Ali Kubba presented us with a case study of a 44 year old women who has been on the progesterone only pill (POP) for four years and had begun noticing some changes; her period is heavier and she’s suffering from vaginal dryness and painful sex. She’s looking for non-contraceptive benefits from her pill as she wants her treatment to address all the symptoms she’s experiencing.
To start, Ali looked at the symptoms she’s suffering from.
- Could her symptoms be phsycho-sexual related to stress and responsibility of life?
- Is she suffering from any other menopausal symptoms she’s embarrassed to raise?
- Could it be the POP that’s the cause of her vaginal dryness?
- Do we need to do a hormone test?
- What are the reasons she is not on the COC pill?
He then discussed, the options available to his patient;
- Could we change her POP? Dependent on her pill-type, could we move her to a lower dose pill?
- Could an IUD be a viable option? This could help with heavy menstrual bleeding
- Is the Copper IUD an option? This may impact her bleeding schedule but is non-hormonal so may remove vaginal dryness
- Could she use a COC/patch/ring? COC has a number of additional benefits which are even more significant to women over the age of 40.
- Could he suggest barrier contraception? This could be an option, if she and her sexual partner are comfortable with this method and familiar with it.
- What about DMPA? – Ali noted this should be the last choice, due to concerns of links to bond density and CVD markers
What questions did she have?
- Am I too old to use COC? No, age alone is not a contraindication to anything!
- When do I stop contraceptive treatment? Under the age of 50 she must use contraception for 2 years after diagnosis of menopause, over the age of 50, she must use contraception for 1 years after diagnosis.
As she is presenting symptoms of estrogen deficiency, it could also be possible to combine the POP with MHT or combine her POP with a local estrogen or lubricant. Moisturisers and lubricants can hydrate the vaginal tissue, remove sensitivity and reduce pain and discomfort but only have a short term effect.
How would we diagnose menopause?
To diagnose menopause we need to look for the presence of amenorrhea and key symptoms. If a patients is using a contraceptive we need to carry out FSH and LH twice, 6 weeks apart. Whilst tests can be done if a patient has an IUD or is on the POP, patients must stop COC for a cycle and stop DMPA for testing. When diagnosing, it’s important to think about the opportunities for screening and education. Discuss cervical screening, breast self-testing, osteoporosis risk, ovarian cancer, diabetes and incontinence, talk about symptoms and risk factors that increase with age.
So what would be the desirable features of a contraception taken up to/during climacteric?
- Sufficient efficacy
- Improved sex life
- Control of climacteric symptoms
- Control of “normal” menstrual cycle
- Decreased risk of gynaecological pathology and hysterectomy
- Provide protection against osteoporosis
- Avoidance of systemic side effects
Ali believes that COC is an appropriate choice for women at 50 as it regulates anovulatory cycles and the cardiovascular risk is small. Data from the RCGP study in over 46,000 women has shown that OC use is even associated with a 20% reduction in risk of colon cancer, a 34% reduction in endometrial cancer and a 33% reduction in ovarian cancer. IUD is also an option, if it’s fitter after the age of 40 it can be kept till menopause.
Perimenopause is a time of; opportunity, risk, confusion and optimism. Ali suggests to use this time to discuss with the patient and get them thinking about what is best for them from a contraceptive and overall health perspective, it’s important to remove concerns around age and myths around treatment options!