What birth control options are recommended for perimenopausal women?

Birth Control Options for Perimenopausal Women

For perimenopausal women, all contraceptive options remain appropriate as no method is contraindicated based on age alone, with the choice depending on medical comorbidities, perimenopausal symptoms, and patient preferences. 1

Hormonal Options

Combined Hormonal Contraceptives (CHCs)

• CHCs (pills, patches, rings) provide both contraception and relief from perimenopausal symptoms including menstrual irregularities 1
• First-line options include pills containing levonorgestrel or norethisterone with ethinyloestradiol 35 μg or less, which have relatively low risk of venous thromboembolism 2
• Low-dose ethinylestradiol/levonorgestrel (20 μg/100 μg) is effective with a Pearl index of 0.88 and cumulative pregnancy rate of 1.9% over 3 years 3
• Extended or continuous regimens with fewer or no inactive pills may be preferred by some women 2
• Blood pressure should be monitored during routine follow-up visits for women using CHCs 4
• For missed pills, follow specific guidelines based on how many pills were missed and when in the cycle they were missed 4

Progestin-Only Methods

• Progestin-only pills (POPs) are valuable for women who cannot or choose not to use estrogen-containing methods 5
• POPs containing desogestrel have shown similar contraceptive effectiveness to CHCs 5
• Other progestin-only options include:
  • Levonorgestrel-releasing intrauterine device (LNG-IUD) 4
  • Implants 4
  • Injectable contraceptives (DMPA) 4
• Progestin-only methods can be used alone or in combination with estrogen replacement therapy to address both contraceptive needs and perimenopausal symptoms 1

Non-Hormonal Options

Copper IUD

• The copper IUD (Cu-IUD) provides highly effective long-term contraception 4
• Can also be used as emergency contraception when inserted within 5 days of unprotected intercourse 4
• Requires periodic checking for the presence of IUD strings during follow-up 4

Emergency Contraception

• Emergency contraception options include:
  • Copper IUD (most effective) 4, 6
  • Ulipristal acetate (30 mg) - effective throughout the entire 120-hour window 4, 6
  • Levonorgestrel (1.5 mg single dose or 0.75 mg twice) - most effective within 72 hours 4
  • Combined estrogen-progestin regimen (least effective) 4, 6
• Ulipristal acetate may be more effective than levonorgestrel in women who are overweight or obese 6

Managing Common Issues

Bleeding Irregularities

• For unscheduled spotting or heavy bleeding with:
  • Cu-IUD: NSAIDs for 5-7 days 4
  • LNG-IUD or implants: NSAIDs for 5-7 days or hormonal treatment with COCs/estrogen for 10-20 days 4
  • Injectable contraceptives: NSAIDs or hormonal treatment with COCs/estrogen 4
  • Extended CHC regimens: Avoid hormone-free intervals during first 21 days of use 4

Follow-up Recommendations

• No routine follow-up visits are required for any method 4
• Women should return if they experience side effects, problems, or want to change methods 4
• For IUDs, implants, or injectables, women should be advised when removal or reinjection is needed 4
• Assessment of satisfaction, changes in health status, and weight changes should be considered at any visit 4

Special Considerations for Perimenopause

• Women with premenstrual symptoms may benefit from CHCs containing drospirenone, which has been shown to reduce symptoms of premenstrual dysphoric disorder 7
• If contraception is still needed after ulipristal acetate emergency contraception, any regular method can be started immediately, but barrier methods or abstinence should be used for 14 days or until next menses 4, 6
• If bleeding irregularities persist or are unacceptable, counsel on alternative methods and offer another option 4