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Contraception - Management
How does the approach of menopause influence choice?

  • The usual (non age-related) UK Medical Eligibility Criteria apply, but if there are no other contraindications to use:
    • Methods that can be used without restriction by perimenopausal women include:
      • Copper intrauterine devices (IUDs), the levonorgestrel-releasing intrauterine system (IUS), progestogen-only pill, progestogen-only implants, barrier methods, and sterilization.
    • Progestogen-only injectables can be used without restriction up to the age of 45 years. In women over the age of 45 years, the benefits generally outweigh the risks.
    • Natural family planning is not generally recommended because irregular menstrual cycles in the menopause make this method difficult to learn and use.
    • Combined hormonal contraception (the combined contraceptive pill, patch, or vaginal ring) is not contraindicated by age alone in perimenopausal women, however:
      • It should not be used (unacceptable health risk) by women 35 years of age or older who smoke 15 or more cigarettes a day, or who develop migraine without aura while using combined hormonal contraception.
      • It is not usually recommended (risks usually outweigh the advantages) for women 35 years of age or older who smoke less than 15 cigarettes a day, or who quit smoking less than 1 year ago, or for women 35 years of age or older who have a history of migraine without aura.
      • Where the combined oral contraceptive (COC) pill is suitable, a pill containing 20 micrograms ethinylestradiol is a reasonable first choice.
  • Non-contraceptive benefits can influence the choice of contraceptive for women with:
    • Vasomotor symptoms (hot flushes): combined hormonal contraception may reduce symptoms.
      • Women experiencing menopausal symptoms while using combined hormonal contraception may wish to try an extended regimen.
    • Osteoporosis: combined hormonal contraception may increase bone mineral density; depot medroxyprogesterone acetate may reduce bone mineral density.
    • Menstrual pain, bleeding, and irregularity: combined hormonal contraception may reduce symptoms.
    • Menstrual pain: progestogen-only methods may reduce symptoms.
    • Heavy menstrual bleeding: the levonorgestrel-releasing IUS reduces menstrual bleeding and can cause amenorrhoea.
  • Hormone replacement therapy (HRT):
    • Women using combined HRT should not rely on this as contraception.
    • A progestogen-only pill can be used with combined sequential HRT to provide effective contraception and adequate endometrial protection (a progestogen-only pill used with oestrogen-only HRT will not provide an adequate level of endometrial protection; combined continuous HRT regimens are not appropriate in this age group due to bleeding).
    • The levonorgestrel–releasing IUS can be used as the progestogenic component for HRT for 5 years (the licence states 4 years), and provide concurrent contraception.
Basis for recommendation
  • These recommendations are based on guidelines published by the Faculty of Sexual and Reproductive Healthcare [FSRH, 2010c].

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