From the Guidelines
Daily oral contraceptive pills (OCPs) can be used in perimenopause, but breakthrough bleeding is a common side effect, especially during the first few months of use. According to the most recent guidelines, low-dose combination OCPs containing estrogen (typically ethinyl estradiol 20-35 mcg) and progestin are generally preferred for perimenopausal women 1. Monophasic formulations like Loestrin, Yaz, or Ortho-Cyclen may cause less breakthrough bleeding than multiphasic options. To minimize breakthrough bleeding, consistent daily timing of pill-taking is crucial, ideally within the same 3-hour window each day. Extended or continuous regimens (skipping the placebo week) may eventually reduce breakthrough bleeding after an initial adjustment period of 3-6 months. If breakthrough bleeding persists beyond 3 months, changing to a different formulation with either higher estrogen content or a different progestin may help. For perimenopausal women with contraindications to estrogen (such as history of blood clots, certain cancers, or cardiovascular disease), progestin-only pills are an alternative but may have higher rates of irregular bleeding.
Some key points to consider when using OCPs in perimenopause include:
- The age at which a woman is no longer at risk for pregnancy is not known, and spontaneous pregnancies can occur in women over 44 years old 1
- The risks of continuing contraception until menopause, including acute cardiovascular events and breast cancer, should be weighed against the benefits of contraception 1
- OCPs in perimenopause offer benefits beyond contraception, including regulation of heavy or irregular periods, reduction of vasomotor symptoms, and protection against endometrial and ovarian cancers 1
- The U.S. MEC states that patients of any age can use IUDs and hormonal contraception, but patients of advanced reproductive age may have chronic conditions or other risk factors that render use of hormonal contraceptive methods unsafe 1
Overall, the benefits of using daily OCPs in perimenopause, including contraception and regulation of menstrual symptoms, outweigh the risks of breakthrough bleeding, making them a reasonable option for women in this stage of life 1.
From the FDA Drug Label
Breakthrough bleeding, spotting, and amenorrhea are frequent reasons for patients discontinuing oral contraceptives. In breakthrough bleeding, as in all cases of irregular bleeding from the vagina, non-functional causes should be borne in mind If both pregnancy and pathology have been excluded, time or a change to another preparation may solve the problem Changing to an oral contraceptive with a higher estrogen content, while potentially useful in minimizing menstrual irregularity, should be done only if necessary since this may increase the risk of thromboembolic disease
The use of daily Oral Contraceptive Pills (OCPs) in peri-menopause may be associated with breakthrough bleeding. To minimize this risk,
- time or
- a change to another preparation may be considered. Additionally, changing to an oral contraceptive with a higher estrogen content may be useful in minimizing menstrual irregularity, but this should be done only if necessary due to the increased risk of thromboembolic disease 2.
From the Research
Daily OCP Use in Peri-Menopause
- Daily Oral Contraceptive Pills (OCPs) can be used in peri-menopause to provide effective contraception and alleviate symptoms such as menstrual irregularity, heavy menstrual bleeding, and vasomotor symptoms 3, 4.
- The use of combined oral contraceptives (COCs) in perimenopausal women can help control these symptoms and significantly reduce the risk of ovarian cancer, endometrial cancer, and colorectal cancer 3.
- However, the use of extended- and continuous-cycle oral contraceptives, which are designed to shorten the duration of menses or completely eliminate menses, may be associated with more breakthrough bleeding and spotting than traditional oral contraceptives 5.
Breakthrough Bleeding
- Breakthrough bleeding is a common side effect of oral contraceptive use, particularly with extended- and continuous-cycle regimens 5.
- The risk of breakthrough bleeding may be higher in perimenopausal women due to hormonal changes and menstrual irregularity 4.
- However, the use of daily OCPs in peri-menopause can help regulate menstrual cycles and reduce the risk of breakthrough bleeding 3, 4.
Health Benefits
- Daily OCP use in peri-menopause can provide several health benefits, including:
- Reduced risk of ovarian cancer, endometrial cancer, and colorectal cancer 3
- Improved regulation of menstrual cycles and reduction of menstrual irregularity 3, 4
- Alleviation of vasomotor symptoms such as hot flashes and night sweats 4
- Reduced risk of postmenopausal hip fractures 4
- Improvement in quality of life 4