A Literature Review Comparing Combined Oral Contraceptive Pill use and Mirena during Perimenopause

Author(s): Rafia Jeddy, Ahmed S. Keshta, Kamel Ikbariah, Mohamed S. Keshta


Perimenopause is the period that heralds menopause and is an alternative countenance of “menopausal transition.” As the median maternal age is increasing a substantial number of women in the age group of 40 – 49 may encounter unexpected pregnancies. It is well known that the risk of miscarriages is high due to poor oocyte quality. Older age women who get pregnant are at increased risk of gestational diabetes mellitus, pre-eclampsia, preterm labor, chromosomal abnormalities, cesarean delivery, and stillbirths apart from neonatal morbidities including intrauterine growth restrictions, low Apgar score, admission to intensive care, and autism. Besides safe contraception, there are several conditions in this age group that could be treated with the use of hormonal contraceptives, including abnormal heavy menstrual cycle, vasomotor symptoms and bone loss, endometrial hyperplasia, and prevention of certain cancers.


Our review aimed to evaluate the benefits and risks of the two main contraceptives in this age group combined oral contraceptive pills and the Mirena intrauterine device. Whereas prior reviews have mainly focussed on all the contraceptive options in this age group, our focus was to compare the benefits and risks of the two main hormonal contraceptives, both of which also aid in reducing heavy menstrual loss common during this period.

Data Synthesis:

We searched MEDLINE using PubMed, EMBASE, GOOGLE SCHOLAR, and Proquest for English-language articles on contraception in older women. Our methodology involved a review of the published literature from mainly 2012 to the end of June 2022. We also reviewed the statements and clinical practice guidelines from the US Centers for Disease Control and Prevention and the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists.


No method of contraception is contraindicated by age alone, although combined hormonal contraception is generally not recommended for women over 50 years. The intrauterine system has specific benefits in perimenopausal women as a low-dose method of effective hormonal contraception, which also helps manage heavy menstrual bleeding and endometrial protection in women necessitating estrogen replacement. It has no contraindications for use in women with comorbidities in this age group, such as cardiovascular risk factors, venous thromboembolism, hypertension, or stroke. The US and UK medical eligibility criteria also favor using progestin-only contraceptive methods for common medical conditions. Although it does not benefit vasomotor symptoms, it can be used with low-dose estrogens in women with an intact uterus as hormone replacement therapy with contraception.

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