Oral contraceptive use in perimenopause

Health benefits of combined oral contraceptives - a narrative review

PURPOSE

This review presents an update of the non-contraceptive health benefits of the combined oral contraceptive pill.

METHODS

We conducted a literature search for (review) articles that discussed the health benefits of combined oral contraceptives (COCs), in the period from 1980 to 2023.

RESULTS

We identified 21 subjective and/or objective health benefits of COCs related to (i) the reproductive tract, (ii) non-gynaecological benign disorders and (iii) malignancies. Reproductive tract benefits are related to menstrual bleeding(including anaemia and toxic shock syndrome), dysmenorrhoea, migraine, premenstrual syndrome (PMS), ovarian cysts, Polycystic Ovary Syndrome (PCOS), androgen related symptoms, ectopic pregnancy, hypoestrogenism, endometriosis and adenomyosis, uterine fibroids and pelvic inflammatory disease (PID). Non-gynaecological benefits are related to benign breast disease, osteoporosis, rheumatoid arthritis, multiple sclerosis, asthma and porphyria. Health benefits of COCs related to cancer are lower risks of endometrial cancer, ovarian cancer and colorectal cancer.

CONCLUSIONS

The use of combined oral contraceptives is accompanied with a range of health benefits, to be balanced against its side-effects and risks. Several health benefits of COCs are a reason for non-contraceptive COC prescription.

Influence of hormonal contraceptives on peripheral vascular function and structure in premenopausal females: a review

Hormonal contraceptives are one of the most widely used prescriptions for premenopausal women worldwide. Although the risk of venous and arterial cardiovascular events (e.g., deep vein thrombosis, arterial clotting) with hormonal contraceptives, specifically oral contraceptive pills, has been established, the literature on early risk indicators, such as peripheral vascular structure and function has yet to be consolidated. The purpose of this review is to summarize literature examining the impact of different hormonal contraceptives on vascular function and structure, including consideration of phasic differences within a contraceptive cycle, and to propose future directions for research. It is evident that hormonal contraceptive use appears to impact both macrovascular and microvascular endothelial function, with phasic differences in some contraceptive types dependent on progestin type, the ratio of ethinyl estradiol-to-progestin, and route of administration. However, hormonal contraceptives do not appear to impact smooth muscle function in the macrovasculature or microvasculature, arterial stiffness, or vascular structure. Underlying mechanisms for observed impacts and areas of future research are discussed. This review provides timely consolidation of research examining hormonal contraceptives and peripheral vascular function and structure and provides guidance on considerations for hormonal contraceptive use in study design.

Overview of perimenopausal contraception

The perimenopause is accompanied by important biological and psychosocial changes. The choice of contraceptive methods for women in the perimenopause, none of which is limited by age alone, will depend on the efficacy, safety, tolerability, and potential benefit of each method in relation to the biopsychosocial profile of the individual woman. Copper intrauterine devices are highly effective in the typical user and are a very safe method with, in general, good tolerability but are of limited use in women with heavy menstrual bleeding and subserous myomata. An additional benefit of copper intrauterine devices is protection against endometrial cancer. All progestogen-based methods share a favorable cardiovascular profile, making their use safe in most perimenopausal women. Long-acting implants and intrauterine systems are user independent and highly effective. Injectables and pills depend on user compliance. There is no evidence of a significant impact on breast cancer. Their impact on the endometrium can be either a negative side-effect (irregularity) or a benefit regarding reduction of heavy menstrual bleeding. Combined hormonal contraceptives have the highest cardiovascular risk. They can act as a promoting factor for breast cancer and cervical cancer, but they have the strongest potential regarding benefits (protection against endometrial and ovarian cancer, positive effect on bone mineral density, menstrual complaints, hyperandrogenic symptoms, hot flushes, and reduced risk regarding benign ovarian cysts and benign breast tumors).

Hormonal contraceptives: pharmacology tailored to women's health

BACKGROUND

In recent years, several new oral contraceptives have become available. In some ways, they represent an evolution in terms of individualization and compliance on the part of women. The new formulations make it increasingly possible to prescribe a specific hormonal contraceptive on an individual basis.

METHODS

A systematic literature search of PubMed was performed using the following combination of terms: 'oral contraceptives', 'estroprogestins' and 'combined oral contraceptive'. Only English-language papers published between January 2000 and July 2014 were included in our analysis. The present review analyzes all aspects of the choice of oral contraceptives in the different phases of a woman's life in detail.

RESULTS

Regarding the estrogen component, lowering the dose of ethinylestradiol (EE) helped reduce associated side effects. Natural estradiol is now available and represents a valid alternative to EE. And regarding progestins, the dose has changed over time, as well as the endocrine and metabolic characteristics. These are the fruit of much research into improvement of old products (19-nor-progesterone-derived progestins) with androgenic effects and testing of new molecules with improved metabolic neutrality in terms of insulin sensitivity and lipid parameters. New progestins were a genuine turning point because they greatly reduced major side effects, such as water retention, and their anti-androgenic properties made them indicated for all forms of hyperandrogenism associated with acne and mild hirsutism. The associations of estradiol/dienogest and estradiol/nomegestrol acetate are the most suitable contraceptives for women with abundant menstrual bleeding and can increase the number of potential users of hormonal contraception.

CONCLUSION

Progress in the provision of new oral contraceptives has improved the risk/benefit ratio, by increasing benefits and reducing risks. The present challenge is to tailor contraceptives to individual needs in terms of efficacy and protection of reproductive health.

Oral contraceptive use and fracture risk around the menopausal transition

OBJECTIVE

The effect of oral contraceptive (OC) use on risk of fracture remains unclear, and use during later reproductive life may be increasing. To determine the association between OC use during later reproductive life and risk of fracture across the menopausal transition, we conducted a population-based case-control study in a Pacific Northwest HMO, Group Health Cooperative.

METHODS

For the January 2008 to March 2013 interval, 1,204 case women aged 45 to 59 years with incident fractures, and 2,275 control women were enrolled. Potential cases with fracture codes in automated data were adjudicated by electronic health record review. Potential control women without fracture codes were selected concurrently, sampling based on age. Participants received a structured study interview. Using logistic regression, associations between OC use and fracture risk were calculated as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Participation was 69% for cases and 64% for controls. The study sample was 82% white; mean age was 54 years. The most common fracture site for cases was the wrist/forearm (32%). Adjusted fracture risk did not differ between cases versus controls for OC use in the 10 years before menopause (OR 0.90, 95% CI 0.74, 1.11); for OC use after age 38 (OR 0.94, 95% CI 0.78, 1.14); for duration of use, or for other OC exposures.

CONCLUSIONS

The current study does not show an association between fractures near the menopausal transition and OC use in the decade before menopause or after age 38. For women considering OC use at these times, fracture risk does not seem to be either reduced or-reassuringly-increased.

Therapeutic, prophylactic, untoward, and contraceptive effects of combined oral contraceptives: catholic teaching, natural law, and the principle of double effect when deciding to prescribe and use

Combined oral contraceptives (COC) have been demonstrated to have significant benefits for the treatment and prevention of disease. These medications also are associated with untoward health effects, and they may be directly contraceptive. Prescribers and users must compare and weigh the intended beneficial health effects against foreseeable but unintended possible adverse effects in their decisions to prescribe and use. Additionally, those who intend to abide by Catholic teachings must consider prohibitions against contraception. Ethical judgments concerning both health benefits and contraception are approached in this essay through an overview of the therapeutic, prophylactic, untoward, and contraceptive effects of COC and discussion of magisterial and traditional Catholic teachings from natural law. Discerning through the principle of double effect, proportionate reason, and evidence gathered from the sciences, medical and moral conclusions are drawn that we believe to be fully compliant with good medicine and Catholic teaching.

Treatment of depression associated with the menstrual cycle: premenstrual dysphoria, postpartum depression, and the perimenopause

Several forms of depression are unique to women because of their apparent association with changes in gonadal hormones, which in turn modulate neuroregulatory systems associated with mood and behavior. This review examines the evaluation and treatment of depression that occurs premenstrually, postpartum, or in the perimenopause on the basis of current literature. The serotonergic antidepressants consistently show efficacy for severe premenstrual syndromes (PMSs) and premenstrual dysphoric disorder (PMDD), and are the first-line treatment for these disorders. The use of antidepressants for postpartum depression is compromised by concerns for effects in the infants of breast-feeding mothers, but increasing evidence suggests the relative safety of the antidepressant medications, and the risk calculation should be made on an individual basis. Estradiol may be effective for postpartum depression and for moderate-to-severe major depression in the perimenopause. In spite of its frequent use, progesterone is not effective for the mood and behavioral symptoms of PMS/PMDD, postpartum depression, or perimenopausal depressive symptoms.

Progesterone and ovulation across stages of the transition to menopause

OBJECTIVE

Detailed characterization of progesterone and ovulation across the menopausal transition provides insight into conception risk and mechanisms of reproductive aging.

METHODS

Participants (n = 108, aged 25-58 y) collected daily urine specimens for 6-month intervals in each of 5 consecutive years. Specimens were assayed for pregnanediol glucuronide (PDG), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estrone glucuronide (E1G). Reproductive stage was determined using cycle length variance. A hierarchical algorithm was used to identify ovulation. Linear mixed-effects models estimated (1) the frequency and day of ovulation by age and stage; (2) differences in FSH, LH, and E1G levels between ovulatory (O) and anovulatory (AO) cycles; and (3) total PDG levels and PDG levels in O cycles by age and stage.

RESULTS

The probability of AO cycles increased across the perimenopause (P < 0.0001); reproductive stage was a stronger predictor than age of the probability of anovulation. Most cycles in late perimenopause were AO (>60%), but one quarter of cycles longer than 60 days were O. Average day of ovulation was later in the late perimenopause (mean [SD] cycle day, 27 [25] d) compared with the premenopause. FSH and LH levels were higher and E1G levels were lower in AO than O cycles (P < 0.0001 for each). Total PDG decreased in the late perimenopause, but 95th percentile PDG in O cycles declined steadily across the transition.

CONCLUSIONS

Exposure to the risk of conception in women experiencing cycles long enough to classify them as late perimenopausal is far from negligible. Reproductive stage is more informative than age about PDG levels and the likelihood of anovulation.

Safety, efficacy and patient acceptability of the combined estrogen and progestin transdermal contraceptive patch: a review

The worldwide introduction of the first, unique patch for hormonal contraception (ethinyl estradiol/norelgestromin, EE/NGMN patch) was widely recognized as a significant event in the development of drug delivery systems. This innovation offers a number of advantages over the oral route, and extensive clinical trials have proved its safety, efficacy, effectiveness, and tolerability. The weekly administration and ease of use/simplicity of the EE/NGMN patch contribute to its acceptability, and help to resolve the two main problems of non-adherence, namely early discontinuation and inconsistent use. The patch offers additional benefits to adolescents (improvement of dysmenorrhea and acne), adults (improvement in emotional and physical well-being, premenstrual syndrome, and menstrual irregularities), and perimenopausal women (correction of hormonal imbalance, modulation of premenopausal symptoms), thus providing high satisfaction rates (in nearly 90% of users). Since its introduction, the transdermal contraceptive patch has proved to be a useful choice for women who seek a convenient formulation which is easy to use, with additional, non-contraceptive tailored benefits for all the ages.

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

OBJECTIVE

To assess the usefulness of follicle-stimulating hormone (FSH) measurements for determining menopause in 40-55-year-old users of depot medroxyprogesterone acetate (DMPA).

STUDY DESIGN

FSH levels were measured in 355 blood samples from 82 amenorrheic women during an 18-month period. Blood was collected every 90 days immediately prior to DMPA administration.

RESULTS

Using FSH values>35 mIU/mL as being in the post menopausal range, 32 women (39.0%) presented at least one FSH measurement in the postmenopausal range and 14 of them (43.7%) had more than one elevated FSH measurement and were considered postmenopausal. In five users (15.6%), only the last FSH measurement was within the postmenopausal range, and in 13 women (40.6%), FSH returned to normal values following one measurement that was within the postmenopausal range.

CONCLUSIONS

The menopausal status in DMPA users in amenorrhea should be determined based on at least two consecutive high FSH evaluations, since, as shown here, 40.6% of the women with high FSH had a low FSH in the subsequent determination. FSH measurements should be done only in women>or=50 years old because there is a greater possibility of being in postmenopause. However, we do not recommend the interruption of DMPA use prior to the quantification of FSH.

Care of the menopausal patient: A nurse practitioner?s view

PURPOSE

To evaluate the benefits and risks of hormone therapy (HT) and other treatment options for early postmenopausal women.

DATA SOURCES

Published clinical trials, selected peer-reviewed literature, and recent clinical practice guidelines.

CONCLUSIONS

Results of the Women's Health Initiative (WHI) studies on HT may not be directly applicable to healthy, early postmenopausal women suffering from hot flushes. HT is the most effective treatment for menopausal symptoms. The benefits of HT in relieving menopausal symptoms are likely to exceed the risks in this population.

IMPLICATIONS FOR PRACTICE

The results of the WHI reinforce the importance of individualized care based on a woman's medical history, medical needs, and desired outcomes. Nurse practitioners can help their patients put recent results into perspective. When HT is used, nurse practitioners should consider using lower doses and reevaluate the need for therapy annually.

Communicating with patients about extended-cycle and continuous use of oral contraceptives

Oral contraceptives (OCs) have been the gold standard for contraception in the United States since their introduction in 1960. They are used for both their contraceptive and noncontraceptive benefits. Although the traditional dosing regimen, 21 active pills and 7 placebo pills, (21/7), reduces many symptoms women suffer with spontaneous cycles, hormone withdrawal symptoms often occur during the 7-day hormone-free interval. New contraceptives are available that decrease the number of hormone-free days each cycle or that increase the time between hormone-free intervals. These changes in packaging are expected to decrease the periodic hormone fluctuations experienced by OC users. Because routine use of extended-cycle/continuous OCs is relatively new and differs from what women have been told for years about the importance of monthly bleeding, women have many questions about and even significant reluctance to using these methods. Numerous studies have shown that extended-cycle and continuous OC use are safe and effective. Total bleeding episodes are reduced, as are problems with bloating and dysmenorrhea. Women usually experience more unscheduled spotting and bleeding in the initial cycles, but those problems decrease with longer use. Amenorrhea may be beneficial and suit the lifestyles of many women. Counseling women about all their contraceptive options and the variety of ways that OCs can be taken may increase women's commitment to correct use and increase efficacy. Good clinician-patient communication, which includes creating an open dialogue with the patient to discuss her individual risks and benefits, should lead to more successful contraceptive utilization.

Low-dose hormone therapy in the perimenopause

OBJECTIVE

To evaluate the effects of low-dose hormone therapy (LD-HT) on bleeding pattern and vasomotor symptoms in perimenopausal women.

METHODS

In a prospective, open-label study at an University clinic, 120 perimenopausal women suffering from irregular menstrual cycles and hot flushes were randomized to micronized 17beta-estradiol 1 mg plus dydrogesterone 10 mg sequential added (LD-HT; group A: 60 subjects) or dydrogesterone 10 mg from day 15 to 28 (group B: 60 subjects). Number and severity of hot flushes and bleeding pattern were assessed throughout the study.

RESULTS

Women in group A experienced a significant reduction in number of hot flushes while no significant variation was observed in group B. The incidence of cyclic bleeding was 86% in group A and 76% in group B, the mean duration was significantly lower in group A than in group B.

CONCLUSIONS

LD-HT may control both irregular bleeding and hot flushes in perimenopausal women.

Perimenopausal contraception in Turkish women: A cross-sectional study

BACKGROUND

Epidemiologic research has shown that perimenopausal contraception is an important medical issue, because women during the perimenopause still need effective contraception. The objective of the study was to assess the contraceptive choices of perimenopausal Turkish women.

METHODS

This is a descriptive cross-sectional study that in a non - random fashion recruited 202 perimenopausal and naturally menopausal women who lived in a suburban area of Istanbul. Women who took part were aged between 45-59 years old. Chief database used to identify the suitable participants in the district. Subjects who voluntarily participated in the study were interviewed in their homes by the researcher. The analysis of the data was evaluated using percentages.

RESULTS

The percentage of sexually active women among the participants was 87.6%. A large majority - 80.2% - of the participants did not have any idea of when they should bring contraception to an end. The method most commonly used was withdrawal (Coitus Interruptus), represented by 38.8%. In regard to the participants' choices of medical contraception, those being utilized were the IUD (24.3%), tubal sterilization (8.9%), condom (5.9%) and COC (6.4%). Additionally, 18% of women used other traditional methods including vaginal lavage, vaginal aspirin, and even inserting a small sponge presoaked with fresh lemon juice or cola deep into the vagina. Among the perimenopausal women who participated, the IUD was the most popular and appropriate contraceptive method.

CONCLUSION

Most perimenopausal Turkish women are still using traditional methods and women's knowledge about contraception in the menopausal stages is very limited. Health professionals should provide information about perimenopausal contraception.

Menstrual-cycle-related symptoms: a review of the rationale for continuous use of oral contraceptives

As many as 80% of reproductive-aged women experience physical changes associated with menstruation, and 20% to 40% experience menstrual-cycle-related symptoms. Decades of research in women with menstrual disorders, such as dysmenorrhea and menorrhagia, have shown that continuous use of oral contraceptives (OCs), without the hormone-free interval, is a safe and effective method to relieve these symptoms and ultimately induce amenorrhea in many women. If given the opportunity, a majority of women would opt for extended-cycle or continuous regimens, and numerous clinical trials have shown that continuous OC regimens induce amenorrhea in 80% to 100% of women by 10 to 12 months of use. For women who do not wish to become pregnant, a continuous OC regimen should be an available option.

Finished herbal product as an alternative treatment for menopausal symptoms in climacteric women

BACKGROUND

There is a paucity of scientific evidence supporting the efficacy of herbal medicines in treating menopausal symptoms.

OBJECTIVE

The aim of this study was to evaluate safety and efficacy of the finished herbal product TMN-1 in the treatment of menopausal symptoms in climacteric women.

DESIGN AND SETTING

A multicenter, prospective, observational follow-up study was conducted from July 2003 to December 2004 in four hospitals in Taiwan.

PARTICIPANTS

Initially, 126 women were included who were between 45 and 55 years of age, were experiencing hot flashes, and were without hormone replacement therapy. Women were excluded if they had any signs of active cancer. Of the participants, 82% completed the study. The reasons for withdrawal included adverse effects (n = 7), failed to return (n = 7), lack of efficacy (n = 6), and from protocol deviation (n = 3).

INTERVENTION

Every participant received TMN-1 treatment 4 g, 3 times per day, for 12 weeks.

MAIN OUTCOME MEASURE

Primary measures were change in frequency of hot flashes and severity of menopausal symptoms measured by Kupperman Index (KI). Secondary outcomes included changes in quality of life and adverse events.

RESULTS

Significant improvement in scores of hot flashes and KI were found at weeks 4 and 12 in the 50 peri- and 53 postmenopausal women who completed this study (p < 0.001). Logistic regression analyses showed that perimenopausal women with hot flashes had sevenfold (95% confidence interval [CI], 1.8-28.0) odds of improvement in favor of treatment, whereas that of the postmenopausal group was 1.5 (95% CI, 0.5 to 4.2). Further analyses showed that TMN-1 produced superior benefit in women with moderate and severe menopausal symptoms (KI > or = 21), compared to those with mild symptoms. It also improved symptoms of insomnia, nervousness, melancholia, and palpitation in perimenopausal women. Five (5) adverse drug reactions were detected: three single events of nausea, abdominal pain, and abdominal fullness; and two events of diarrhea.

CONCLUSIONS

This study provides evidence that 12 weeks of TMN-1 therapy is a viable alternative treatment to consider in perimenopausal women with hot flashes, particularly in those with palpitations, emotional disturbance, and insomnia.

Low-dose transdermal estradiol for symptomatic perimenopause

OBJECTIVE

To determine whether low-dose transdermal estrogen therapy is associated with a reduction in vasomotor symptoms in women who continue to have menstrual cycles.

DESIGN

An open-label, observational evaluation conducted over 12 months in 22 consecutive perimenopausal women with vasomotor symptoms.

RESULTS

Improvement in vasomotor symptoms was reported by 16 (73%) of women evaluated. Of responders, 11 characterized symptom relief as complete and 6 as moderate. Fifteen (68%) of the women remained on transdermal estrogen at 12 months. No adverse health-related events were attributed to estrogen therapy.

CONCLUSION

Low-dose transdermal estrogen is well tolerated and was associated with a reduction in complaints of vasomotor symptoms before menopause. The steady-state pharmacokinetics of transdermal delivery of unopposed estrogen may be advantageous in a population sensitive to fluctuations in circulating hormone levels.

The efficacy of non-contraceptive uses for hormonal contraceptives

In addition to providing safe and effective contraception, both the combined oral contraceptive pill (COCP) and selected long-acting progestogen-only contraceptives have significant health benefits. The COCP may reduce menstrual blood loss, dysmenorrhoea and premenstrual syndrome; unequivocally reduces the later incidence of endometrial and ovarian cancer; appears to help protect future fertility, probably by reducing the risk of acute pelvic inflammatory disease, endometriosis and uterine fibroids. The quality of evidence for individual non-contraceptive health benefits of the COCP is very variable.

Gynecologic problems of the perimenopause: evaluation and treatment

The gynecologic problems associated with the perimenopause and detailed in this review represent common and often vexing concerns for women during this transition. By heeding the evidence-based approaches to evaluation and treatment described herein, clinicians can improve the health and lives of their perimenopausal patients.

Preventive care for the menopausal woman

In summary, menopause represents a stage in a woman's life for the primary care physician to have an important impact on health [43]. Decision-making must weigh individual risk factors for health disease, osteoporosis and breast cancer. Hormone replacement therapy remains an important issue for the postmenopausal woman [44]. More evidence is needed to define the specific health benefits and risks of HRT, particularly as it relates to the prevention of CHD. A patient centered approach using a shared decision making model is most likely to result in improved patient satisfaction and desired health outcome.

Using a low-dose contraceptive in women 35 years of age and over: 20 microg estradiol/100 microg levonorgestrel

The efficacy, safety, and cycle control of a low-dose oral contraceptive (OC) containing 20 microg ethinyl estradiol (EE) and 100 microg levonorgestrel (LNG) has been demonstrated in a large trial with 1708 women (>or=15 years old with regular menstrual cycles). The objective of this study was to analyze the same parameters in 218 of the 1708 women who were 35 years of age and older. Women were administered the 28-day, combination OC (20 microg EE/100 microg LNG; 21 days active medication/7 days placebo) for up to 3 years. During 3859 cycles evaluated for efficacy, one pregnancy occurred (Pearl index 0.34). The most common adverse events cited as reasons for discontinuation were hypertension (3% of subjects), headache (2%), and metrorrhagia (2%). One subject withdrew as a result of a serious adverse event. Breakthrough bleeding, spotting, and bleeding and spotting occurred in 2.9%, 11.0%, and 6.8%, respectively, of the 3739 cycles evaluated for cycle control. This low-dose, monophasic regimen of 20 microg EE/100 microg LNG is an effective, safe, and tolerable contraceptive and provides good cycle control for women 35 years of age and older.

Contraceptive applications of estrogen

Estrogens are a primary component of several contraceptive methods: combined oral contraceptive pills, a combined injectable contraceptive, the combined contraceptive vaginal ring, the combination transdermal contraceptive patch, and combined emergency contraceptive pills. Contraceptive formulations that contain estrogen are referred to as combined contraceptives because they also contain some form of progestin. This article reviews the contraceptive methods containing estrogen, beginning with a discussion of combined oral contraceptive pills. Formulations and clinical management, mechanisms of action, noncontraceptive benefits of use, therapeutic uses in addition to contraception, side effects, contraindications to use, and drug-drug interactions are described. Information follows about the newer combined contraceptive products including the injection, vaginal ring, and patch. Finally, combined emergency contraceptive pills are reviewed. Thorough knowledge of the contraceptive methods containing estrogen enables clinicians to provide expert care for women using these products.