IUD Use in Perimenopause: Considerations and Recommendations
The levonorgestrel intrauterine device (LNG-IUD) is the preferred contraceptive option for perimenopausal women due to its high efficacy, safety profile, and additional non-contraceptive benefits including management of heavy menstrual bleeding. 1, 2
Contraceptive Needs During Perimenopause
- Women in perimenopause still require effective contraception as pregnancy can occur until menopause is confirmed (cessation of menses for 2 years before age 50, or 1 year after age 50) 1
- Despite decreased fertility, unintended pregnancies during perimenopause carry higher risks for maternal complications and poor outcomes 1
- Reliable contraception should be used until menopause is confirmed by either cessation of menses or by two elevated FSH values ≥20-30 IU/L while off hormonal methods for at least 2 weeks 1
IUD Options for Perimenopausal Women
Levonorgestrel IUD (LNG-IUD)
- Has particular benefits during perimenopause and is safe for most women 1
- FDA-approved for treatment of heavy menstrual bleeding, a common concern during perimenopause 1
- Can provide endometrial protection during transition from contraception to hormone therapy 1, 3
- Reduces menstrual blood loss, which is beneficial for women experiencing perimenopausal menorrhagia 2, 3
- May help avoid more invasive procedures like hysterectomy or endometrial resection for heavy bleeding 3
Copper IUD
- Highly effective with a favorable safety profile 2
- Non-hormonal option for women who prefer to avoid hormones 2
- May increase menstrual bleeding, making it less suitable for women with heavy menstrual bleeding 2
- Provides protection against endometrial cancer 2
Safety Considerations
- No contraceptive method is contraindicated based on age alone 1, 4
- IUDs have a U.S. MEC Category 1 rating (no restriction) for women ≥20 years of age 5
- For women with a history of breast cancer, estrogen-containing methods should be avoided, making IUDs a preferred option 5
- The safety of LNG-IUD in breast cancer patients remains controversial; a meta-analysis of three randomized trials did not show increased breast cancer recurrence or cancer-induced death 5
- Women with liver disease can safely use IUDs, including those with decompensated cirrhosis or graft failure after liver transplant 5
Practical Considerations for IUD Use
- Bimanual examination and cervical inspection are necessary before IUD insertion 5
- If STD screening is indicated per guidelines, it can be performed at the time of insertion 5
- Women should be counseled about potential side effects, particularly bleeding pattern changes 5
- Approximately half of LNG-IUD users experience amenorrhea or oligomenorrhea by 2 years of use 5
- For women transitioning to menopause, the LNG-IUD can be left in place and used as the progestogen component of hormone therapy 3, 6
Non-Contraceptive Benefits
- LNG-IUD is particularly beneficial for managing heavy menstrual bleeding during perimenopause 1, 3
- Can be used to provide endometrial protection for women on estrogen therapy 3
- May help manage other perimenopausal symptoms when combined with supplemental low-dose estrogen 6
- Long-acting reversible contraceptives like IUDs eliminate concerns about daily compliance 4
When to Discontinue Contraception
- Contraception should be continued until menopause is confirmed 1
- Menopause can be confirmed by cessation of menses for 2 years prior to age 50, for 1 year after age 50, or by two elevated FSH values ≥20-30 IU/L while off hormonal methods 1
- Spontaneous pregnancies have been reported in women up to age 59, so sterility cannot be assumed until at least age 60 1
In conclusion, IUDs represent an excellent contraceptive choice for perimenopausal women, with the LNG-IUD offering additional benefits for managing common perimenopausal symptoms like heavy menstrual bleeding. The choice between copper and hormonal IUDs should be based on the woman's specific needs, with particular attention to bleeding patterns and any contraindications to hormonal methods.