In light of the Women’s Health Initiative (WHI) findings, is the use of oral contraceptives (OCs) safe in low-risk perimenopausal women?
—Debra Palfrey, PA-C, Plymouth, Mass.

A low-estrogen OC (20 µg ethinyl estradiol) remains an appropriate treatment for perimenopausal women who seek relief of menopausal symptoms as well as those who desire contraception or need control of dysfunctional uterine bleeding. Women older than 50 might stop the pill altogether or change to an estrogen-only regimen if needed for symptoms. However, the OC contains higher doses of both estrogen and progestin than conventional estrogen-progestin therapy and provides optimal symptom relief and control of bleeding through suppression of the hypothalamic-pituitary-ovarian axis.

Of course, women older than 35 who smoke should not use an OC, nor should women who have had an ischemic or hemorrhagic stroke. According to the World Health Organization, women with a history of venous thromboembolism should not use these medications either. For women who do not smoke, there is a real but extremely small increased risk of cardiac disease. However, most experts feel this increased risk does not represent a contraindication to use in low-risk women. Oncogenic risk also appears very low, and concerns about increased cancer have not been supported by adequate data.

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For further discussion, see Martin KA, Douglas PS. Risks and side effects associated with estrogen-progestin contraceptives, and Martin KA, Barbieri RL. Treatment of menopausal symptoms with hormone therapy. Both in: UpToDate. Rose BD, ed. Wellesley, Mass.; 2007.
—Reuben W. Zimmerman, PA-C (110-20)