Hormonal Contraceptives Help Women Manage Perimenopause
Women near the end of their reproductive years may experience fewer perimenopausal symptoms if they use a hormonal contraceptive, such as a hormonal intrauterine device (IUD). Hormonal contraception can help women prevent unwanted pregnancy as they begin transitioning to menopause. It may improve their quality of life and provide additional noncontraceptive benefits, research shows.1,2 These benefits include:
- Treatment of abnormal uterine bleeding;1
- Relief from vasomotor symptoms/hot flashes;1,2
- Relief from menstrual migraines;2
- Protection against bone loss;2
- Endometrial protection in women who are using estrogen therapy;1
- Protection against musculoskeletal issues and mood disorders.1
“It’s not much studied, but it is an incredible benefit in perimenopause for preventing bleeding problems that normally occur and require doctor’s visits, biopsies, and evaluations,” says Mitchell Creinin, MD, a professor and director of the Complex Family Planning Fellowship at University of California, Davis Health. “As women go through perimenopause, they get irregular bleeding. Sometimes, it’s heavy and your body thinks you’re 25 years old, and sometimes it thinks you’re 55.”
Perimenopausal women end up with irregular and heavy bleeding, which also is a symptom of uterine cancer. “Women have the nuisance of bleeding, and they end up having biopsies,” Creinin says.
This is where the 52 mg levonorgestrel IUD can help. It will prevent unpredictable bleeding and reduce menstrual flow. “If you have prolonged use, you have an increase in amenorrhea,” Creinin notes. “It stays that way all the way out for eight years.”
Any patient experiencing perimenopause could use the hormonal IUD to relieve bleeding symptoms and prevent unnecessary fear and tests for cancer or an unnecessary hysterectomy to end the bleeding and the risk of cancer.
“I love using the hormonal IUD in advanced reproductive-age patients because it reduces all of the other symptoms,” Creinin says. “One out of every two patients I see are obese and at a higher risk of endometrial cancers. Their bleeding is heavy, and they’ll need a biopsy. If they get an IUD, they’re done and don’t have to go through all of that.”
The levonorgestrel IUD also is useful to reduce migraines caused by estrogen withdrawal. Typically, women experience increased migraine prevalence during perimenopause. Evidence suggests migraines without aura can be affected by fluctuating estrogen levels and triggered by estrogen withdrawal.3
The levonorgestrel IUD provides continuous progestogens, which is preferred for reducing perimenopausal migraines because cyclical progestogens can have an adverse effect on migraine, according to research results.3
Other research recommends a levonorgestrel IUD combined with estrogen therapy. The author of one study noted most physicians are unaware of how useful the hormonal IUD can be when combined with estrogen therapy in premenopausal, perimenopausal, and postmenopausal women. Using the IUD is one of the most effective, best accepted, and safest ways to treat some symptoms of perimenopause, the author concluded.4
The levonorgestrel IUD also was shown to prevent endometrial proliferation and endometrial hyperplasia — a precancerous condition in which irregular thickening of the uterine lining occurs.5
The levonorgestrel IUD is commonly used in perimenopausal women with irregular bleeding and heavy menstrual bleeding, says Stephanie Delkoski, DNP, APRN, WHNP-BC, a clinical assistant professor at the University of Minnesota School of Nursing.
“The [LNG-IUD] can be a nice way to decrease the amount of bleeding they’re having,” Delkoski says. “It doesn’t take away the irregularity, but it can decrease the amount of bleeding. It’s not uncommon that the people I see use the contraceptive for up to one full year without a period. If someone is having irregular periods in perimenopausal transition and having some vasomotor functions, we could do a combined hormonal contraceptive pill that has both estrogen and progesterone in it. This provides good contraception and also helps with hot flashes and night sweats, so that’s another option for this transition period.”
This tactic is not for all women. For example, this may not be a viable option for patients with hypertension or increased risk factors for hypertension.
Vasomotor symptoms are caused by decreases in estrogen, so providers often prescribe estrogen for symptom management. But since it could place women at increased risk of endometrial cancer if they receive estrogen alone, some clinicians also recommend the LNG-IUD because its progestin is protective against endometrial cancer.
“We need to give progesterone to balance out that and decrease the risk of endometrial changes,” Delkoski explains. “Commonly, in this age group, we give oral progesterone.”
For people who cannot tolerate oral progesterone, the LNG-IUD is an alternative and off-label solution.
“If I have a perimenopausal patient with the levonorgestrel IUD in place, but they’ve started having night sweats and hot flashes, we’d want to add in estrogen therapy that’s commonly given in patch form or oral. We could use the levonorgestrel IUD off label as the progesterone to prevent endometrial changes,” Delkoski says.
Some patients do not care for oral progesterone because of systemic side effects, including breast tenderness and joint pain. The LNG-IUD does not produce those side effects. “[Patients] don’t have to remember to take it every day, so it is a really positive experience,” Delkoski adds.
When OB/GYNs want to help women in their 40s and 50s manage bleeding, hormonal IUDs are a nice option.
“We can always add in estrogen as a patch or oral estrogen and counsel them on using the IUD as an endometrial protection component,” Delkoski explains. “They can keep the IUD in until it expires or age 55, which is when the North American Menopause Society says we can reasonably consider someone not able to conceive any longer.”
Another reason women may prefer to use the LNG-IUD during their 40s is because they are at increased risk of an abnormal pregnancy outcome as they approach menopause, which is defined as one full year without a period.
“Even if their periods stop, they could still be ovulating,” Delkoski says.
While the miscarriage rate is estimated to be 9% to 17% for women in their 20s, it increases to 80% of all pregnancies in women who are older than age 40 years.6 This also means that women are at increased risk of needing an abortion procedure if the miscarriage threatens their health. They also are at greater risk of a dangerous pregnancy from conditions such as pre-eclampsia, placenta previa, and gestational diabetes. Fetal abnormalities, including Down syndrome, are twelvefold more likely in people who get pregnant after age 40 years.7
With abortion restrictions and bans in states affecting more than half of American women of reproductive age, adequate care for women experiencing a miscarriage or a dangerous pregnancy may not be available. Women in the perimenopausal years may need an IUD or some other form of contraception to prevent the possibility of an abortion to preserve their health and lives, even if they are not concerned about needing contraception to prevent pregnancy in their later years.
REFERENCES
- Troia L, Martone S, Morgante G, Luisi S. Management of perimenopause disorders: Hormonal treatment. Gynecol Endocrinol 2021;37:195-200.
- Grandi G, Di Vinci P, Sgandurra A, et al. Contraception during perimenopause: Practical guidance. Int J Womens Health 2022;14:913-929.
- MacGregor EA. Migraine, menopause and hormone replacement therapy. Post Reprod Health 2019;24:11-18.
- Wildemeersch D. Why perimenopausal women should consider to use a levonorgestrel intrauterine system. Gynecol Endocrinol 2016;32:659-661.
- Clark K, Westberg SM. Benefits of levonorgestrel intrauterine device vs. oral or transdermal progesterone for postmenopausal women using estrogen containing hormone therapy. Innov Pharm 2019;10:10.24926/iip.v10i3.2002.
- Fink JLW, Lloyd III WC. How common is miscarriage? Healthgrades. Dec. 15, 2020.
- Harmanci R. The truth about pregnancy over 40. The New York Times. April 15, 2020.
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Women near the end of their reproductive years may experience fewer perimenopausal symptoms if they use a hormonal contraceptive, such as a hormonal intrauterine device.
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