Do women aged over 40 need different counseling on combined hormonal contraception?

NOMAC-E2 compares to LNG combined oral contraceptives in women over forty: real-world PRO-E2 study

OBJECTIVE

To investigate safety and effectiveness of NOMAC-E2 and levonorgestrel-containing COCs (COC_LNG) in users over 40.

METHODS

In this large, observational study, new users¹ of NOMAC-E2 and COC_LNG were recruited in Europe, Australia, and Latin America and followed-up via questionnaires. Incidence of venous thromboembolism (VTE) was expressed as incidence rate (IR; events/10⁴ women-years [WY]). Unintended pregnancy was expressed by the Pearl Index (PI; contraceptive failures/100 WY). Mood and weight changes were defined as mean changes in mood score and percentage of body weight.

RESULTS

Overall, 7,762 NOMAC-E2 and 6,059 COC_LNG users over 40 were followed-up. NOMAC-E2 showed no increased VTE risk compared to COC_LNG; confirmed events: 5 NOMAC-E2 (IR 5.9; 95% CI, 1.9-13.7) vs 4 COC_LNG (IR 5.9; 95% CI, 1.6-15.1). Unintended pregnancy did not differ substantially between cohorts; confirmed events: 4 NOMAC-E2 (PI 0.05; 95% CI, 0.01-0.13) vs 5 COC_LNG (PI 0.08; 95% CI, 0.03-0.18). No differential effect on mood and weight was observed between cohorts.

CONCLUSIONS

NOMAC-E2 can be considered a valid alternative to COC_LNG in perimenopausal women.

Factors affecting contraceptive choice in women over 40: a qualitative study

OBJECTIVE

To explore the views of women over 40 years in choosing and using contraception, and to inform how contraceptive counselling for this age group could be improved.

DESIGN, SETTING AND PARTICIPANTS

Fourteen women aged 40-52 years were recruited through social media platforms to take part in online, semistructured, in-depth interviews. Transcripts were analysed using a qualitative thematic approach.

RESULTS

(1) Participants were anxious about unplanned pregnancy, and still highly motivated to avoid this. (2) Changes of contraceptive method over the lifecourse were occasionally precipitated by emergent health conditions, but healthcare providers often recommended a change in method on the basis of age alone. (3) Participants were experiencing perimenopausal symptoms but were largely unaware of how hormonal contraception could be used to treat these symptoms. (4) Prior negative experiences with contraceptive methods, coercive experiences with healthcare providers, and traumatic life events all contributed to a narrowing of contraceptive preference in later life.

CONCLUSION

Women over 40 years may be highly motivated to avoid pregnancy. This age group may have complex contraceptive histories with emerging perimenopausal symptoms. Women over 40 years may have accumulated adverse experiences which impact their contraceptive choices. These factors need to be explored by clinicians, to facilitate shared decision-making.

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.

A cohort study of the efficacy of the dienogest and the gonadotropin-releasing hormone agonist in women with adenomyosis and dysmenorrhea

PURPOSE

To study the efficacy and safety of the dienogest and the gonadotropin-releasing hormone agonist (GnRH-a) in symptomatic females with uterine adenomyosis.

METHODS

A total of 127 patients with adenomyosis with a chief complaint of dysmenorrhea were recruited. The first group received 2 mg of dienogest (DNG) daily, whereas the second group received goserelin acetate (GS) (3.6 mg/4 weeks) for 12 weeks. Outpatient follow-up was undertaken after 12 weeks.

RESULTS

Among 127 women, 56/63 (88.9%) patients completed the treatment in the DNG group, whereas 62/64 (96.9%) patients completed the treatment in the GS group. A significant decrease in dysmenorrhea symptoms as measured by the visual analog scale (VAS) and Carcinoma antigen125 (CA125) after 12 weeks of treatment was observed in both groups (p < .001). The hemoglobin of anemic patients did not significantly improve after 12 weeks of treatment (p＝0.21) and the uterine volume slightly increased without statistical significance (p＝0.10) in the DNG group. Simultaneously, The hemoglobin of anemic patients significantly improved (p < .001) and the uterine volume significantly decreased (p < .001) in the GS group.

CONCLUSIONS

Dienogest effectively alleviates the symptoms of dysmenorrhea in patients with adenomyosis, but it cannot improve the anemia or reduce the size of the uterus. GnRH-a is more effective in improving anemia and reducing the uterine volume in patients with adenomyosis. TRIAL REGISTRATION: ChiCTR1900024958.

Use of Combined Oral Contraceptives in Perimenopausal Women

While perimenopausal women have low fecundity, they are still capable of becoming pregnant and the majority of pregnancies occurring during perimenopause are unintended pregnancies. Therefore, even during perimenopause, contraception must be used if unintended pregnancies are to be avoided. However, many perimenopausal women and healthcare providers believe that older people should not take combined oral contraceptives (COC) because doing so may be dangerous. However, to date, there is no evidence that taking COC presents an increased risk of cardiovascular events or breast cancer for middle-aged women as compared to other age groups, and in their recommendations, the Centers for Disease Control and Prevention (CDC) also do not list age itself as a contraindication for COC. Perimenopausal women often experience menstrual irregularity, heavy menstrual bleeding, and vasomotor symptoms. Taking COCs can help control these symptoms and significantly reduce the risk of ovarian cancer, endometrial cancer, and colorectal cancer. The objective of the present review is to examine the usage methods of COC among perimenopausal women and the health issues that may arise from taking COC in perimenopausal women.

Anti-Müllerian hormone, follicle stimulating hormone, antral follicle count, and risk of menopause within 5 years

OBJECTIVE

To evaluate the ability of concentration of anti-Müllerian hormone (AMH), antral follicle count (AFC), and concentration of follicle stimulating hormone (FSH) to predict the onset of menopause.

STUDY DESIGN

The Coronary Artery Risk Development in Young Adults Study (CARDIA) Women's Study was an ancillary study to CARDIA, a population-based study of adults aged 18-30 years followed for 3 decades. For this report, participants were women (n=426) who had attended the CARDIA year 15-16 (2000-2001) examination, had at least one ovary, were not pregnant, and underwent serum AMH and FSH measurement and transvaginal ultrasonography in 2002-2003.

MAIN OUTCOME MEASURES

The probability of menopause in 5 years based upon AMH, FSH, and AFC.

RESULTS

The mean age of the women at the time of AMH, FSH, and AFC assessment was 43 years. The cumulative incidence of menopause at 25 years (or follow-up) was 27% (n=426), and the incidence within 5 years was 13% (n=55). Among women aged 45-49 years, undetectable AMH concentrations were associated with a greater than 60% probability of menopause within 5 years, whereas approximately 1/3 of women with no or just one antral follicle experienced menopause within 5 years. Both low and high concentrations of FSH were associated with greater odds of menopause than intermediate concentrations. Models with multiple markers did not improve the prediction of menopause over that afforded by models with single markers.

CONCLUSION

The ability to predict onset of menopause was improved with any of the three menopausal markers in addition to age. AMH concentrations were more closely associated with menopause than AFC or FSH.

Contraception for the perimenopausal woman

Perimenopause, or the menopause transition, is a time in a woman's life that bridges her reproductive years through to the non-surgical cessation of ovulation, or menopause. For many women this time is one of changes: changes in gynecological issues, onset of symptoms not experienced in her youth and increasing risks for adverse medical conditions. Despite the clear changes that occur for many women during this time, one critical issue is frequently ignored, namely, that, until the onset of menopause, she is exposed to pregnancy if sexually active, and pregnancy for older reproductive women is fraught with considerable increases in morbidity and mortality compared to younger women. This paper will present a review of the reproductive issues of the perimenopause and interventions geared to preventing pregnancy and relieving menopause-related symptoms. As counseling remains a critical aspect in empowering women to make informed choices about their health care, this paper will present current evidence that will help clinicians provide accurate reproductive counseling to women in the menopause transition.