Thursday, December 30, 2004

Perimenopause and the Pill

Perimenopause is a transition stage between regular ovarian/uterine cycle function [the monthly release of an egg from the ovary/shedding of the uterine lining] and cessation of that function [no more egg release/menses], or menopause. The start and duration of this transition is variable, but it generally starts in your mid-forties.

There are more than 19 million women aged 45 to 54 in the US. Some health concerns common during perimenopause are:

  • anovulatory [no egg released from the ovary; no ovulation] dysfunctional uterine bleeding [Basically, the sex hormone levels are highly variable, the ovarian and the uterine cycles are out of sync; this leads to irregular periods.]

  • vasomotor instability [hot flushes]

  • loss of bone density [osteopenia and osteoporosis]

  • gynecologic cancers [ovarian, uterine, etc.]

  • Combination birth control pills can be beneficial for perimenopausal women.

    Here's a very good review article (pdf) detailing the advantages/disadvantages of using the Pill if you're in your mid to late 40s.

    From the article, a summary of the benefits of perimenopausal Pill use:


    -- Effective contraception (pregnancy protection)

    -- Regulation of menses

    -- Treatment of anovulatory bleeding abnormalities (eg, DUB, prolonged, and/or painful periods)

    -- Relief of vasomotor symptoms

    -- Decreased long-term risk of endometrial [uterine] and ovarian cancers


    -- Treatment of skin disorders (ie, acne and hirsutism [excessive hairiness])

    -- Decreased risk of postmenopausal hip fracture

    -- Prevention of osteopenia and osteoporosis [bone loss]

    -- Prevention of colorectal cancer

    And the take-home points:

  • Perimenopause is a transitional stage during which many of the symptoms traditionally associated with menopause begin to occur.

  • Irregular bleeding is a major issue for perimenopausal women because it causes anxiety about underlying disease. Oral contraceptives (OCs) regularize dysfunctional uterine bleeding and thus can successfully address this complaint.

  • OCs have also been shown to relieve vasomotor symptoms and appear to provide greater protection against perimenopausal loss of bone density than does traditional hormone replacement therapy.

  • Both women and their clinicians have concerns and misconceptions about the risks of perimenopausal OC use. However, considerable evidence suggests that OC formulations containing less than 50 µg of ethinyl estradiol are associated with little to no increased risk of myocardial infarction, stroke, or breast cancer in healthy, nonsmoking women without risk factors for these conditions. Weight gain caused by OC use is a myth.

  • [When the article's author says the weight gain is a myth, he doesn't mean it can't or doesn't happen to individual Pill users. Some women gain weight while on the Pill, and some experience no effect. Others lose weight. However, the available studies have not found that OC use causes weight gain.]

  • By addressing these concerns and providing education about the important health benefits derived from continuing or initiating OC use during the perimenopause, clinicians can help women successfully use OCs into their mid-50s, at which time a shift to hormone replacement therapy may be made if desired.

  • [Use of OC in reproductive age women, including perimenopausal women, and use of hormone replacement therapy (HRT) in menopausal woman are not one and the same thing. In other words, the hormone formulations, dosages, and regimens used for OC and HRT are different, the women's physiology is different, as are the risks/benefits. This is important for you to remember. Briefly, women before menopause produce sex hormones, so by using OCs all you're doing is substituting one type of hormone (body made) with another one (synthetic, from the OC). Menopausal women no longer produce sex hormones, so by using HRT you are adding hormones where there are none.]

  • Selection of an OC formulation with an estrogen dosage sufficient to regularize menses and minimize unscheduled bleeding is essential in establishing long-term compliance.

  • The appropriateness of OC therapy should be carefully considered for every perimenopausal woman. Initial history and physical examinations should aim to uncover any risk factors for adverse outcomes.