Clinical Medicine Insights: Reproductive Health

¹Assistant Prof OBGYN, ²Instructor OBGYN, ³Assistant Professor Internal Medicine, College of Medicine at Mayo Clinic, Rochester, MN, U.S.A.

Abstract

Despite an increasing number of available contraceptive options, about 49% of the annual U.S. pregnancies remain unintended.¹ Surprisingly, over a third of all pregnancies in women in their forties are unintended. Perhaps due to safety considerations and co-existing medical conditions, these patients may be directed toward less effective, compliance dependent methods. In addition to reliable contraception, perimenopausal women may need to stabilize hormonal fluctuations and minimize irregular heavy menstrual flow. The ideal contraceptive for the perimenopausal woman would be compliance independent and provide non-contraceptive benefits.  With the perimenopausal woman’s needs in mind , we will discuss all contraceptive options currently available in the United States, review the risks and benefits of each and describe the transition from contraception to postmenopausal hormone therapy. We include a summary of the efficacy of various contraceptives in Table 1.  As women enter their perimenopausal years, they are often faced with contraceptive decisions along with the onset of new medical conditions. These conditions include cardiovascular risk factors such as hyperlipidemia, hypertension, diabetes and obesity. Cardiovascular disease increases dramatically with age and is the leading cause of death among adult women in the U.S. Cardiovascular risk factor man- agement is therefore a critical component in the care of perimenopausal women. It is prudent to educate women seeking contraceptive counseling about the importance of a healthy diet, exercise and avoidance of smoking. It is known that coronary artery disease in women who undergo natural menopause occurs about 10 years later than men. However, women who undergo early natural menopause or bilateral oophorectomy develop coronary artery disease at a younger age. The decline in ovarian function is related to changes in the lipid profile and subsequent risk for developing coronary artery disease.²  Studies have not shown an increased risk of myocardial infarction or stroke in women who are current users of oral contraceptives containing less than 50 ug of EE.³ However, women older than 35 years of age who smoke and have a history of hypertension are at increased risk for myocardial infarction and stroke.⁴ Women with a history of diabetes but no other risk factors such as hypertension or vascular disease including nephropathy are candidates for combination oral contraceptives. Those who have diabetes in addition to multiple other cardiac risk factors should be offered progestin only or non- hormonal contraceptives.  In short, from the standpoint of medical eligibility, combination estrogen-progestin contraception is most appropriate for lean, healthy, non-smoking women without significant cardiovascular risk factors. Women with multiple cardiovascular risk factors are ineligible for combination estrogen-progestin contraceptives. These women need to be counseled regarding a healthy lifestyle and management of risk factors and ideally be offered progestin only or non-hormonal contraceptives.⁵