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 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.     

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.     

The use of hormonal contraception in perimenopause is still a hazard?]

The need for contraception in a period of life characterized by irregular menstrual cycles as the perimenopause represents a social and biological event for each woman and a challenge for the gynecologist. The use of oral contraceptives in perimenopause has been vastly discussed in the last decade. Several investigators have focused their attention on the risks related to hormonal administration to older women neglecting all the advantages. The introduction of new lower-dose formulations and progestin-only preparations as implants or intra-uterine system has deeply changed the indications for hormonal contraception allowing their use in patients in whom it was previously contraindicated. Cumulative evidence has demonstrated that the use of hormonal contraception during the perimenopausal period does not offer only advantages in term of cycle control but also gives an important protection against the development of gynecological malignancies. However, in clinical practice the use of hormonal contraceptives in older women has not been accepted by a large number of physicians who continue to consider hormonal contraception in women over forties a tabù. The aim of this review is to discuss lights and shadows of the use of hormonal contraception in perimenopause.     

Contraceptive needs of the perimenopausal woman

Although there are many definitions of the perimenopause, all include the concept of transition from physiologic ovulatory menstrual cycles to hyperestrogenic anovulation and ultimately to hypoestrogenic ovarian shutdown. With this comes a transition from childbearing, and its requirement for contraception, to the infertility of menopause. There is no contraceptive method that is contraindicated merely by age. The contraceptive needs of the perimenopausal woman, however, may be better suited to some methods over others. This article explores various methods of contraception for the perimenopausal woman, including female sterilization, barrier methods, intrauterine devices, injectables, implants, and oral contraceptives.     

Progress in contraception: new technology

Unintended pregnancy continues to be a major public health issue in this country. Approximately 50% of pregnancies in the United States are unintended, and, of these, half end in abortion. Although tubal sterilization is highly effective, many women subsequently express regret and remorse. Oral contraceptives represent an effective, reversible method. However, many women have difficulty using them consistently and correctly. Recently, four new delivery systems for hormonal contraception have become available in the United States: the monthly injection, the levonorgestrel intrauterine system, the combination hormonal contraceptive vaginal ring, and the transdermal contraceptive patch. All four new methods are effective, readily reversible, generally discreet, and reduce daily compliance challenges. The monthly injection, vaginal ring, and transdermal patch can be discontinued without the need for an office visit. This expanded menu of effective contraceptive options should help women find a method that suits their particular life style.     

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.     

Update on contraception

Since the introduction of hormonal contraceptives in the 1960s, great advances have been achieved in contraception. Biological effects of sexual steroids as well as risks and benefits of oral contraception are better estimated. After the development of a new hormone-containing intra-uterine system, new hormone delivery systems offer women safe and effective contraceptive options. These new options that combine high efficacy and ease of use should allow better acceptance and compliance than daily pill ingestion and should then reduce the high rate of unintended pregnancies terminated by elective abortion. Transdermal contraceptive system and vaginal ring offer a promising innovative approach in pregnancy prevention. Subdermal implants give women the choice of a highly effective contraceptive system in spite of significant side effects. New hormonal delivery systems such as injectables are under development. Hysteroscopic tubal sterilization is now also available and is a very effective procedure. This wide variety of new contraceptive methods offers a marked improvement from previous medications for users by providing better efficacy and tolerability.     

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 in nulliparas

After a discussion of the physiologic, psychologic, and social needs of married, single and adolescent nulliparas, the applicability for these women of IUDs, pills, injectables, once monthly pills, condoms, and diaphragms is considered. Physiologically, the uterus is small and tonic, and the hypophyseal system is immature. Psychologically, the chief dichotomy is between mature and young women. Nulliparas may be uninformed sexually and susceptible to contraceptive failure because the nullipara is "incomplete." Socially, nulliparas often are involved with irresponsible partners who will not accept coitus-associated methods of contraception and do not contribute to the woman's mature sexual development. The IUDs and pills are contraindicated in young nulliparas, but should be considered because of their particular need for effective contraception. Condoms could be suggested for those in need of protection from venereal disease or diaphragms for the well-informed, but estrogen morning-after pills should be available.     

New contraceptive methods

OBJECTIVE: To provide an update on the current trend toward increasing use of emergency postcoital contraception, continuous (or "extended-use") oral contraceptives (OCs) and longer-acting contraceptive delivery systems. DATA SOURCES: This review is based largely upon patient care-oriented clinical experience data, including some original work submitted to the U.S. Food and Drug Administration by the primary investigators of these novel methods, supplemented, when appropriate, with basic pharmacologic and pharmacokinetic information. METHODS OF STUDY SELECTION: This review is a distillation based on an exhaustive literature search of each of the following topics: emergency postcoital contraception, continuous (extended-use) oral contraception, the weekly patch, the monthly vaginal ring and the monthly injectable. The issue of OC formulations recently begun to be marketed in this country was excluded since they have been extensively reviewed elsewhere. RESULTS: Emergency postcoital contraception is highly effective, though not as effective as available proactive methods of hormonal contraception. Of the popular regimens available, all have similar efficacy; those without estrogen are associated with less nausea and vomiting. The prophylactic administration of an antiemetic 1 hour prior to the first contraceptive dose can mitigate this adverse side effect. Continuous (or "extended" use) of OCs has become increasingly popular. This can decrease or eliminate menstruation as well as several menstruation-related complaints (e.g., dysmenorrhea, menstrual migraines and premenstrual symptoms). Despite the fact that combination OC regimens offer highly reliable contraception as well as several noncontraceptive health benefits, they are limited by the issue of daily compliance. To address this limitation, several longer-acting delivery systems were recently developed. The weekly patch, monthly vaginal ring and monthly injectable have efficacy and side effect profiles similar to those of comparable OC formulations. They offer the advantages of longer action and lower and more steady steroid levels and are free of the challenges associated with daily compliance. CONCLUSION: We need to continue to develop new and highly effective means of contraception that offer women ease of use and minimal side effects, hence leading to successful and effective use.     

“It's Worked Well for Me”: Young Women's Reasons for Choosing Lower-Efficacy Contraceptive Methods

Study ObjectiveTo understand the diverse reasons why some young women choose contraceptive methods that are less effective at preventing pregnancy, including condoms, withdrawal, and emergency contraception pills, even when more effective contraceptive methods are made available to them.DesignIn-depth interviews with young women at family planning clinics in July-November 2016. Interview data were thematically coded and analyzed using an iterative approach.SettingTwo youth-serving family planning clinics serving predominantly Latinx and African American communities in the San Francisco Bay Area, California.ParticipantsTwenty-two young women ages 15-25 years who recently accessed emergency contraception to prevent pregnancy.InterventionsNone.Main Outcome MeasuresYoung women's experiences using different methods of contraception, with specific attention to methods that are less effective at preventing pregnancy.ResultsYoung women reported having previously used a range of higher- and lower-efficacy contraceptive methods. In interviews, they described affirmative values that drive their decision to use lower-efficacy methods, including: a preference for flexibility and spontaneity over continual contraceptive use, an emphasis on protecting one's body, and satisfaction with the method's effectiveness at preventing pregnancy. Some young women described using a combination of lower-efficacy methods to reduce their pregnancy risk.ConclusionYoung women make contraceptive decisions on the basis of preferences and values that include, but are not limited to, effectiveness at preventing pregnancy. These reasons are salient in their lives and need to be recognized as valid by sexual health care providers to ensure that young women receive ongoing high-quality care.     

Perimenopause and depression: strength of association, causal mechanisms and treatment recommendations

Perimenopause represents a significant transition in a woman's life. The evidence to support an association between perimenopause and depression is mixed, yet recent prospective studies have provided stronger evidence to support such an association. Interpretation of study data are complicated by methodological issues, such as a lack of standard definition for perimenopause or depression, reducing comparability. A variety of causal factors, including psychological, genetic and physiological, have been implicated in depression during perimenopause, which lends weight to a multifactorial model. Physicians should consider initiating dialogue about menopause and symptom relief at age 40 and screening perimenopausal women for depressive symptoms. Selective serotonin reuptake inhibitors are a first line of treatment for depression, but hormone therapy could be considered for women experiencing menopausal symptoms unless there are contraindications. Future research should focus on establishing temporality and studying these potential relationships among women of different ethnicities.     

New aspects of injectable contraception

Despite the availability of efficacious and safe contraceptive agents, not all women's contraceptive needs are being met. An injectable contraceptive method offers convenience and encourages compliance, both very important aspects for women seeking ideal contraception. Depot medroxyprogesterone acetate (DMPA) is a long-acting injectable, and is highly effective; one injection provides 3 months of contraception. Drawbacks of DMPA include irregular bleeding and a slow return to fertility. A new monthly injectable contraceptive agent is medroxyprogesterone acetate/estradiol cypionate suspension (Lunelle). It provides menstrual regulation and a rapid return to fertility. The estrogen ensures a withdrawal bleed monthly; however, women with contraindications to estrogen-containing contraception are not candidates for Lunelle.     

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     

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.     

Changes in contraceptive practice and the transition of reproduction pattern in the Czech population

Objectives?To analyse changes in contraceptive practice among Czech women, during the last two decades, and to evaluate the associated demographic impacts.

Methods?Recent trends in fertility and abortion are presented and compared with earlier survey data on contraceptive use. Data from four Czech surveys carried out as part of international projects in 1993, 1997, 2005, and 2008 were used to document changes in contraceptive practice among Czech women.

Results?Greater availability and greater acceptance of new birth control methods have resulted in increased contraceptive use and in the replacement of traditional methods with more effective alternatives. While only 42% of women in union (married and cohabiting) used condoms, the pill or an intrauterine contraceptive in 1993, 75% of all women with a partner currently use effective contraceptives. The fertility transition towards delayed childbearing has not resulted in additional requirements in terms of family planning as no increase in the abortion rate among young women is observed.

Conclusion?The shaping of a new reproduction pattern in the Czech Republic has been accompanied by significant improvements in contraceptive practice. Despite the fact that the Czech population cannot be considered to perform outstandingly in terms of use of contraception, any remaining unmet need for modern contraception is marginal.     

Family planning needs: new opportunities,emergency contraception and other new technologies

Modern contraception is considered to be one the major advances of the 20th century. Yet, as the next century begins, it is estimated that there is still a largely unmet need for contraception, with millions of couples worldwide who express a wish to limit the number of their children but do not use or are not satisfied with their contraceptive method. While the reasons are numerous, it is clear that there is a need for improved and new methods which are easier to use, under the user's control, with fewer side-effects and responding to the needs of different groups of users, including men. To respond to this need, current contraceptive research and development efforts focus on five main areas: emergency post-coital methods, user-controlled long-acting methods, dual protection methods against both pregnancy and sexually transmitted infections, methods for men, and methods with fewer side-effects including some that are more targeted to specific reproductive biological events. A number of leads are presented which are at various stages of development. Concluding remarks stress the numerous challenges of contraceptive development, not the least of which is the vision required of what the needs of future generations will be, since it takes 10-15 years to bring a new contraceptive to the market. More fundamentally, overall progress towards reducing the unmet need for contraception will depend on the status of women, specifically their decision-making power, and access to education and income.     

Counseling on vaginal delivery of contraceptive hormones: implications for women’s body knowledge and sexual health

Abstract

Background: Healthcare providers (HCPs) have an important role in helping women select the contraceptive method that best matches their needs and lifestyle. Recent surveys outline the need of women to be informed about all available choices, including the newest methods (particularly those not requiring daily administration), such as vaginal contraception.

Methods: The most relevant publications on combined contraceptive vaginal ring are revised in the context of counseling as an opportunity to empower women in term of vaginal health and sexual functioning.

Results: HCPs should explain the main characteristics of the combined contraceptive vaginal ring including the anatomical and physiological implications that make the vagina an ideal route of hormonal administration and the basic notions about functional modifications of the vagina during reproductive life. Clinical data on the vaginal ring should be summarized with regard to efficacy, tolerability, pharmacokinetics, cycle control and user acceptability, including recent findings on extra-contraceptive benefits (also compared to other hormonal contraceptives) on the vaginal flora and on sexual function.

Conclusion: Vaginal contraception offers various benefits and should always be discussed during contraceptive counseling. An open dialogue about vaginal contraception will also help enhance body knowledge and sexual health.