Choosing contraceptive options for perimenopausal women

In a presentation at the NPWH 25th Annual Premier Women's Healthcare Conference, Lois McGuire, MSN, APRN, WHNP-BC, NCMP, discussed the risks of unintended pregnancy in perimenopausal women and explored each contraceptive option using the US Medical Eligibility for Contraceptive Use Guidelines.¹

McGuire began by outlining the 4 key areas to consider when discussing contraceptive options with perimenopausal women: frequency of intercourse, desire or need for non-contraceptive benefits, completion of child-bearing, and natural decline of fertility. Nearly half of women aged 40 to 44 reported no contraceptive use in a 2009 study. “That was a really staggering number to me,” McGuire said. “Think about all the bad information they’re getting about birth control pills or combination hormonal contraceptives, the IUD,” she continued, “Undoing some of that bad information is important.”

It’s understandable, McGuire added, that many women have misconceptions around pregnancy in their 40s, citing an interesting qualitative study on the perspectives of 17 women aged 35 to 49. All women were menstruating regularly, sexually active, and not desiring pregnancy. According to the results, 9 women reported an unintended pregnancy after 35 and 8 women reported no unplanned pregnancies. Most of these women used condoms, but after unintended pregnancies, 2 women switched to more reassuring methods (IUC and contraceptive implant). “They all viewed contraception as a hassle,” she said. As for the 8 women with no unplanned pregnancies—all using combination hormonal contraceptives—saw contraception as a protector. “They had a whole different viewpoint of how contraception looked,” said McGuire.

Next she recommended progestin-only options for perimenopausal women who smoke, are obese, have migraines, diabetes, or hypertension. It may be contraindicated, however, for women with a history of breast cancer.

The levonorgestrel-releasing IUD is a great option, according to McGuire, because it serves a dual purpose. It reduces heavy menstrual bleeding by 72% to 98% in this age group and prevents endometrial hyperplasia. “For women that are overweight or obese, this is a great thing to suggest to them,” she said, “Because not only are you giving them a contraceptive option, but you're also protecting their endometrium at the same time.”

She advised avoiding the birth control shot—medroxyprogesterone acetate—for perimenopausal women due to concerns regarding bone loss and its potential to delay returns to fertility. McGuire also expressed her hesitation with the progestin-only pill due to its short half-life.

Another good option, McGuire said, is the copper IUD. While it may increase menstrual flow and cramping, it’s effective for 10 years and has a failure rate of 0.8% and may also be beneficial for breast cancer patients.

McGuire then recommended the US Medical Eligibility for Contraceptive Use (MEC), an app that offers evidence-based recommendations for contraceptive options deemed safe to use with a variety of medical comorbidities and patient characteristics. The US Selective Practice Recommendations—on the same app—are practical and evidence-based guidelines to inform providers how to use and manage the various contraceptive options most effectively.

Reference

1. McGuire L. Perimenopausal Contraception. Nurse Practitioners in Women’s Health 25th Annual Premier Women’s Health Conference. Houston, Texas. September 28 to October 2.