Oral Contraceptives for Perimenopausal Women

Women going through the transitional phase of perimenopause may need help dealing with the body's reaction to the slightly decreased levels of the ovarian hormone estrogen. Oral contraceptives are increasingly being considered to fulfill this role. Even though the use of oral contraceptives in this way has not been approved by the FDA, it has been scientifically proven that these contraceptives also offer several additional health benefits beyond birth control for the perimenopausal woman. However, just as when used in earlier years of a woman's life, oral contraception does carry some risks. Be sure to consult a doctor when considering this option for treatment of any perimenopausal symptoms.

Starting Oral Contraceptives for Perimenopause
Unlike regular hormone replacement therapy, there are not well-defined criteria for when a woman can start using oral contraceptives to treat perimenopausal symptoms. If a woman suspects that she has symptoms due to perimenopause that bother her enough to need medication, she can really start whenever she wants. All she needs to do is see her doctor to make sure none of the contraindications apply to her.

Benefits of Oral Contraceptives for Perimenopause
In addition to protecting a woman against unwanted pregnancy, oral contraceptives are also very effective at relieving the annoying symptoms that may be brought about by perimenopause. Some of these symptoms that can be relieved are:

  • Pre-menstrual syndrome: PMS can sometimes get worse with the onset of perimenopause.
  • Menstrual cycle irregularity: perimenopausal women will often start to experience an erratic menstrual cycle.
  • Growing menopausal symptoms: oral contraceptives may relieve minor hot flashes, irritability, insomnia, and any other symptoms common to the beginnings of menopause.

Side-Benefits of Oral Contraceptives
While the main goal of using birth control pills for perimenopausal women is to get rid of certain perimenopausal symptoms, women using these pills can also get some other important health benefits. Some of them are:

  • A small decrease in bone loss: estrogen prevents the reabsorption of bone while stimulating the release of calcitonin, which maintains bone mass. Therefore, a decline in estrogen levels due to perimenopause results in bone loss, which can lead to osteoporosis and fractures. Supplementing a woman's body with small extra doses of estrogen can thus slow this harmful process. The best dose to use is 25-35 micrograms of ethinyl estradiol combined with the progestin norethindrone (click here for a list of birth control pills that fit this criteria).
  • Management of fibroids: some perimenopausal women will develop leiomyomas (tumors made up of smooth muscle tissue) in their uterus. Oral contraceptives may be useful for treatment of these tumors (also called fibroids).
If oral contraceptives are used for long periods of time, they can also play a role in the prevention of endometrial and ovarian cancer. Increasing the amount of time that these pills are taken results in more protection. However, the minimal number of years required to see these positive effects for endometrial cancer is 2 years and for ovarian cancer it is 3. Therefore, if a perimenopausal woman is simply using oral contraceptives for a year to get rid of some of her pesky symptoms, she will not get these benefits. Some good news though is that, as long as she is healthy and does not smoke, oral contraceptive use in perimenopausal women does not increase the risk of having a stroke. Lipid levels are also not negatively affected.

The effect of hormonal supplements on the risk of breast cancer is a topic that has long been debated. It has been shown that oral contraceptives may have a protective effect against the development of breast cancer only for the breast tissue that has no sign of malignancy already. The caveat here is that, if some breast cells have already become malignant, the use of oral contraceptives can actually speed up the development of breast cancer in these cells. But, there is no evidence that it causes those malignancies in the first place.

Special Considerations for Migraine Sufferers
Unlike the average woman, women who experience migraine headaches should think twice about using oral contraceptives during perimenopause. It has been suggested that a history of migraines can increase a womans risk of having a stroke. However, this seems to be limited to women who have an aura before their migraines or who have other neurological symptoms. For this reason, if a woman is considering starting birth control pills for the alleviation of perimenopausal symptoms and is also experiencing migraines, she should be sure to see a neurologist first. He/she will be able to tell whether or not it would be okay to start on the pills.

For women who have migraine headaches that are not associated with neurologic symptoms, a low-dose oral contraceptive can probably be used, but consulting a doctor would be a good idea. Use of the pills should be ended if the headaches get any worse or if they start occurring more frequently.

Who is Not Eligible
The contraindications listed for use of oral contraceptives in women past age 35 are:

  • Smoking
  • Hypertension
  • History of thromboembolism (a condition that involves blood vessel clots)
  • Stroke
  • Estrogen-dependant abnormal tissue growth (tumor or cancer)
  • Undiagnosed atypical genital bleeding (vaginal bleeding)
  • Cholestatic jaundice (jaundice that is caused by blockage of the outlet of the gallbladder)
Transition to Hormone Replacement Therapy At some point after oral contraceptives have been used to alleviate the symptoms of perimenopause, the woman will need to transition to regular HRT. It has been suggested that FSH (follicle stimulating hormone) levels during time off from the pills (during use of a placebo) can be used, but this method may be unreliable. This is because the pill suppresses the woman's own hormone levels so that they may not return to their natural levels in this short time. A combination of FSH and estradiol levels should be used instead for greater accuracy. An easier way to transition is simply to pick a time somewhere between the ages of 50-52 to switch from oral contraceptives to hormone replacement therapy. Since a woman is already taking a form of hormone replacement, the start of regular HRT is not as critical.

Here are some HRT programs to consider when transitioning:
  • Continuous combined therapy: involves a combination of estrogen and progesterone administered on a daily basis. The optimal dosage would be the equivalent of 0.625 mg of conjugated estrogen and 2.5-10 mg of medroxyprogesterone.
    Pros: may stop menstruation
    Cons: breakthrough bleeding (particularly during the first year); may not be as effective for preventing endometrial cancer.
  • Cyclic therapy: estrogen given on a daily basis with progesterone added in for the first 12-14 days of each month. The estrogen dose should be the equivalent of 0.625 mg of conjugated estrogen and the progesterone dose should be 5-10 mg of medroxyprogesterone.
    Pros: less breakthrough bleeding
    Cons: still have menstruation (occurs monthly when progesterone is stopped)
  • Cyclic therapy: estrogen given for the first 25 days of each month and progesterone added on days 13-25. Again, use a dose of estrogen that is equivalent to 0.625 mg of conjugated estrogens and 5-10 mg medroxyprogesterone.
    Pros: less breakthrough bleeding
    Cons: still have menstruation (when progesterone is stopped)
  • Estrogen combined with progesterone for the first 25 days of each month.
    Pros: may be more effective in protecting endometrium
    Cons: still have menstruation (occurs monthly when hormone doses stop)
Oral Contraceptives to Use
Here is a list of the oral contraceptives that are the best for use during perimenopause to slow bone loss. All of them contain 25-35 micrograms of ethinyl estradiol plus norethindrone.
  • Norinyl 1+35
  • Ortho-Novum 1/35
  • Brevicon
  • Modicon
  • Ovcon 35
  • Ortho-Novum 10/11
  • Tri-Norinyl
  • Ortho-Novum 7/7/7
  • Jenest 28

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