What is the better birth control option for perimenopausal women, the levonorgestrel-releasing intrauterine device (LNG-IUD) or combined oral contraceptives (COCs)?

Levonorgestrel-Releasing IUD is Superior to Combined Oral Contraceptives for Perimenopausal Women

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the preferred contraceptive option for perimenopausal women compared to combined oral contraceptives (COCs) due to its superior management of perimenopausal symptoms, reduced bleeding, and fewer systemic effects. 1, 2

Advantages of LNG-IUD for Perimenopausal Women

• LNG-IUD provides highly effective contraception with failure rates comparable to sterilization while remaining completely reversible 1

• LNG-IUD significantly reduces menstrual bleeding and dysmenorrhea, which are common concerns during perimenopause 3, 4

• LNG-IUD can be used for endometrial protection when combined with estrogen therapy for management of climacteric symptoms 2, 4

• Heavy or prolonged bleeding is uncommon with LNG-IUD use, making it ideal for perimenopausal women who often experience menorrhagia 5, 6

• LNG-IUD has minimal systemic hormonal effects compared to COCs, reducing concerns about cardiovascular risks that increase with age 7

Limitations of COCs in Perimenopausal Women

• COCs require regular blood pressure monitoring, which is not necessary with LNG-IUD use 5

• Perimenopausal women have increased risk factors for cardiovascular disease, which may be exacerbated by COCs 5

• COCs may mask the onset of menopause due to withdrawal bleeding during hormone-free intervals 2

• COCs require daily adherence, while LNG-IUD provides long-term contraception for up to 5 years without user intervention 1

Management of Side Effects

• For unscheduled spotting or bleeding with LNG-IUD:

  • NSAIDs for 5-7 days can effectively manage these symptoms 5
  • If bleeding persists, hormonal treatment with COCs or estrogen (10-20 days) may be considered if medically eligible 5

• For COC users with extended or continuous regimens:

  • Hormone-free intervals are not recommended during the first 21 days of use 5
  • Hormone-free intervals should not be used more than once per month as contraceptive effectiveness might be reduced 5

Special Considerations

• LNG-IUD has been shown to reduce dysmenorrhea in all women and is superior to copper IUDs for improving this symptom 3

• LNG-IUD can be combined with estrogen therapy (gel, patch, or oral) to provide a smooth transition through menopause while maintaining contraception 2

• The average age for LNG-IUD insertion in perimenopausal women is around 48 years, with high continuation rates 2

• LNG-IUD is beneficial for treating endometrial hyperplasia, which may be a concern in perimenopausal women 4, 7

Clinical Pitfalls to Avoid

• Failing to rule out underlying pathology before initiating contraception can lead to ineffective treatment 6

• Not providing adequate counseling about expected changes in bleeding patterns with either method can lead to discontinuation 6

• Assuming that irregular periods in perimenopausal women indicate lack of fertility - contraception is still needed until menopause is confirmed 2

• Overlooking the non-contraceptive benefits of LNG-IUD that are particularly valuable during perimenopause, such as protection against endometrial hyperplasia 4