At what age should a patient being treated for perimenopausal bleeding and other symptoms discontinue birth control pills? What tests do you recommend to confirm menopause?—ANN OSBORNE, NP, Concord, N.C.
For many perimenopausal women, birth control pills can serve as effective and safe contraception, as well as treatment of abnormal bleeding. Before initiating or maintaining a regimen of birth control pills in women older than age 35 years with abnormal or heavy bleeding, an endometrial biopsy and/or transvaginal ultrasound should be done to rule out uterine cancer (especially in obese women or women who smoke cigarettes). If other underlying physiologic causes for abnormal bleeding (e.g., thyroid or liver dysfunction) are suspected, appropriate diagnostic tests should be undertaken. These tests are not mandatory in otherwise asymptomatic women.
Previously considered a mainstay of evaluation for menopausal status, follicle-stimulating hormone (FSH) testing is now generally regarded as inaccurate and unnecessary because of its unpredictable fluctuations during the perimenopausal period. A single elevated FSH level is no longer considered diagnostic of menopause. In a woman using oral contraceptives, FSH level should be checked no sooner than day 5-7 of the hormone-free interval (placebo week) and must be repeated. As always, BP should be checked routinely in women on birth control pills. If cardiac risk factors are present, a cholesterol panel and fasting blood sugar should be done. Otherwise, order routine health maintenance tests (e.g., annual mammography, fecal occult blood testing, and Pap smear).
There is no specific age at which birth control pills must be discontinued. Clinicians and patients usually decide together when to transition from oral contraceptives to hormone therapy or to stop hormones altogether (typically age 50 years or the age at which the patient’s mother went through menopause). Sexually active women should use a barrier method of contraception until menopause is confirmed through amenorrhea. Patients with no relevant health risks who are happy taking birth control pills can be maintained on a low-dose pill until age 50-55 years.—Lisa Stern, APRN (133-9)