Contraception During Perimenopause: Practical Guidance

Figures & data

Figure 1 Comparisons between the percentage of voluntary abortions between 2010 and 2020 according to the different age groups in the Emilia-Romagna region (Italy).

Notes: Data from: Regione Emilia-Romagna. Salute. Assessorato politiche per la salute; Relazione sull’interruzione volontaria digravidanza in Emilia-Romagna nel 2020 [Health Policy Department; Report on the voluntary termination of pregnancy in Emilia-Romagna in 2020]; 2021. Available from: https://salute.regione.emilia-romagna.it/siseps/applicazioni/ig/documentazione. Accessed February 1, 2022. Italian.¹⁰¹

Box 1 Practical Guidance for Contraception Use in Perimenopause

SARCs

Combined Oral Contraceptive (COC)

All doses of COCs are still appropriate for use in all otherwise healthy, perimenopausal women.

Check the WHO Guidelines^Citation19 for eligibility (excluding smoking, hypertension, migraine, systemic lupus erythematosus with antiphospholipid antibodies, thrombosis history, known thrombogenic mutations, etc.).

Possible use in Virgo women.

Prefer products containing estradiol (quadriphasic estradiol valerate/dienogest, monophasic estradiol/nomegestrol acetate), in particular as the first CHC prescription.^Citation40,Citation42,Citation43

Possible extra-contraceptive benefits

Menstrual cycle control.

Reduction of primary/secondary dysmenorrhea.

Treatment of women with endometriosis.^Citation95

Reduction of vasomotor symptoms, such as hormone-related headaches or menstrual migraines.

Protection of bone health.

Reduction of endometrial, colorectal and ovarian cancer risk.

Vaginal Ring

Check the WHO Guidelines^Citation19 for eligibility (excluding smoking, hypertension, migraine, systemic lupus erythematosus with antiphospholipid antibodies, thrombosis history, known thrombogenic mutations, etc.).

Consider in women who desire to avoid daily pill intake/forgetful.

Possible extra-contraceptive benefits

Menstrual cycle control.

Reduction of primary/secondary dysmenorrhea.

Treatment of women with endometriosis.^Citation95

Reduction of vasomotor symptoms, such as hormone-related headaches or menstrual migraines.

Protection of bone health.

Improvement in vaginal lubrication.

Improvement in lactobacillus species in vaginal flora.^Citation96

Patch

Check the WHO Guidelines^Citation19 for eligibility (excluding smoking, hypertension, migraine, systemic lupus erythematosus with antiphospholipid antibodies, thrombosis history, known thrombogenic mutations, etc.).

Possible use in Virgo women.

Consider in women who desire to avoid daily intake/forgetful.

Its use in this age group is infrequent/not preferable (higher estrogen levels).^Citation97

Possible extra-contraceptive benefits

Menstrual cycle control.

Reduction of primary/secondary dysmenorrhea.

Treatment of women with endometriosis.^Citation95

Reduction of vasomotor symptoms, such as hormone-related headaches or menstrual migraines.

Protection of bone health.

Progestin-only pill (POP)

Check the WHO Guidelines^Citation19 for eligibility (excluding personal history of active or recent (within 5 years) breast cancer or lupus erythematosus with positive or unknown antiphospholipid antibodies, etc.).

Possible use in Virgo women.

Consider in women with a contraindication to oestrogens.

Possible extra-contraceptive benefits

Menstrual cycle control (unpredictable, possible amenorrhea).

Reduction of primary/secondary dysmenorrhea.

Treatment of women with endometriosis.^Citation95

Possible reduction of menstrual migraines.

LARCs

Cu-IUD

Check the WHO Guidelines^Citation19 for eligibility (excluding distorted uterine cavity, current pelvic inflammatory disease, purulent cervicitis, chlamydial infection or gonorrhoea, Wilson syndrome, etc.).

Avoid in women with heavy menstrual bleeding.

Consider in women who should avoid exposure to hormones, eg, [hormone fears and misconceptions or with contraindications to oestrogen and progestin assumption (eg, breast cancer survivors)].

Possible extra-contraceptive benefits

Reduction of endometrial, cervical and ovarian cancer risk.

Possible use as an emergency contraceptive.

Implant

Check the WHO Guidelines^Citation19 for eligibility [exclude personal history of active or recent (within 5 years) breast cancer or lupus erythematosus with positive or unknown antiphospholipid antibodies, etc.].

Possible use in Virgo women who desire LARC use.

Consider in women with BMI >30 and metabolic diseases.

Consider in women with contraindication of oestrogens.

Possible extra-contraceptive benefits

Menstrual cycle control (unpredictable/possible amenorrhea).

Reduction of primary/secondary dysmenorrhea.

Treatment of women with endometriosis.^Citation95

Depot medroxyprogesterone acetate (DMPA)

Check the WHO Guidelines^Citation19 for eligibility (excluding personal history of active or recent (within 5 years) breast cancer or lupus erythematosus with positive or unknown antiphospholipid antibodies, etc.).

Possible use in Virgo women

Its use in this age group is infrequent/not preferable (negative effect on bone health).^Citation65

LNG-IUS

Check the WHO Guidelines^Citation19 for eligibility (excluding personal history of active or recent (within 5 years) breast cancer or lupus erythematosus with positive or unknown antiphospholipid antibodies, distorted uterine cavities, etc.).

Consider in women with a contraindication to oestrogens

Possible extra-contraceptive benefits

Menstrual cycle control.

Reduction of primary/secondary dysmenorrhea.

Treatment of women with endometriosis.^Citation95

Treatment of abnormal uterine bleeding without an organic cause (on-label).

Treatment of women with fibroids (not distorting the endometrial cavity) and adenomyosis (off-label).

Prevention/treatment of endometrial polyps.

Prevention/treatment of endometrial hyperplasia/endometrial intraepithelial neoplasia.

Possible use as a progestin component for postmenopausal hormone therapy (on-label).

Reduction of endometrial, cervical and ovarian cancer risk.

Figure 2 Pros and cons of the use of combined hormonal contraceptives (CHCs) or progestin-only contraceptives in the perimenopause.

Figure 3 When to stop contraception? In the case of progestin-only pill, implant and levonorgestrel-realising intrauterine system use (A), depot medroxyprogesterone acetate use (B) and combined hormonal contraceptive (pill, vaginal ring and patch) use (C).

Regione Emilia-Romagna. Salute.Assessorato politiche per la salute; Relazione sull’interruzione volontaria digravidanza in Emilia-Romagna nel 2020 [Health Policy Department; Report on the voluntary termination of pregnancy in Emilia-Romagna in 2020]; 2021. Available from: https://salute.regione.emilia-romagna.it/siseps/applicazioni/ig/documentazione. Accessed February 1, 2022. Italian

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