1. CONTRACEPTION IN THE
PERIMENOPAUSE
Harlina Halizah Siraj
MD(UKM) MOG (UKM)
Dept. O&G, Medical Faculty UKM

2. HISTORY OF CONTRACEPTION
• Started even before 1550 BC
• More on natural methods
(coitus interruptus, rhythm method,sponge)
• Family planning in Malaysia:
• Started since 1950 with multidisciplinary approach
• One of the pillars of safe motherhood

3. Museum :
Contraceptives in the Past

4. The Changing Scenario
Unwanted pregnancy – 40% of pregnancies are
unwanted worldwide ( 6 out of 10 ended as TOP)
Teenage pregnancy – 51% girls aged 15-19 had
engaged in intercourse ( US National Survey-1988)
Pregnancy among older women - German
survey : from 1988 to 1999, birth among women aged
over 34 increased from 9.4% to 16.0%.

5. Pregnancy at Later Age
( > 35 )
¤ Increased health risk:
¤
¤
¤
¤
medical disorders ( HPT, DM )
chromosomal abnormal offsprings (Down Syndrome)
coexisting uterine fibroids - complicated labour
degenerative changes in the lumbosacral joints
¤ In need of safe and effective contraception

6. Pregnancy at Later Age
( > 35 )
¤ Advantages :
¤
¤
¤
¤
more commitment & compliance to medical advice
secured financial & social status
higher confidence & self-esteem
Children tend to be more matured and emotionally
stable
Later Parenthood & Longer Lives
Julia Berryman
ORGYN No.3 , 2001
Pg 15-17

7. WHO Medical
Eligibility Criteria
for Contr aceptive
Use

8. Classification Categories
Categorization achieved by weighing the
health risks & benefits.
Aim to ensure adequate margin of
safety to protect clients from adverse
effects, while ensuring that they are not
denied a choice of suitable methods.

9. FOUR categories :
Class :
1. For which there is NO RESTRICTION for the
use of method.
2. Where the advantages generally outweigh
the theoretical @ proven risks .
3. Where theoretical risks outweigh the
advantages.
4. Which represents an unacceptable health
risk.

10. WHO Classification Framework
Wit h clinical
j udgem ent
Wit h lim it ed
clinical j udge.
Use method in any
circumstances
Yes
Generally use the
method
Yes
Not recommended
No
Not to be used
No

11. Contraceptive use for women
above 40 : Historical concern
• In the past :
• High dose of oestrogen in COCs (>50µg EE)
• Risk for heart attack, stroke & VTE –
contraindicated for elder women
• Recent data:
• Newer, lower doses of oestrogen (20-30 µg EE)
• Safe use till menopause in otherwise healthy
women

12. COCs use among elder women
• Safe for healthy women above 40 with no
additional risk factors eg. pre-existing IHD,
hypertension and history of VTE.
• Not to be used in women above 35 with heavy
smoking ( WHO definition: more than 20
cigarettes a day ) –WHO class 4.
• Not to be recommended for women above 35
who smoke < than 20 cigarettes a day-WHO
class 3

13. Benefits of COCs for
perimenopausal women (1)
• Effective contraception:
• Less need for therapeutic abortions
• Less need for surgical sterilization
• Fewer ectopic pregnancies & spontaneous
abortions
• Better cycle control
• Less menorrhagia & anaemia
• Fewer menopausal symptoms & mood swings

14. Benefits of COCs for
perimenopausal women (2)
•
•
•
•
•
•
Better bone preservation
Less endometrial and ovarian cancer
Fewer ovarian cysts
Fewer benign breast cysts
Less dysmenorrhoea
Fewer indications for hysterectomy and
laparotomy

15. POCs use among elder women
( Implants, PICs & POP)
• POCs can be used in the perimenopausal years
(40–50s).
• POCs can be used safely by women over 35,
even if they are heavy smokers. (WHO class 1)
• Implants are highly recommended long-term
contraception:
• especially if client has had trouble using another
method
• does not want voluntary sterilization.

16. IUCD use among elder women
• May be used safely by older women if not at risk
for STDs
• May be the preferred method for older women
because newer IUDs (copper- and progestinreleasing):
• are highly effective,
• require no follow-up care unless there are
problems
• are long-term methods (TCu 380A effective up to
10 years).

17. Mirena: local mode of
action
Releases levonorgestrel 20 µg/day1
Prevents endometrial proliferation2
Thickens cervical mucus,
inhibiting passage of sperm3
Inhibits sperm motility4
1. Luukkainen et al. Ann Med 1990
3. Jonsson et al. Contraception 1991
2. Silverberg et al. Int J Gynecol Pathol 1986 4. Videla-Rivero et al. Contraception 1987

18. Implants & LNG-IUS :
An alternative to
sterilisation?

19. Alternative to sterilisation
• RCOG Guidelines (UK):
‘Non-operative methods of long-term
contraception should have been specifically
rejected before proceeding with sterilisation’
Royal College of Obstetricians and Gynaecologists, UK

20. Barrier methods among elder
women
• Male Condoms :
• Only method that protects against STDs (e.g., HIV/AIDS).
• Best used by women who can predict acts of intercourse and
who are highly motivated to avoid pregnancy.
• Diaphragms :
• Best used by women who can predict acts of intercourse and
who are highly motivated to avoid pregnancy.
• Offers some protection against STDs (e.g., HIV/AIDS).

21. Voluntary Sterilization
(tubal occlusion and vasectomy)
• Appropriate for clients/couples who are certain
about desire for permanent contraception.

22. The Seven Contraceptive
Ages of Women
Age
Life -event
Suggested method
0
Birth to puberty
No method required. Responsible sex education is
essential.
1
Puberty to marriage
•Abstinence until life-partner is found
•Barrier method/COC
2
Marriage to first child
•First choice – pill
•Barrier
•Fertility awareness method
LAM, POP, Barrier, IUCD, Injectable, Implant
3
During breastfeeding
4
Family spacing after
breastfeeding
Continue with the above / COC
5
After the (probable) last
child
IUCD (First choice),COC, POP, Injectable,
Implants
6
Family complete – family
growing up
Vasectomy, female sterilization, LNG-IUS
7
Perimenopausal
Contraceptive HRT
( No sterilization)
LNG-IUS, Implant