"Doctor, I don't want to get pregnant!"

The majority of women in the perimenopausal period have completed their childbearing and resolutely do not want to conceive at this age. This gives rise to the question as to what contraceptive method they should use to prevent an unwanted pregnancy. At this stage in their lives, an unintended pregnancy would be devastating, and it is something they are usually very eager to avoid. Many women at this age have chosen sterilization, either of themselves or their partner. Thus, avoiding pregnancy is not a problem for them. However, for other sexually active women, this remains a very important concern. As discussed in last month's column, the incidence and quality of ovulation has decreased dramatically by this time, and women in the perimenopausal range are certainly less fertile than younger women. While it is not always a good idea, many women relinquish contraception and rely on this decreased fertility for contraception. However, the chances of conception are certainly not zero until the FSH is over 30-40 and the menses have ceased. Seventy-five percent of pregnancies in women after the age of 40 are unintended, and in the United States over one half of these end in the pregnancies being terminated. This is in addition to a miscarriage rate double that of women in their twenties and thirties. Until the parameters discussed above and last month [link to last month's column] appear, signaling the cessation of ovulation has occurred, women should still consider potential pregnancy as a possibility. As long as they are still ovulating, even occasionally, women should consider employing some type of contraception method.

Oral contraceptives are a very common type of contraception for women at some time in their life, but they are not commonly utilized in the perimenopausal period. Early studies suggested increased risks to women over the age of 35 using birth control pills, but this subsequently been shown to not be the case. Later studies have shown that increased age is not a risk factor, and in the absence of other factors, taking oral contraceptives is accepted as a safe method. However, the main complicating factor associated with risks of oral contraceptives is the combination of smoking. Smoking has been shown to dramatically increase the risk of complications in this age range, and it is universally accepted that women who smoke should strongly consider other methods of contraception. This warning also applies to women with hypertension or diabetes mellitus. If a woman smokes, has high blood pressure, or has diabetes, then she is not a candidate for the pill. However, in the absence of these risk factors, a woman in her forties is considered a good candidate for a low-dose oral contraceptive.

Another less common type of oral contraceptive is the progesterone-only type of pills, which carry less risks than the combination ones. One's health care provider may suggest this type of pill for certain women, as they can be used in some situations where the combination pills are contraindicated. An example of this is in a woman in whom estrogen may be contraindicated. There are also several other types of contraceptives utilizing progesterone. This hormone can be used in injections, subdermal implants, or, as mentioned, in progesterone-only pills. Each has different pros and cons, and each may be used by women who should not take estrogen.

There are numerous benefits to oral contraceptives, and often these are overlooked when considering various methods of contraception. Women who have been on the pill have a significantly decreased incidence of both endometrial and ovarian cancer, and this effect on ovarian cancer seems to last for years after stopping the pill. There is some data that suggests that women on the pill in the perimenopause have an increased bone density, and this infers that they may enter the menopausal period with more bone mass than had they not taken oral contraceptives. Oral contraceptives may also help with some of the early symptoms of menopause, such as hot flashes and irregular menses. Erratic menses during this time are very common in perimenopause women, and the pill will help to regulate and reduce their menses. Women in this age range may have often worked their way up in the professional world, and missing work because of increased bleeding becomes a progressive problem for them. In fact, many women who have already been sterilized still utilize the low dose pill simply to control their menses. When to stop oral contraceptives and consider hormone replacement was discussed in last month's column, and this is a decision that will need to be discussed and decided upon with one's health care provider.

The intrauterine device (IUD) is still an excellent method of contraception, but has not been utilized extensively in the United States simply for liability reasons. It has been shown to be a perfectly safe method of contraception, and it is utilized much more extensively in other parts of the world. The copper 380-T IUD has now been approved to stay in place for ten years, and women may be able to use it well into menopause when it becomes much easier to determine that she is not ovulating or menstruating. The downside is that the IUD may make the menses heavier or more frequent, and sometimes women in this age range already have this problem. There is another type of IUD, the Progestasert, which uses hormones and does decrease menses, but it tends to be more expensive and must be replaced annually.

Barrier methods, such as condoms, the diaphragm and spermicidal agents, are also viable choices for women in this transition period. While their effectiveness is usually quoted as somewhat less than other methods, their overall effectiveness increases significantly when combined with the decreased fertility of women in this age range. The rhythm method, or avoiding intercourse during ovulation, is often difficult to employ, as it is dependent on regular and predictable menstrual cycles. During the perimenopause phase, the menses tend to become erratic and unreliable, thus undermining the dependability of the rhythm method in the perimenopause.

A pregnancy in the perimenopausal time would be a difficult occurrence in the lives of many women and could create some very difficult choices. Her likely decisions, should she have to confront these choices, should also be a factor in her choices of contraception. While the chances of conceiving are certainly lower at this age, they are not zero until the FSH has risen and the menses have ceased for a year. Women in the perimenopausal period have to carefully weigh all their options, along with their choices and ramifications in the event of a failure, when considering contraception during this transition time period of their life.