Clinical Review

Managing perimenopause: the case for OCs

OBG Manag. 2002 May;14(5):49-59

References

1. Casper RF, Dodin S, Reid RL, et al. The effect of 20 mcg ethinyl estradiol/1 mg norethindrone acetate (Minestrin™), a low-dose oral contraceptive, on vaginal bleeding patterns, hot flashes, and quality of life in symptomatic perimenopausal women. Menopause. 1997;4:139-147.

2. Davis A, Godwin A, Lippman J, et al. Triphasic norgestimate-ethinyl estradiol for treating dysfunctional uterine bleeding. Obstet Gynecol. 2000;96:913-920.

3. Friedman AJ, Thomas PP. Does low-dose combination oral contraceptive use affect uterine size or menstrual flow in premenopausal women with leiomyomas? Obstet Gynecol. 1995;85:631-635.

4. Ross RK, Pike MC, Vessey MP, Bull D, Yeates D, Casagrande JJ. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. BMJ. 1986;293:359-362.

5. Parazzini F, Negri E, LaVecchia C, et al. Oral contraceptive use and the risk of fibroids. Obstet Gynecol. 1992;79:430-433.

6. Hankinson SE, Colditz GA, Hunter DJ, Spencer TL, Rosner B, Stampfer MJ. A quantitative assessment of oral contraceptive use and risk of ovarian cancer. Obstet Gynecol. 1992;80:708-714.

7. The reduction in risk of ovarian cancer associated with oral-contraceptive use. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. N Engl J Med. 1987;316:650-655.

8. Ness RB, Grisso JA, Klapper J, et al. Risk of ovarian cancer in relation to estrogen and progestin dose and use characteristics of oral contraceptives. Am J Epidemiol. 2000;152:233-241.

9. Schlesselman JJ. Risk of endometrial cancer in relation to use of combined oral contraceptives; a practitioner’s guide to meta-analysis. Human Reprod. 1997;12:1851-1863.

10. Combination oral contraceptive use and the risk of endometrial cancer. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. JAMA. 1987;257:796-800.

11. Milsom I, Sundell G, Andersch B. The influence of different combined oral contraceptives on the prevalence and severity of dysmenorrhea. Contraception. 1990;42:497-506.

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13. Gambacciani M, Spinetti A, Cappagli B, et al. Hormone replacement therapy in perimenopausal women with a low dose oral contraceptive preparation: effects on bone mineral density and metabolism. Maturitas. 1994;19:125-131.

14. Kleerekoper M, Brienza RS, Schultz LR, Johnson CC. Oral contraceptive use may protect against low bone mass. Arch Intern Med. 1991;151:1971-1975.

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Dispelling myths

Like their patients, some health-care providers have unfounded concerns about the use of OCs in women over 40. But the evidence indicates that complications are highly unlikely in healthy nonsmokers and that the benefits far outweigh the risks.^1,13,28 OCs do increase the risk of venous thrombosis from a baseline risk of less than 1 per 10,000 person-years in nonusers to 3 to 4 per 10,000 person-years in OC users.^29,30 Rarely are these venous thrombolic events fatal, however. In addition, the World Health Organization (WHO) recently found that nonsmoking, normotensive, nondiabetic women of any age who use OCs face no increased risk of MI compared with nonusers.³⁰ In another study, the risk of MI increased among women using second-generation OCs (those containing levonorgestrel) but not third-generation formulations (those containing desogestrel).³¹ Although the relative risk of ischemic or hemorrhagic stroke does not appear to rise in healthy nonsmoking OC users, it does increase in women who smoke, are hypertensive, or have a history of migraine headaches.^30,32-34

Patients also may need to be reassured that long-term use is safe. As mentioned earlier, some of the benefits of long-term use are a reduction in the incidence of ovarian and endometrial cancers, stable or enhanced bone density, and a lower occurrence of menstrual disorders. By emphasizing these benefits, the health-care provider may improve compliance.

OCs to HRT

Women reach menopause at an average age of almost 52. However, if all patients were to stop taking OCs by the age of 52, half of them would still experience menses.³⁵ As long as the patient has remained a healthy nonsmoker and is doing well on OCs, it is safe for her to continue until the age of 55. Most women will have become menopausal by then, at which time hormone replacement therapy (HRT) can be initiated. If the patient continues to menstruate after discontinuing OCs at age 55, she can reinitiate them for an additional year. Another option is to measure follicle-stimulating hormone (FSH) levels at the end of the patient’s last pill-free interval.^36-38 Levels exceeding 20 mIU/mL suggest—but do not confirm—that menopause has occurred.

Counseling patients about OC use

When any woman begins taking oral contraceptives (OCs), she should be counseled carefully. This is especially true for perimenopausal patients, since the public remains relatively unaware of the many benefits OCs offer this age group. When counseling patients, I typically do the following:

Rule out contraindications. Women with a history of myocardial infarction (MI), thromboembolism, stroke, breast cancer, or serious liver disease should not take OCs. Perimenopausal women with risk factors for cardiovascular disease, e.g., smoking, hypertension, diabetes, or morbid obesity, should be discouraged from taking OCs.

Emphasize noncontraceptive benefits. Not surprisingly, many women associate birth control pills with just that: birth control. But OCs offer other advantages as well, including fewer menstrual irregularities, a lower incidence of ovarian and endometrial cancer, and the protection and possible enhancement of bone density. These should be highlighted.

Dispel the myths. Explaining the reality behind the many misconceptions associated with OC use helps allay a patient’s unsubstantiated fears and encourages her to try the regimen.

Detail side effects. The patient needs to be advised that “nuisance” side effects are common, occurring to some degree in almost all women during the first 1 to 3 months of OC use. These include nausea, headache, breakthrough bleeding, breast tenderness, bloating, and mood swings. I describe potential side effects clearly, since women generally are more tolerant of them when they aren’t taken by surprise. I also reassure patients that any adverse effects often resolve spontaneously within the first 3 cycles.

Review rare complications. Although uncommon, venous thrombosis is increased in OC users and should be discussed with perimenopausal patients initiating OCs.

Encourage strict compliance. I ask patients to commit to a 3-month trial of therapy, as this tends to enhance compliance. If a woman is just starting OCs—or has not taken them for many years—I also review the packaging and instructions.

Discuss alternative regimens. I make it a point to inform my patients that deviations from the standard 21/7-day regimen may be beneficial to decrease hormone withdrawal symptoms and monthly menstruation.

Schedule the next visit. I encourage new OC users to schedule follow-up appointments after they finish the second cycle of pills or have begun the third. At that time, I ask about side effects and alter the regimen accordingly if they are occurring primarily during the 7-day hormone-free interval.

—Patricia J. Sulak, MD

Conclusion

As ovarian function becomes increasingly erratic during the perimenopausal years, a number of gynecologic disorders may occur that have both a physical and an emotional impact. These include menorrhagia or other abnormal uterine bleeding, fibroid growth, ovarian cysts, sleep disruption, depression, and vasomotor symptoms. For this reason, I recommend OC therapy for healthy nonsmokers as they enter this transition and look for any disorder that may be alleviated by oral contraceptives.