so contraception for forty years old women remains necessary. Several contraceptive methods are available: local contraception, intra-uterine devices, hormonal contraception. Progestogen-only pills, microdosed and continuously administered are to be avoided at this time of life because they can result in hyperestrogenic adverse events. Progestin implants are interesting if the woman presents contraindication with estrogens or if she is non compliant with oral contraceptives. Oral contraceptive use is associated with numerous benefits during forty: it controls properly cycles and menstruations, it decreases bone loss and it decreases gynaecological disorders and risk of endometrial and ovarian cancer... But cardiovascular risk (venous and arterial thrombo-embolism) remains increased, whatever oral contraceptive is used, second or third generation, and in spite of lower dose of ethinylestradiol, even if a trend towards the decrease of this risk is observed. Contraindication for one kind of oral contraceptive means contraindication for all oral contraceptives and necessarily bare respect of this. These contraindications led to contraceptive use of progestin with antigonadotropic activity; however if pregnane derivatives are devoid of any deleterious metabolic effects, they have no indication for contraception in their marketing authorization.     

Use and knowledge of contraceptive methods in female students of children education

An inquire about contraception use and knowledge was applied to 292 female students. (Average of age = 21.3 years) An 88.4% of the woman with sexual activity had used contraceptive methods at least once. Principal reason for not going on using them, was not having sexual intercourse. In single women, the use of contraceptive methods was related with age, while the type selected was related with sexual intercourse's frequency. The most used contraceptive methods were rhythm and pill, which were not the best known ones.     

ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 46, September 2003. (Replaces technical bulletin number 222, April 1996)

Bilateral tubal sterilization and vasectomy are both safe and effective permanent methods of contraception; more than 220 million couples worldwide use them as their contraceptive method of choice. Sterilization continues to be the most commonly used contraceptive method in the United States, with 11 million U.S. women relying on the method. Approximately 700,000 tubal sterilizations and 5000,000 vasectomies are performed in the United States annually. The purpose of this document is to review the evidence for the safety and effectiveness of sterilization in comparison with other forms of contraception, as well as evidence of the likelihood that a woman will regret having had a sterilization procedure.     

Difficulties with contraception and voluntary pregnancy termination: a survey carried out at the hopital Saint-Louis

A 1985 prospective study at the Saint-Louis Hospital in Paris indicated that 138 of 252 abortions (53.8%), were associated with problems of contraception and 114 were not. The percentages of cases involving problems with contraception varied from 34% to 58.2% according to the physicians participating in the study. Despite the very subjective nature of the estimates, at least 1/3 of abortions at this hospital are associated with difficulties in contraception. In 64 of 138 cases, the problems were caused by psychological factors, including ambivalent desire for pregnancy in 24 cases, psychological refusal of contraception in 15 cases, psychological immaturity in 4 cases, various psychological problems in 4 cases, and a psychological factor associated with some other difficulty in 17 cases. Among the various psychological problems were 1 woman using abortion as a contraceptive method who had undergone 9 abortions and 1 case of cultural resistance to contraception. Among the 17 cases where the psychological problem was associated with some other difficulty there were 7 cases of ambivalent desire for pregnancy, 4 cases of psychological refusal of contraception, and 6 cases of various psychological problems. Among these cases, available contraceptive methods were contraindicated or poorly tolerated apart from the psychological difficulty. Among the 74 cases of contraceptive difficulty not associated with psychological factors were: 12 cases of nulliparity and nontoleration of combined oral contraceptives (OCs); 22 cases of nulliparity and OCs contraindicated or inadvisable; 22 cases of OCs and IUDs contraindicated, inadvisable, or refused; 5 cases of IUD failure with OCs not possible; 2 cases of failure of local methods with other methods not possible; and 11 cases of various difficulties including 4 of difficulties of communication for linguistic reasons and 7 cases of repeated forgetting or incorrect taking of pills. It is not known whether the 252 cases in this survey are representative of the entire population. Problems in contraception are common among women seeking abortions and appear to affect at least 1 in 3 such women. The psychological factor is very significant among these women. Cases of contraceptive problems apart from psychological factors have primarily referred to nulliparous women unable to take pills and other women unable to use either OCs or IUDs. Vaginal contraceptive methods are not used as much as they could be in such cases. 4 cases are briefly described to illustrate the problems some women encounter in finding a suitable contraceptive method.     

Alternatives to oral regimens of contraception

Alternatives to oral contraceptives are an integral part of contraception used worldwide. In order to empower women to correctly use contraception for as long as they choose not to become pregnant, healthcare practitioners and their patients must be educated about these methods as well as the full spectrum of available birth control options. Effective counseling is a key factor in helping a woman effectively chose a method that is appropriate for her. In order for contraceptive counseling to be effective, information should be accurate and provided in an unbiased manner. This review will help provide healthcare practitioners with current information regarding the use of nonoral contraceptives so as to facilitate the counseling of women and allow them to make informed and appropriate contraceptive decisions.     

Hormone replacement therapy in perimenopausal women with a triphasic contraceptive compound: a three-year prospective study

Two hundred perimenopausal women who suffered from several symptoms and signs of menopause participated in this 3-year prospective study. Because they were still menstruating more or less regularly, these women were afraid of becoming pregnant and asked for contraception as well as hormone replacement therapy (HRT). Therefore the HRT chosen was a low dose triphasic oral contraceptive. The patient population was divided into two groups; one group (100 women) took the triphasic contraceptive as HRT and the other group served as controls (100 women). During the three years of this study this form of HRT was demonstrated to prevent conception and bone-mass loss, combat vaginal dryness and sexual disturbances, eliminate hot flushes and profuse sweating, correct breast atrophy, and prevent or improve psycho-functional disturbances, such as depressive mood, loss of concentration, insomnia, nervousness, palpitations and fatigue. It was concluded, based on the results of this study, that the triphasic oral contraceptive is the treatment of choice in the prevention and treatment of menopausal symptoms during the perimenopause--when contraception is still required.     

Intrauterine hormonelle Kontrazeption

Levonogestrel-IUS (LNG-IUS) are an innovative hormonal method of contraception. LNG-IUS have the advantages of oral contraceptives and IUD without specific disadvantages of these methods. The contraceptive safety is very high (Pearl-index =?0.16). LNG-IUS can be used in all woman, if the local uterine conditions are given. It is also possible in nulliparous woman, especially in cases of contraindications of other methods. The exclusion of genital infections is very important. A regular PAP-smear not older than 6 months is necessary. A postpartal use of LNG-IUS is possible 6 weeks after birth. LNG-IUS has no influence to lactation, so it is possible to use LNG-IUS also in the period of lactation. The risk of ectopie pregnancy is in LNG-IUS users lower in comparison to women using CU-IUD or no contraception. Bleeding disorders in the first months of LNG-IUS use occurred often, but a treatment is not necessary. In the first months of use LNG-IUS ovarian cysts occurred more often, but in the most of cases no treatment is necessary because they disappear spontaneously. After use of LNG-IUS no disadvantages for fertility are expected, LNG-IUS has also a place in specific situations because LNG-IUS has a lot of therapeutical side effects. LNG-IUS has labelling and is successfully woman suffering from heavy menstrual bleedings. Also in patients with endometriosis or adenomyosis the use of LNG-IUS has clinical advantages. Adenomyosis associated symptoms will be treated by LNG-IUS with a success rate of 70?%. In the perimenopause LNG-IUS is also a good contraceptive option because the endometrial protection effect is useful also for the prevention and treatment of endometrial hyperplasia. The introduction of low dose IUS (Jaydess^®) will extent the spectrum of intrauterine contraception. Advantages of Jaydess^® are especially the easier insertion in nulliparous women. In comparison to other contraceptive methods IUS have a lot of advantages.     

Contraceptive Use Among Canadian Women of Reproductive Age: Results of a National Survey

ObjectivePast studies indicate that despite a wide range of contraceptive options, Canadian women tend to use a narrow selection of contraceptive methods. New contraceptive methods have recently been introduced in Canada. The objective of this research is to characterize Canadian women’s current contraceptive choices and adherence to contraceptive regimens.MethodsA national cross-sectional survey was conducted in November 2006. A standardized, confidential, Internet questionnaire was administered to female members of a previously recruited national market research panel. Percentages of current contraceptive use and consistency of use were calculated by age group, marital status, and province and were weighted according to age and region. Chi-square test was used to detect within-group differences for consistency of contraceptive use, oral contraceptive (OC) use, and condom use. Multivariate logistic regression analyses predicting consistent contraception use, OC use, and condom use were performed.ResultsOf 5597 survey respondents, 3253 were eligible for data analysis. Of these women, 2751 had had vaginal intercourse in the previous six months, were not trying to conceive, and reported whether they or their partner had used contraception. Of these 2751 women, 410 (14.9%) never used contraception. Among contraception users, the most frequently used methods of contraception were condoms (54.3%), OCs (43.7%), and withdrawal (11.6%). Newer contraceptive methods were used by less than 4%. Choice of contraceptive method varied by age. Only 65.2% of respondents who were sexually active and not trying to conceive “always used” contraception. Multivariate logistic regression analyses found significantly higher odds of no contraception use in women over 40 years of age, without higher education, living in PEI or Newfoundland, married or living common-law, or having annual household incomes under $100 000.ConclusionDespite many contraceptive options, Canadian women continue to use a narrow range of contraceptive methods and to use contraception inconsistently. Consistent contraceptive use is influenced by a number of independent social variables. Future public health initiatives should focus on raising awareness of contraception options, increased access to a variety of contraceptive methods, and assisting with contraceptive adherence.     

Hormonal contraceptive methodology: an historical review

The introduction of the first hormonal contraceptive was one of the most important events of the twentieth century for women. The availability of oral contraceptives (OCs) provided women with greater control over their reproductive lives. As OC usage steadily increased, so did concern over health risks associated with their use. Concluding that adverse events were dose-related, scientists sought to develop lower-dose formulations. In the four decades since the first OC, women seeking contraception have benefited from the development of non-oral hormonal delivery systems, including injectables, intrauterine devices, implants, a vaginal ring, and a contraceptive patch. It is hoped that this expanding menu of choices affords women opportunities to find methods better suited to their individual needs. Clinicians should continually evaluate their patients' hormonal contraceptive needs, and provide adequate counseling so that every woman is afforded the opportunity to achieve contraceptive success.     

La anticoncepción en la mujer obesa

The increasing prevalence of obese women of childbearing age is a public and social health crisis. Contraception is a key issue in women with obesity. Obese women have a sexual activity no different from women of normal weight, and the use of contraception is considered less effective, as there is a higher risk of having an unwanted pregnancy. Due to a variety of metabolic disorders, obesity is a cardiovascular risk factor that can increase when combined with hormonal contraception. All these factors should be considered when choosing a contraceptive method in an obese woman. The objective of this review is to evaluate the risk-benefit of each type of available contraception, and the problem of contraception after bariatric surgery, in order to provide doctors with a practical guide on the use of oral contraceptive pills in obese women.