Can oral contraceptives (OCs) be used to manage perimenopause symptoms?

Using Oral Contraceptives for Perimenopause Symptoms

Combined oral contraceptives (COCs) are an effective option for managing perimenopause symptoms in healthy, non-smoking women while providing contraception, which hormone replacement therapy does not offer. 1, 2

Benefits of Oral Contraceptives in Perimenopause

• Symptom management:

  • Regularizes unpredictable menstrual cycles and reduces heavy bleeding
  • Relieves vasomotor symptoms (hot flashes)
  • Provides effective contraception (still needed during perimenopause)

• Long-term health benefits:

  • Decreases risk of postmenopausal hip fractures
  • Reduces risk of endometrial and ovarian cancers
  • May reduce need for surgical intervention for benign menstrual conditions 2

Patient Selection and Contraindications

COCs should not be used in perimenopausal women with:

• Age ≥35 years who smoke (especially heavy smokers)
• Uncontrolled hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
• History of breast cancer
• Active or recent venous thromboembolism
• Active liver disease
• History of stroke or cardiovascular disease
• Unexplained vaginal bleeding 1

Caution or special monitoring is needed for:

• Women with controlled and monitored hypertension
• Light smokers (<15 cigarettes/day) aged ≥35 years
• Migraines without focal neurologic symptoms in women <35 years
• Known hyperlipidemia 3

Formulation Selection

1. Progestin component:

   • Fourth-generation progestins (drospirenone) have antiandrogenic effects
   • Third-generation progestins (desogestrel, gestodene) are less androgenic
   • All COCs have a net antiandrogenic effect when combined with ethinyl estradiol 3

2. Estrogen component:

   • Lower estrogen doses (≤35 μg ethinyl estradiol) are preferred to minimize risks

3. FDA-approved options for acne (may be beneficial for perimenopausal skin changes):

   • Ethinyl estradiol/norgestimate
   • Ethinyl estradiol/norethindrone acetate/ferrous fumarate
   • Ethinyl estradiol/drospirenone
   • Ethinyl estradiol/drospirenone/levomefolate 3

Monitoring and Follow-up

• Blood pressure monitoring (especially if history of hypertension)
• Annual assessment of cardiovascular risk factors (lipid profile, fasting glucose)
• Regular follow-up every 3-6 months to assess symptom control and side effects
• Annual gynecological assessment 1

Alternative Options

If COCs are contraindicated, consider:

1. Progestin-only methods:

   • Levonorgestrel IUD (can be combined with low-dose estrogen therapy)
   • Progestin implant
   • Depot medroxyprogesterone acetate 4

2. Non-hormonal options:

   • Copper IUD
   • Barrier methods
   • SSRIs for vasomotor symptoms (paroxetine 10-12.5mg reduces hot flashes by 62-65%)
   • Gabapentin for hot flashes 1, 5

Transitioning to Menopause

• Continue COCs until age 50-55 (or until menopause is confirmed)
• Consider switching to hormone replacement therapy when contraception is no longer needed
• When discontinuing COCs, check FSH levels after 6-8 weeks off hormones to confirm menopause 6

Key Considerations

• COCs provide both symptom relief and contraception, while HRT does not provide contraception
• COCs can mask the transition to menopause by inducing regular withdrawal bleeding
• The benefits of COCs in perimenopausal women typically outweigh risks in healthy, non-smoking women 2, 5