On World Contraceptive day: Review of contraception during perimenopausal years.

September 26^th is World Contraceptive day, it is annual worldwide campaign to improve global awareness about contraception, with the dream that every pregnancy is intentional.

RCOG has released a review paper about contraceptive methods around menopause, published today in RCOG journal The Obstetrician and Gynecologists. The WHO defines the menopause as permanent cessation of menstruation caused by the loss of ovarian follicular activity, which is essentially a retrospective diagnosis.

There exists no accurate biological marker that defines the moment when the woman ceases to be fertile.  During the perimenopausal years menstrual irregularities are very common with irregular scanty or heavy blood loss.

Although after 30’s natural fertility is on decline, effective contraception should still be used till menopause to avoid unintended pregnancies.

Some important key contents of this review paper on perimenopausal contraception are:

No method of contraception is contraindicated based on age alone, up to the age of 50 years, HRT does not provide adequate contraception as it inhibits ovulation in only 40% of women.

Some hormonal contraceptive also helps in relieving common perimenopausal gynecological problem.  Contraception must be used alongside HRT to avoid unplanned conception. Progestogen-only methods and intrauterine contraception (IUC) are suitable.

During the perimenopausal years, in women over the age of 50 years not using hormonal methods, contraception can be stopped after 1 year of amenorrhea as fertility is unlikely to return, while in women under 50 years of age, contraception should be continued for 2 years, as the return of fertile ovulation is more likely to occur.

The Faculty of Sexual and Reproductive Healthcare (FSRH) recommends that contraception should be continued for 1 year after recording two FSH levels at >30 IU/l, taken at least 6 weeks apart.

Alternatively, women can consider stopping their method of contraception at the age of 55 years when most will have reached natural infertility.

Women must be advised on all available methods of contraception, including long-acting reversible methods (LARC), so they can make an informed choice.

Combined oral contraception have the advantage of regular bleeding pattern and relief in hot flushes, but increased risk of thrombosis, and breast and cervical cancer. Some women prefer progesterone only pills because it is contraindicated in few medical conditions but irregular bleeding is a problem.

Progesterone only injectables are long acting but they often mask menopause, causes loss of BMD and once injected cannot be removed.

Copper intrauterine device and Levonorgestrel-releasing device are unsuitable if women have irregular uterine cavity.

Barrier methods are best, without any side effects and can be safely used till menopause.

Women can also avail emergency contraception in the perimenopausal age group. Levonorgestrel an oral progestogen; ulipristalacetate (UPA) an oral selective progestogen receptor modulator; and the copper IUD can be used in emergency.

Contraceptives of future: Frameless IUDs and Intrauterine ball has recently been licensed in Austria and will likely be marketed elsewhere in Europe and North America. It is a frameless IUD consisting of a shaped memory alloy (Nitinol^®) thread that holds 20 tiny copper spheres. The device becomes spherical once delivered into the uterus and might have greater potential for use in non-uniform endometrial cavities. As a hormone-free method, there will be no contraindications to its use in perimenopausal women.

http://newatlas.com/intra-uterine-ball-iub/23534/

Microchip drug-release technology is currently under development and will allow a progestogen-releasing microchip to be implanted for up to 16 years of use, which can be switched on and off with a remote control.

http://news.mit.edu/2015/implantable-drug-delivery-microchip-device-0629

Researchers are working on vaginal ring releasing UPA, a selective progesterone receptor modulator that will provide estrogen free contraception.

Not much progress has been made in areas of male contraception and condoms and sterilization are only current methods available.

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