Combination Contraceptive for Perimenopausal Women with Monthly Menses
For perimenopausal women with regular monthly menses, low-dose combined oral contraceptives containing 20 μg ethinyl estradiol with levonorgestrel (100 μg) are the recommended first-line option, providing both effective contraception and management of perimenopausal symptoms. 1, 2
Primary Recommendation: Combined Hormonal Contraceptives
Combined hormonal contraceptives (CHCs) are appropriate for perimenopausal women and no contraceptive method is contraindicated based on age alone. 1, 3 These methods include:
- Oral contraceptive pills (various formulations) 1
- Transdermal contraceptive patch (releasing 150 μg norelgestromin and 20 μg ethinyl estradiol daily) 1
- Vaginal contraceptive ring (releasing 120 μg etonogestrel and 15 μg ethinyl estradiol daily) 1
Specific Formulation Guidance
Low-dose ethinyl estradiol formulations (20 μg) combined with 100 μg levonorgestrel demonstrate excellent efficacy with a Pearl index of 0.88 and cumulative pregnancy rate of 1.9% over 3 years. 4, 5 This formulation offers:
- Effective contraception with typical use failure rate of approximately 9 per 100 women-years 1
- Acceptable cycle control with breakthrough bleeding occurring in 12.9% of cycles and spotting in 10.1% 4
- Good tolerability profile with headache and metrorrhagia being the most common reasons for discontinuation (2% each) 4, 5
Additional Benefits for Perimenopausal Women
CHCs provide dual benefits beyond contraception for perimenopausal women with regular menses:
- Control of menstrual irregularities that commonly occur during perimenopause 3, 6
- Relief of vasomotor symptoms (hot flashes) experienced by approximately 80% of perimenopausal women 7, 6
- Management of heavy menstrual bleeding (menorrhagia) affecting 25% of perimenopausal women 7
- Improvement in bone density and metabolic parameters 6
Initiation Protocol
CHCs can be initiated at any time if it is reasonably certain the woman is not pregnant. 1
Timing and Back-Up Contraception:
- If started within the first 5 days of menstrual bleeding: No additional contraceptive protection needed 1
- If started >5 days after menstrual bleeding started: The woman must abstain from sexual intercourse or use additional contraceptive protection for 7 days 1
Monitoring Requirements
Blood pressure should be monitored during routine follow-up visits for women using CHCs. 2 The Centers for Disease Control and Prevention notes that:
- No routine follow-up visits are required for any contraceptive method 2
- Assessment of satisfaction, changes in health status, and weight changes should be considered at any visit 2
- Women should return if they experience side effects, problems, or want to change methods 2
Alternative Options When Estrogen is Contraindicated
If the patient has contraindications to estrogen-containing methods, progestin-only methods are valuable alternatives, including: 2
- Levonorgestrel-releasing intrauterine device (LNG-IUD) - particularly beneficial when combined with supplemental low-dose menopausal estrogen for symptom management 6
- Progestin implants 2
- Injectable contraceptives (DMPA) 2
The LNG-IUD with supplemental low-dose menopausal estrogen shows positive results for managing disruptive perimenopausal symptoms and long-term outcomes based on available comparative data. 6
Important Caveats
- Medical eligibility must be confirmed before initiating CHCs, particularly assessing cardiovascular risk factors, thromboembolism risk, and smoking status in women over 35 years 1
- CHCs do not protect against sexually transmitted diseases; consistent and correct use of male latex condoms reduces STD risk including HIV 1
- For missed pills, specific CDC guidelines should be followed based on how many pills were missed and when in the cycle 2
- Cycle control typically improves over the first few cycles, with the highest incidence of intermenstrual bleeding occurring initially and decreasing thereafter 5