Usefulness of FSH measurements for determining menopause in long-term users of depot medroxyprogesterone acetate over 40 years of age

Contraception During Perimenopause: Practical Guidance

Climacteric is by no means in itself a contraindication to safe contraception. On the contrary, there are several conditions related to the perimenopause that could benefit from the use of modern contraceptives, mainly hormonal, with the goals of avoiding unintended pregnancies and giving further possible benefits beyond contraception (menstrual cycle control, a reduction of vasomotor symptoms and menstrual migraines, a protection against bone loss, a positive oncological risk/benefit balance). This narrative review aims to provide practical guidance on their possible use in this particular life stage, both short- and long-acting reversible contraceptives, and to assist clinicians for women transitioning from contraception to their menopausal years, including the possible initiation of postmenopausal hormone therapy. Comprehensive contraceptive counselling is an essential aspect of the overall health and wellbeing of women and should be addressed with each such patient irrespective of age.

Menopause: A Global Perspective and Clinical Guide for Practice

Perimenopause and menopause are a time of great transition for women-physically, mentally, and emotionally. Symptoms of the menopause transition and beyond impact women worldwide. Unfortunately, physician knowledge and comfort with addressing menopausal concerns vary greatly, limiting the support physicians provide to women in need. This review aims to increase physician understanding of the epidemiology, physiology, symptomology, and treatment options available for perimenopausal and menopausal women. Our goal is to empower physicians to educate and treat their patients to reduce the negative impact of perimenopausal changes and enhance overall well-being for women.

Management of perimenopause disorders: hormonal treatment

Perimenopause represents a transition period of a woman's life during which physiological, affective, psychological, and social changes mark progression from a woman's fertile life to menopause, with wide sexual hormones fluctuations until the onset of hypergonadotropic hypogonadic amenorrhea. Contraception during menopause should not only avoid unwanted pregnancies, but also improve quality of life and prevent wide range of condition affecting this population. Hormonal contraceptives confer many noncontraceptive benefits for women approaching menopause: treatment of abnormal uterine bleeding, relief from vasomotor symptoms, endometrial protection in women using estrogen therapy, musculoskeletal protection, and mood disorders protection. The main point remains selecting the most adequate contraceptive option for each woman, considering her risk factor, comorbidities, and keeping in mind the possibility of continuing contraception until reaching menopause and even further, creating a bridge between perimenopause and menopause hormonal therapy. Correct perimenopause management should rely on individualized medical therapy and multidisciplinary approach considering lifestyle and food habits as part of general good health of a woman.

Contraception for midlife women: a review

Family planning represents a key component of reproductive health care. Accordingly, the provision of contraception must span the reproductive age spectrum, including perimenopause. The risk of pregnancy is decreased, but not trivial, among women over 40 years of age. Evidence-based guidelines for contraceptive use can assist clinicians in counseling their patients in this population. Intrauterine contraception is one of the most effective methods and is safe to use in midlife women with few exceptions. Progestin-only contraception is another safe option for most midlife women because it is not associated with an increased risk of cardiovascular complications. Combined (estrogen-containing) contraception can be safely used by midlife women who do not have cardiovascular risk factors. Unique noncontraceptive benefits for this population include: improvement in abnormal uterine bleeding, decreased hot flashes, and decreased cancer risk. Finally, guidelines state that contraception can be used by midlife women without medical contraindications until the age of menopause, at which time they may consider transition to systemic hormone therapy.

[Contraception for women after 40: CNGOF Contraception Guidelines]

INTRODUCTION

Choosing contraception for women over 40 can be sometimes difficult but it is crucial since fertility and pregnancy's risks still exist. It requires a thorough evaluation of the situation, in order to identify any vascular and metabolic risk factors, along with the uterine and mammary benign pathologies already diagnosed.

OBJECTIVE

The objective of this review was to elaborate some guidelines for clinical practice regarding contraception's prescription for women over 40.

METHODS

A systematic review of the French and English existing literature was conducted. Pubmed and the Cochrane library were used to identify studies about contraception for perimenopausal women. International guidelines published by scientific societies were also reviewed (RCOG, FSRH, ESHRE, ACOG, WHO, HAS).

RESULTS

No contraceptive methods are contraindicated on the sole basis of age alone. However, because age is a risk factor for vascular and metabolic diseases, combined hormonal contraception and DMPA should not be prescribed at first intention. Copper IUD and progestin-only contraceptives (pill, implant, intrauterine device) should primarily be considered, since they offer good efficacy with lower risks.

CONCLUSIONS

Contraception for women over 40 should not be put aside. Long acting reversible contraception and progestin-only pill have to be prescribed as first-ine. Contraception is no longer needed for women over 50 who use non-hormonal contraception, after a 12 month-amenorrhea. Patients treated with combined hormonal contraception must stop using it over 50. Measuring hormonal levels while using hormonal contraception is not recommended. An hormonal-contraception-free interval must be considered, while using barrier contraception method. If an ovarian activity persists, a non-hormonal contraception or progestin-only contraception (except for DMPA) should be (re-)established.

Serum anti-müllerian hormone level is not altered in women using hormonal contraceptives

BACKGROUND

Anti-müllerian hormone (AMH) is secreted from granulosa cells of antral follicles into the circulation of adult women and hence could serve as an ovarian function test. This would be of value to hormonal contraceptive users if its serum level is unaffected by the use of hormonal contraceptives.

STUDY DESIGN

We prospectively recruited 95 women using combined oral contraceptive (n=23), combined injectable contraceptive (n=23), progestogen-only pills (n=9), progestogen-only injectable (n=20) and levonorgestrel intrauterine system (n=20), and measured their serum AMH concentration before and 3-4 months after treatment.

RESULTS

No significant difference in pre- and post-treatment serum AMH level was evident in all the treatment groups studied.

CONCLUSIONS

Being unaffected by hormonal contraceptives, serum AMH measurement is potentially a useful clinical test in hormonal contraceptive users for the differential diagnosis of anovulatory disorders and determination of menopause.

Carbohydrate complexity and proportion of serum FSH isoforms reflect pituitary-ovarian activity in perimenopausal women and depot medroxyprogesterone acetate users

BACKGROUND

FSH is synthesized and secreted in multiple glycosylation variants with different oligosaccharide structures; the endocrine milieu regulates the composition of FSH carbohydrate moiety.

OBJECTIVES

To characterize serum FSH isoforms according to their sialic acid content and oligosaccharide complexity in regularly menstruating women and in depot medroxyprogesterone acetate (DMPA) users during the menopausal transition. Subjects and methods Ten regularly menstruating perimenopausal women aged 45-52, with mid-follicular phase FSH levels < or =10 IU/l and 10 regularly menstruating women, aged 20-39, were included. Blood samples were collected on the ninth day of the menstrual cycle. Twenty DMPA users were divided into two groups (n = 10) according to age: DMPA(1), age range 20-39 and DMPA(2), age range 45-52. Blood samples were collected 90 +/- 5 days after the last injection of DMPA. Oestradiol (E(2)), inhibin B (Inh B), Pro-alphaC levels and the relative abundance of FSH isoforms on the basis of charge (preparative isoelectric focusing) and carbohydrate complexity (Concanavalin A chromatography) were determined.

RESULTS

Decreased Inh B and moderately elevated E(2) levels were observed in perimenopausal women associated with an increase in FSH sialylation and a decrease in its oligosaccharide complexity. DMPA induced changes in the hormonal profile and FSH molecular microheterogeneity; the secreted hormone was more heterogeneous and its oligosaccharides were less complex under this condition.

CONCLUSION

Serum FSH glycoforms with increased sialylation and decreased oligosaccharide complexity reflect the decline of the gonadal activity induced either by age or by the use of a DMPA as a contraceptive.

Forearm bone mineral density in postmenopausal former users of depot medroxyprogesterone acetate

BACKGROUND

The aim of the study was to compare the bone mineral density (BMD) of postmenopausal women who had used depot-medroxyprogesterone acetate (DMPA) or a copper intrauterine device (IUD) as a comparison group until menopause.

STUDY DESIGN

BMD was measured using dual-energy X-ray absorptiometry at the nondominant forearm for up to 3 years following menopause in 135 women aged 43-58 years: 36 former DMPA users and 99 former IUD users.

RESULTS

Mean duration of use was (mean+/-SEM) 9.4+/-3.8 and 14.7+/-6.2 years for the DMPA and IUD groups, respectively. One year after menopause, mean distal radius BMD was 0.435 and 0.449 in DMPA and IUD users, respectively, and 0.426 and 0.447 at 2-3 years following menopause. Ultra-distal BMD was 0.369 and 0.384 in DMPA and IUD users, respectively, at 1 year, and 0.340 and 0.383 at 2-3 years.

CONCLUSIONS

At 1 and 2-3 years following menopause, no significant differences were observed in the BMD of postmenopausal women aged 43-58 years, who had used DMPA or an IUD until menopause.