Contraception for midlife women: a review

Contraceptive technology is failing to meet the needs of people in the U.S. because of under-investment in new methods

This commentary considers if contraceptives currently available in the U.S. are meeting all current or potential user needs and presents the case for the funding of research to enhance contraceptive options. People experience high rates of contraceptive failure, unintended pregnancies, and a non-trivial proportion experience a high level of dissatisfaction with available contraceptive methods. Given increasing restrictions on abortion, additional options that better meet the needs of non-users or dissatisfied users rise in importance. Priorities for improvement include fewer side effects, affordability, and ease of use, all coupled with high effectiveness. Although available products are safe for most users, and those with risks can be identified by screening, additional methods that are safe without screening and address dissatisfactions and contraindications would be desirable. Addressing these gaps through typical market mechanisms is not happening. The level of interest and investment in contraceptive research and development (R&D) is very low in part because extensive use and the apparent diversity of contraceptive options may drive a mistaken perception that contraception is a "solved problem." Even with the incentive of a global contraceptive market of $25 billion annual U.S. contraceptive R&D expenditures in 2021 totaled only $149 million compared to total pharma R&D outlays of $250 billion. An increase in both the priority and funding of contraceptive R&D is needed. Annual outlays of ~$500 million to $1 billion would be needed to address the key challenges holding back the field.

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.

Use of Hormonal Contraceptives in Perimenopause: A Systematic Review

INTRODUCTION

Hormonal contraceptives have been used in perimenopausal women to manage a variety of symptoms and prevent unintended pregnancy. However, it is unclear what contraceptive regimen is best for these women.

OBJECTIVE

To evaluate hormonal contraceptive methods in women experiencing perimenopause using two prespecified outcomes: perimenopausal symptom management and long-term effects.

METHODS

A literature search of PubMed and EMBASE databases was performed (January 1990 to October 2021) using search terms "perimenopause" and "contraception." Relevant full-text articles in English were included.

RESULTS

Fifteen clinical articles were reviewed. Fourteen were internationally-based and one study was conducted in the United States. Nine articles evaluated symptom resolution, and six of these nine reported statistically significant changes in favor of treating perimenopausal women with hormonal contraceptives compared with no treatment. Seven studies evaluated long-term outcomes including bone loss and metabolic parameters, and six of these seven showed statistically significant improvements with hormonal contraceptives. Based on limited data and a lack of comparative studies, the use of a levonorgestrel intrauterine device with supplemental low-dose menopausal estrogen has positive results for the management of disruptive perimenopausal symptoms and long-term outcomes.

CONCLUSION

Hormonal contraception in perimenopausal women improves symptom management and long-term outcomes if patients do not have contraindications. When selecting a contraceptive for women in perimenopause, clinicians and pharmacists need to address specific patient risk factors, symptom profiles, long-term risks and benefits, and patient preferences.

Sexuality, pelvic floor/vaginal health and contraception at menopause

A multitude of biopsychosocial factors influences sexual health at midlife, a common concern in daily practice along with vaginal and pelvic health. Health-care providers (HCPs) need to be proactive in dealing with possible symptoms because in most cases early management prevents distress and improves quality of life. Female sexual dysfunctions (FSDs) may have a complex etiology but sexual history is not difficult implementing basic knowledge of risk factors and some skills helping women to cope with hormonal and age-related changes. This work summarizes key points to approach sexual symptoms in midlife women, providing principles to diagnose and manage hypoactive sexual desire disorder (HSDD) and genitourinary syndrome of menopause (GSM)/vulvovaginal atrophy (VVA), as well as manage contraceptive needs.

"Since I'm a little bit more mature": contraception and the arc of time for women in midlife

Background

Contraceptive methods have rapidly evolved over the past several decades, but little research has explored how women interact with contraception over time. Exploring contraceptive beliefs, perceptions, and attitudes of women in midlife can reveal much about how lived experience affects contraceptive decisions and reproductive health choices.

Methods

Individual, semi-structured interviews were conducted with 20 women between the ages of 40 and 55 who had not reached menopause and did not have a permanent method of sterilization. Data were coded using qualitative descriptive methods.

Results

Three major themes were identified: 1) journey toward empowerment; 2) finding the right fit: evolution over time; and 3) anticipating a transition. Past experiences with or fear of side effects and hormones were common reasons to change or avoid certain contraceptive methods. Most participants were happy with their contraceptive method; however, those who were unhappy were more likely to vocalize fatigue at continuing to need contraception as menopause approached.

Conclusion

Approaching contraceptive counseling from a place that considers the journey with contraception over a reproductive life span will help identify how beliefs, perceptions, and attitudes of women affect their contraceptive practices and choices.

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 high risk patients

In the context of medically complicated pregnancies, a "high risk patient" is an individual who is at increased risk for having a complicated pregnancy. These patients often experience limited contraceptive counseling and access, despite the fact that most effective contraceptive methods are associated with less risk than that of pregnancy. Free evidence-based resources are available to assist healthcare providers in discerning fact from myth about the risks of contraception. This review covers all available contraceptive methods, with particular focus on the benefits, risks, and attributes most relevant to high risk patients as well as the benefits and risks of initiating contraception post-pregnancy.

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).