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This chapter presents a case study of a 42 year old female (Alison), who suffered from heavy painful periods. Alison's situation is far from unusual for this age group, where the risk of relationship breakdown is high. It is apparent that Alison's first priority is a highly effective contraceptive method. However, she requires much more from her method: effective control of bleeding and dysmenorrhoea; restoration of menstrual predictability and/or amenorrhoea. A bimanual examination for Alison is undertaken to assess for uterine enlargement (fibroids, adenomyosis), uterine mobility and adnexal masses and/or tenderness. Alison was advised about how the levonorgestrel-releasing intrauterine system (LNG-IUS) works by profound endometrial glandular and stromal suppression, cervical mucus changes and a foreign body effect within the endometrium. Progestogen-only pills (POPs) would be an option for Alison if she has contraindications to taking oestrogens.
Synthetic derivatives of progesterone are variously known as progestogens, progestagens or progestins and have a key role in hormonal contraception, either alone or in combination with oestrogen. Progestogen-only methods of contraception include pills, subdermal implants, injectables and the intrauterine system. There are several different types of subdermal implant licensed for contraceptive use across the world. The Nexplanon implant contains etonogestrel and is the most widely available subdermal contraceptive implant. Other progestogen-only contraceptive implants are licensed or being developed and include Jadelle, a two-rod implant containing levonorgestrel, and Capronor, a biodegradable single-rod implant also containing levonorgestrel. The two types of progestogen-only injectable contraception, both of which are long-acting reversible contraception (LARC) methods, are depot-medroxyprogesterone acetate (DMPA) and norethisterone oenanthate (NETEN). The most commonly used progestogen-releasing intrauterine system in most countries is the levonorgestrel-releasing intrauterine system (LNG-IUS) known as Mirena.
The woman presenting for contraceptive advice in her 50s is in a different position to younger women. Although the peri-menopause is a stage of life when a woman has lowered fertility, the consequences of an unplanned pregnancy are serious, and contraception is still important, particularly when the additional associated non-contraceptive benefits of hormonal use are considered. A woman in her 50s, or during the menopause transition, may need her contraceptive options re-evaluated. The levonorgestrel-releasing intrauterine system (LNG-IUS) is one of the long-acting reversible methods of contraception (LARC) which has the benefit of being highly effective whilst requiring minimal compliance once inserted by a trained practitioner. Women in their 50s requesting contraception often have additional needs, particularly regarding the management of menopausal symptoms. Consultations such as this offer the opportunity to provide balanced information regarding contraception, management of the menopause, relationship issues and erectile dysfunction (ED).
Male or female sterilisation is chosen by almost 50% of British couples in their 40s as their main method of contraception. Of these, 15% of men and 12% of women choose either vasectomy or tubal occlusion. Vasectomy is the most effective contraceptive method available, with failures now quoted as having a life-time risk of one in 2000 after two azoospermic samples taken 2-4 weeks apart at least 8 weeks after the procedure. Mirenai (Schering), the levonorgestrel-releasing intrauterine system (LNG-IUS), is an ideal contraceptive method for the older woman. Epidemiological data support the prescribing of combined hormonal contraceptives (CHCs) to non-smoking, normal-weight, low-risk women who do not suffer from migraine until the menopause. The median age of the menopause in Western women who do not smoke is 51.3 years. Symptoms of the menopause are often masked in women using CHCs but some may complain of vasomotor symptoms in the hormone-free week.
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