Contraceptive Counseling in the Perimenopausal Woman

Rachael R. Dirksen, MD1,2, Mitra Razzaghi, MD2,3, Amy Huebschmann, MD3

University of Colorado Denver School of Medicine, Primary Care Internal Medicine Residency Program1,
Womens Integrated Services in Health Clinic2, Division of General Internal Medicine3

Discussion

Learning Objective

Clinical Case
A 52-year-old female with one year of irregular
menses presents to clinic asking for a
pregnancy test. She and her husband had
unprotected intercourse three weeks ago.
They do not use contraception as she believed
she could not conceive given her age. Her
last menstrual period was approximately three
months ago. She describes symptoms similar
to those that she experienced in her prior
pregnancies, including bilateral breast swelling
and food cravings. She confides that if she is
pregnant, she would like to terminate the
pregnancy.
Physical Exam: unremarkable except for a
mildly enlarged uterus, which is firm & mobile
Labs: Urine HCG Negative
After discussing contraceptive options with the
patient, she elected to use barrier
contraception.

TEMPLATE DESIGN 2008

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Over a third of all pregnancies are unintended in

women aged 40 years and older, a higher
percentage than that observed in women aged
30-39 years. One likely reason for this disparity
in unintended pregnancy rates is the common
misconception in perimenopausal women that
they are no longer fertile once they develop
irregular menses. In one study of women older
than age 40 years with an unintended
pregnancy, 56% terminated the pregnancy.
Graph 1: Unintended Pregnancy and Abortion Rates in 2001

Percentage

To recognize the importance of reviewing

sexual histories and providing contraceptive
counseling as part of the clinical management
of perimenopausal women.

90
80
70
60
50
40
30
20
10
0

Combination oral contraceptive (OCP)

Benefits: Improves vasomotor symptoms &
menorrhagia; Prevents bone loss, benign breast
disease & ectopic pregnancy; Reduces ovarian &
endometrial cancer
Risks: Increases risk of venous thromboembolism
(VTE) but less so than pregnancy; increases CV
complications, of particular concern in smokers
Progestin Only Oral Contraceptive (POP)
Benefits: Less thrombotic than estrogen containing;
may increase lactation quality/duration postpartum
Vaginal Ring

Unintended
Pregnancy Rate
Abortion Rate

1519

2024

2529

3034

3539

Recommendations

Contraceptive Agents: Risks & Benefits

>40

Age

Our patient had the misconception that her

irregular menses would prevent her from
becoming pregnant. As general internists, we
need to counsel our perimenopausal patients
regarding their fertility and contraceptive options.
For optimal contraceptive counseling, we need
to be knowledgeable of contraceptive options in
women with and without medical comorbidities,
as well as the benefits of various contraceptive
agents for treating perimenopausal symptoms.
In our clinical management of perimenopausal
patients, we must address sexual histories &
proactively provide appropriate contraceptive
counseling in order to reduce the disparate rate
of unwanted pregnancies in this population.

Benefits: Less medication interaction because

avoids first pass hepatic metabolism; Simple
monthly dosing promotes adherence
Risks: Similar profile to combination OCP
Implanon: Implantable progesterone rod
Benefits: No deleterious effects on bone
Risks: Irregular bleeding; lacking long-term data on
other potential risks
IUD:
Benefits: Adherence independent for both copper
and Mirena; Copper-hormone free; Mirena-reduces
menorrhagia, prevents endometrial hyperplasia
Risks: Copper-menorrhagia

Specific to perimenopausal women:

Avoid injectable medroxyprogesterone acetate
given deleterious effect on bone mineral density;
avoid hormonal patch given increased odds of VTE
and MI as compared to OCP
Women >35 years: Individualize OCP use based
on cardiovascular (CV) risk factors including
obesity, hypertension, hyperlipidemia
Smokers: Avoid OCPs given increased risk of
cardiovascular disease, particularly in women 35
years or older, POP may be appropriate
Hypertension: OCP may be used if blood pressure
well controlled on medication, but expect ~7mmHg
increase in systolic blood pressure
Diabetes: OCP do not impair metabolic control,
theoretical risk spurs recommendation that OCP be
avoided in diabetic women over age 35 years with
diabetic complications (e.g. retinopathy)
History of VTE: avoid OCP but may use POP,
acceptable to use OCP if patient therapeutically
anticoagulated, particularly if treating complications
of anticoagulation (e.g. menorrhagia)
History of coronary artery disease, heart failure,
cerebrovascular disease: OCP contraindicated
but POP may be appropriate

Barrier: Male & Female Condom

Benefits: Hormone-free; protection against sexually
transmitted infection
Risks: High failure rates; adherence dependent

References:
1)

2)
3)

Sterilization: Tubal ligation, vasectomy

Benefits: Effective; adherence independent

4)

Risks: Surgical risks; high relative cost

5)

ACOG Committee on Practice Bulletins. ACOG practice bulletin. No. 73: Use of
hormonal contraception in women with coexisting medical conditions. Obstet
Gynecol. 2006 Jun: 107(6): 1453-72.
Bonnema, RA, et al. Contraceptive Choices in Women with Underlying Medical
Conditions. American Family Physician. 2010 Sept 15: Vol 82, No 6, 621-628
CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Adapted
from World Health Organization Medical Eligibility Criteria for Contraceptive Use,
4th Edition. Morbidity and Mortality Weekly Report. 2010 May 28, Vol. 59.
Available at www.cdc.gov/mmwr
Finer LB & Henshaw SK. Disparities in rates of unintended pregnancy in the
United states, 1994 & 2001. Perspect Sex Reprod Health. 2006 Jun: 38 (2): 9096
Petra CM, et al. Contraceptive Options for the Perimenopausal Woman. Clinical
Medicine: Reproductive Health. 2008:2, 5-18