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.     

Oral contraception: safety issues re-examined.

Oral contraceptives are highly effective contraceptive agents that are used throughout the world. However, misperceptions about the safety of oral contraceptives as well as a relative lack of information concerning their numerous and important noncontraceptive benefits may limit their use and place women at increased risk for unintended pregnancy. Safety issues concerning the use of oral contraceptives have largely been laid to rest; indeed, except for a slight increased risk of venous thromboembolism in combination oral contraceptive users, conventional oral contraceptive use is not associated with an increased risk for cardiovascular events. In addition, fears regarding breast cancer development in OC users have been unsubstantiated by the plethora of available data. Clinicians must provide accurate and empathetic counseling concerning the safety and applicability of oral contraceptives and other pregnancy prevention methods.     

Oral contraceptives. Risks

The modern combination oral contraceptive (OC) has become a mainstay in the effort to provide safe, reliable, and effective contraception. Safety concerns with OC use have largely been laid to rest as a result of multiple and extensive studies. Even so, misperceptions about the risks of OC use and a relative lack of recognition concerning the numerous and important noncontraceptive benefits limit their use, thus putting women in needless danger for unintended pregnancy. Indeed, even fears concerning breast cancer risk and OC use have been unsubstantiated by an abundance of data. Clinicians should be aware of the safety of low-dose OCs so that they can provide accurate and individualized counseling concerning the applicability of OCs and other contraceptive methods.     

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 for women in selected circumstances

OBJECTIVE: To review new evidence regarding ten controversial issues in the use of contraceptive methods among women with special conditions and to present World Health Organization recommendations derived in part from this evidence. DATA SOURCES: We searched MEDLINE and PREMEDLINE databases for English-language articles, published between January 1995 and December 2001, for evidence relevant to ten key contraceptive method and condition combinations: combined oral contraceptive (OC) use among women with hypertension or headaches, combined OC use for emergency contraception and adverse events, progestogen-only contraception use among young women and among breast-feeding women, tubal sterilization among young women, hormonal contraception and intrauterine device use among women who are human immunodeficiency virus (HIV) positive, have AIDS, or are at high risk of HIV infection. Search terms included: "contraception," "contraceptives, oral," "progestational hormones," "medroxyprogesterone-17 acetate," "norethindrone," "levonorgestrel," "Norplant," "contraceptives, postcoital," "sterilization, tubal," "intrauterine devices," "hypertension," "stroke," "myocardial infarction," "thrombosis," "headache," "migraine," "adverse effects," "bone mineral density," "breast-feeding," "lactation," "age factors," "regret," and "HIV." STUDY SELECTION: From 205 articles, we identified 33 studies published in peer-reviewed journals that specifically examined risks of contraceptive use among women with pre-existing conditions. TABULATION, INTEGRATION, AND RESULTS: Combined OC users with hypertension appear to be at increased risk of myocardial infarction and stroke relative to users without hypertension. Combined OC users with migraine appear to be at increased risk of stroke relative to nonusers with migraine. The evidence for the other eight method and condition combinations was either insufficient to draw conclusions or identified no excess risk. CONCLUSION: Of ten contraceptive method and condition combinations assessed, the evidence supported an increased risk of cardiovascular complications with combined OC use by women with hypertension or migraine. As new evidence becomes available, assessment of risk and recommendations for use of contraceptive methods can be revised accordingly.     

无痛人工流产者避孕知识与行为的调查

目的:了解无痛人工流产者对避孕知识的知晓程度与实际使用情况及影响因素。方法:采用横断面调查的方法,对因非意愿妊娠而自愿要求无痛人工流产者进行面对面的问卷调查,探究她们对于避孕方法的知与行的异同及其原因,并采用单因素和多因素非条件Logistic回归法分析每种避孕方法使用情况的影响因素。结果:在609名无痛人工流产者中,平均年龄为28.3±5.2岁,重复人工流产率为50.1%,首次性生活年龄为22.0±2.8岁。知道≥3种避孕方法者占95%以上。对某种避孕方法,使用者与知晓者的比例总体上从高到低顺序为避孕套(91.0%)、紧急避孕药(71.2%)、安全期(63.3%)、体外排精(58.8%)、杀精剂(21.1%)、口服避孕药(OC)(19.2%)、宫内节育器(IUD)(8.9%);目前使用者与曾经使用者的比例总体上从高到低顺序为安全期(83.4%)、避孕套(79.0%)、体外排精(71.2%)、杀精剂(50.0%)、紧急避孕药(36.1%)、IUD(11.4%)、OC(10.0%)。IUD和OC的停用和不愿使用的比例较高,主要原因是顾虑其副作用。未婚无分娩史者对安全期、体外排精、IUD和OC的知晓率较低,有分娩史者使用安全期、避孕套和IUD的比例最高,使用OC的比例最低;年龄、收入、流产次数对未婚无分娩史者选用避孕方法的影响比较大。结论:妇女对避孕方法的知晓度较高,但多未使用高效的避孕方法,避孕失误多,应加强流产后服务及避孕知情选择工作,指导妇女正确地选择和使用避孕方法,提高避孕效率。     

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.     

Gynaecology: Diagnosis of Menopause in Perimenopausal Women Taking Oral Contraceptives

The low-dose oral contraceptive (OC) is frequently being used by low-risk, non-smoking, perimenopausal women for a variety of indications, including cycle control, management of irregular bleeding and contraception. As the OC masks the signs and symptoms of menopause, the question of when to discontinue the OC, or switch from OCs to hormone replacement therapy inevitably arises. The “traditional” but insensitive method of diagnosing menopause in women taking the OC has been measurement of a serum FSH value of > 30 IU/L on day seven of the pill-free interval. Two recent studies suggest that measurement of serum estradiol and FSH:LH ratio on day seven of the pill-free interval will improve diagnostic sensitivity.     

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.     

Attitudes towards contraception and some reasons for discontinuation

3101 women aged 20-44 were surveyed in Flanders in 1982-83 concerning their perceptions of the contraceptive methods they used. The survey was part of a larger longitudinal study of changes in family formation in Belgium. Traditional and modern contraceptive methods were perceived very differently. Withdrawal/periodic abstinence and the condom were regarded as effective by 61% and 79% of respondents, while the IUD, pill, and female sterilization were believed by 99% of respondents to be effective. Traditional and intermediate contraceptive methods were believed to be less convenient to use, to be more frustrating sexually, but to be more natural. The IUD and pills were associated with higher risks of secondary effects, but oral contraceptive (OC) users believed their method to be much more harmful to their health than did IUD users. IUD users complained of physical secondary effects, while OC users complained of physical, psychic, and sexual secondary effects. Fewer IUD users than OC users believed their method to be highly effective. Considerable proportions of withdrawal, periodic abstinence, and condom users appeared to overestimate the efficacy of their method. Sterilization users believed the accessibility of their method to be significantly lower than did users of other methods, perhaps because sterilization has become accepted and widely available in Flanders only in the past few years. The most frequently cited advantages of withdrawal/periodic abstinence and the condom were naturalness, innocuity, and lack of secondary effects, while the most frequently cited advantage of OCs and sterilization was their efficacy. Ease of use and efficacy were both cited as advantages by IUD users. A large number of women, especially those using modern methods, stated their method had no major disadvantages. The principle disadvantages cited by withdrawal, abstinence, and condom users were low efficacy and inconvenience for sex life, while the principle disadvantages for the pill and IUD were health worries and secondary effects. Perception of the attributes of the contraceptive method used was influenced more by prior contraceptive use than by age, educational level, ideology or completeness of the family. As in other countries, users of modern methods seem to be more satisfied with their choice. Reasons for terminating use of different methods used in the past were directly related to their perceived disadvantages. Secondary effects and health worries were the major reasons for terminating OC and IUD use. A nonnegligible proportion who terminated IUD use cited its lack of efficacy.     

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.     

Contraceptive use and behavior in the 21st century: a comprehensive study across five European countries.

OBJECTIVE: The choice of currently available contraceptive methods has increased considerably in recent years, offering women of reproductive age a variety of different methods dependent on their needs and lifestyle. In order to determine the pattern of use of current methods in contraception, a survey was conducted in a large population of women drawn from five European countries (France, Germany, Italy, Spain and the United Kingdom). METHOD: More than 12,000 randomly selected women, aged 15-49 years, were interviewed using a standardized questionnaire which addressed the use of current methods of contraception. The responses were analyzed for the total study population, and, where appropriate, by country and age. RESULTS: An oral contraceptive (OC) was confirmed as the most widely used method of contraception for women in the European study population, with an estimated 22 million users in the five countries. Women using an OC reported very high levels of satisfaction (>90%). Male and female sterilization were the main methods of contraception in women aged 40 years and older. One-half of the women had undergone their sterilization before the age of 35 years. More than 50% of the women who had undergone sterilization had not been adequately informed and counselled about alternative reversible contraceptive options. No method of contraception was being used currently by 23% of the European study population, and unreliable methods of contraception (including cap/diaphragm, chemical, and natural and withdrawal methods) were being used by a further 6% of the population. Although valid reasons (e.g. not in a sexual relationship, wish to become pregnant) were given by many women who were not using contraception, there still remains a large number of women who need counselling regarding the importance of using reliable contraceptive methods. The number of women aged 15-49 years in the five European countries who are considered at risk of an unwanted pregnancy is estimated to be 4.7 million (6.5%). CONCLUSIONS: Differences in the use pattern of contraceptive methods were demonstrated that emphasize the social and cultural differences between the countries. The findings in the current study can be used as a baseline from which to monitor trends in contraceptive use and behavior in subsequent studies.     

Contraceptive use and behavior in the 21st century: a comprehensive study across five European countries

Objective?The choice of currently available contraceptive methods has increased considerably in recent years, offering women of reproductive age a variety of different methods dependent on their needs and lifestyle. In order to determine the pattern of use of current methods in contraception, a survey was conducted in a large population of women drawn from five European countries (France, Germany, Italy, Spain and the United Kingdom).

Method?More than 12?000 randomly selected women, aged 15–49 years, were interviewed using a standardized questionnaire which addressed the use of current methods of contraception. The responses were analyzed for the total study population, and, where appropriate, by country and age.

Results?An oral contraceptive (OC) was confirmed as the most widely used method of contraception for women in the European study population, with an estimated 22 million users in the five countries. Women using an OC reported very high levels of satisfaction (?>?90%). Male and female sterilization were the main methods of contraception in women aged 40 years and older. One-half of the women had undergone their sterilization before the age of 35 years. More than 50% of the women who had undergone sterilization had not been adequately informed and counselled about alternative reversible contraceptive options. No method of contraception was being used currently by 23% of the European study population, and unreliable methods of contraception (including cap/diaphragm, chemical, and natural and withdrawal methods) were being used by a further 6% of the population. Although valid reasons (e.g. not in a sexual relationship, wish to become pregnant) were given by many women who were not using contraception, there still remains a large number of women who need counselling regarding the importance of using reliable contraceptive methods. The number of women aged 15–49 years in the five European countries who are considered at risk of an unwanted pregnancy is estimated to be 4.7 million (6.5%).

Conclusions?Differences in the use pattern of contraceptive methods were demonstrated that emphasize the social and cultural differences between the countries. The findings in the current study can be used as a baseline from which to monitor trends in contraceptive use and behavior in subsequent studies.     

A case-control study of oral contraceptive use in women with adenocarcinoma of the uterine cervix

To evaluate oral contraceptive (OC) use as a possible cause of the changed ratio between adenocarcinoma and squamous cell carcinoma of the uterine cervix a case-control study was performed. The OC use among 23 women with adenocarcinoma of the uterine cervix was compared with that of a matched group of 46 women with squamous cell carcinoma. No differences in percentage of OC use, duration of such use or period of OC use in relation to diagnosis could be demonstrated between the two groups compared.     

The progestogen-only pill

This commentary reviews the indications for and side effects of the progestogen-only oral contraceptive (OC) pill, which accounts for under 3% of hormonal contraceptive sales in the UK. The progestogen-only pill has the advantage of fewer metabolic changes, a lower dose of progestogen, and avoidance of the use of estrogen. It is the hormonal method of choice for breast feeding women, older women, and women who are unable to tolerate an estrogen-containing preparation. Its failure rate ranges from 0.9 to 3.0/100 woman-years, which is comparable to that for other reversible methods. The failure rate tends to be lower in older age groups, perhaps reflecting advancing sensitivity with age to the contraceptive effects of progestogen. The major problem associated with use of progestogen-only contraceptives is irregular vaginal bleeding, experienced by 20-30% of users. Progestogen has been reported to induce a variety of effects on the endometrium as well as in ovarian steroid secretion. A high prevalence of functional ovarian cysts has been noted in users. It is now believed that the contraceptive efficacy of the progestogen-only pill depends more upon its effects on ovarian function than was previously realized. A new approach to overcoming some of the problems associated with progestogen-only contraception has involved combining progestogen with sulpiride. This combination appears to be more effective than either component alone in suppressing ovarian activity. There is a need to make progestogen-only OCs more widely available to women in developing countries, where 30-40% of women of reproductive age may be breast feeding at a given time. Numerous studies have demonstrated either no effect or a beneficial effect on lactation.     

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.     

The bone sparing effect of oral contraceptive use in non-smoking women.

In a group of 30 women, mean age 23.7 years, we have examined the urinary calcium: creatinine ratio (Ca:Cr) as an indicator of bone resorption, before and 6.8 months after oral contraceptive (OC) use. Fasting Ca:Cr decreased significantly during OC use, being more pronounced in nonsmokers. We agree with those who propose the use of OC in women also after 35 years of age, in view of their good effect on bone density.     

Little risk of stroke for healthy young women using oral contraceptives

The association between the risk of stroke and combined oral contraceptive (OC) use was investigated in the World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception. Included were 2198 cases of stroke (1068 hemorrhagic) and 6086 matched controls. Overall, current OC use was associated with a slight increase in the risk of both ischemic and hemorrhagic stroke. The increased risk was statistically significant in developing countries but not in Europe. Age over 35 years, smoking, and a history of high blood pressure substantially increased stroke risk. It was concluded that about 13% of all strokes in women 20-44 years of age in Europe and about 8% of those in women the same age in developing countries may be attributable to OC use. However, since stroke is a rare event among young women, this increased risk is very small (1-2 cases/year) in absolute terms.     

Demographic analysis of post-abortive and interval-administered hormonal contraceptive methods.

OBJECTIVE: To compare, using method type and application time, the demographic characteristics of women using hormonal contraceptive methods administered after abortion or during the interval period with those of intrauterine device (IUD) users. METHODS: The demographic characteristics of women to whom oral contraception (OC), monthly injection, depot medroxyprogesterone acetate (DMPA), or IUD were administered in the post-abortive and interval periods between January 1998 and September 2001 in our clinic, were evaluated with the help of a registration system based on the Microsoft Access software used in our clinic. Demographic characteristics recorded were: age, reproductive expectation, previous contraceptive method, education level, number of live children, number of induced and spontaneous abortuses. RESULTS: A total of 10 500 women were included in the study. Of these, 6601 women had taken a contraceptive method during the interval period, and 3899 women had taken a contraceptive method post-abortion. Only 4.6% of the cases were younger than 20 years, 48.3% were between 21 and 30 years, 37.2% were between 31 and 40 years and 9.9% were 41 years old or over. The DMPA-administered group contained the highest number of women > or = 41 years when compared to other groups (22.8%). In reproductive expectations, 65.8% of the cases wanted no more children; 1.3% wanted to have a baby within a 2-year period whereas 23.7% wanted a child after 2 years. The proportion of women wanting no more children was greatest in the DMPA-administered group (77.3%). No previous use of contraceptive methods was reported by 20.7% of women; 27% were using coitus interruptus. The education level of the women was as follows: 10% had no education, 58.3% had education to primary school level, 23.2% to secondary-high-school level and 2.1% to university level. The group of women who chose OC as their contraceptive method contained the highest proportion of university graduates (6.5%). Only 6.26% of the women had no children. The proportion of women in the DMPA-use group with three or more children was higher compared to that in other groups (33.2%). CONCLUSION: The evaluation of demographic characteristics plays an important role in counseling, and in the efficacy and continued use of contraceptive methods.