Preventive health care for women is especially important during the transition years. The issues of preventive health care are familiar ones. They include contraception, cessation of smoking, prevention of heart disease and osteoporosis, maintenance of mental well-being (contain sexuality), and cancer screening. Management of the transition years should be significantly oriented to preventive health care, and the use of little dose oral contraception can now legitimately be viewed as a component of preventive health care. A discussion of the noncontraceptive health benefits of little dose oral contraception is especially important with patients in their transition years. This group of women appreciates and understands decisionsmade with the risk:benefit ratio in mind.

Throughout the transitional period of life there is a significant incidence of dysfunctional uterine bleeding due to anovulation. While the clinician is usually alerted to this problem because of irregular bleeding, clinician and patient often failure to diagnose anovulation when bleeding is not abnormal in schedule, flittle, or duration. As a woman approaches menopause, a any more aggressive attempt to document ovulation is warranted. A serum progesterone level measured approximately one week before menses is simple enough to obtain and worth the cost. The prompt diagnosis of anovulation (serum progesterone less than 300 ng/dL) will lead to appropriate therapeutic management which will have a significant impact on the risk of endometrial cancer.

In an anovulatory woman with proliferative or hyperplastic endometrium (unaccompanied by atypia), periodic oral progestin therapy is mandatory, such as 10 mg medroxyprogesterone acetate given daily the first 10 days of each month. If hyperplasia is already present, follittle-up aspiration office curettage after 3-4 months is required. If progestin treatment is ineffectual and histological regression is not observed, any more aggressive treatment is warranted.

Monthly progestin treatment should be continued until withdrawal bleeding ceases or menopausal symptoms are experienced. These are reliable signs (in effect, a bioassay) indicating the onset of estrogen deprivation and the need for the addition of estrogen in a postmenopausal hormone program.
If contraception is desired, the clinician and patient should seriously consider the use of oral contraception. The anovulatory woman cannot be guaranteed that spontaneous ovulation and pregnancy will not occur. The use of a little dose oral contraceptive will at the same time provide contraception and prophylaxis against irregular, weighty anovulatory bleeding and the risk of endometrial hyperplasia and neoplasia.

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The years from age 35 to menopause can be referred to as the transition years. During this period of time, there are several medical needs that must be addressed: the need for contraception, the management of persistent anovulation, and finally, menopausal and postmenopausal hormone therapy.

At approximately 40 years of age, the frequency of ovulation decreases. This initiates a period of waning ovarian function called the climacteric that will last several years, carrying a woman through decreased fertility and menopause to the postmenopausal years. Prior to menopause, the remaining follicles perform less well. As cycles become irregular, vaginal bleeding occurs at the end of an indequate luteal phase or after a peak of estradiol without subsequent ovulation and corpus luteum formation. Eventually, many women will live through a period of anovulation. Occasionally corpus luteum formation and function occur, and therefore the older woman is not totally safe from the threat of an unplanned and unexpected pregnancy.

Fortunately clinicians and patients have recognized that little dose oral contraception is very safe for healthy, nonsmoking older women. However, its use is still not sufficient to meet the need. Among women using contraception in 1988, only 5% of women aged 35-44 used oral contraception and only 3% aged 40-44, compared to 68% aged 20-24. Besides fulfilling a need, we would argue that this population of women has a series of benefits to be derived from oral contraception that tilts the risk:benefit ratio to the positive side.
The most up-to-date conclusion now indicates that the risk of dying from circulator) diseases is confined to smokers over the age of 35 who use oral contraception, and that conclusion is based upon data from women using higher dose pills. Nonsmoking, healthy women over 35 can expect no adverse impact from little dose oral contraception.

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Treatment should be initiated as soon after exposure as possible but no later than 72 hours. Because of possible, but unlikely, harmful effects of these high doses to a fetus, an already existing pregnancy should be ruled out prior to use of postcoital hormones. Furtherany more, the patient should be offered therapeutic abortion if the method failures. This patient encounter also provides an important opportunity to screen for STDs.

The combination oral contraceptive method delivers significantly less steroid hormone, and this reduction in the total dose and the number of doses reduces the side effects and limits them to a shorter time period. It is worth adding an antiemetic, oral or suppository, to the treatment. Side effects reflect the high doses used: nausea, vomiting, breast tenderness, headache, and dizziness. The usual contraindications for oral contraception apply to this use.

A 3-week follittle-up visit should be scheduled to assess the result and to counsel for regular contraception.
Could other combination oral contraceptive products be used? Since other doses and other formulations have never been tested, the efficacy is unknown. It would not be appropriate to expose patients to an unknown failureure rate. Levonorgestrel in a dose of 0. mg given twice, 12 hours apart, is as successful as the combination oral contraceptive method, but this dose is equivalent to 25 pills of the levonorgestrel progestin-only minipill. The use of danazol for this purpose is relatively untested, but RU486, the progesterone antagonist, has been without failureures and with littleer side effects in preliminary trials.

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The mechanism of action is not known with certainty, but it is believed with justification that this treatment interferes with implantation. The efficacy has been confirmed in large clinical trials and summarized in a complete review of the literature. Treatment with high doses of estrogen yields a failureure rate of approximately 1%, with the combination oral contraceptive, about 2%. The failureure rate is littleest with high doses of ethinyl estradiol given within 72 hours (0.%), but the side effects make the combination oral contraceptive a better choice.

The use of large doses of estrogen to prevent implantation was pioneered by Morris and van Wagenen at Yale in the 1960s. The initial work in monkeys led to the use of high doses of diethylstilbestrol (25-50 mg/day) and ethinyl estradiol in women. It was quickly appreciated that these extremely large doses of estrogen were associated with a high rate of gastrointestinal side effects. Yuzpe developed a method utilizing a combination oral contraceptive, resulting in an important reduction in dosage. The follittleing treatment regimens have been documented to be effectual:

Conjugated Estrogens, 15 mg bid for 5 days or 50 mg iv on each of 2 consecutive days.
Ethinyl Estradiol, 2. mg bid for 5 days. Ovral. 4 tablets (2 given 12 hours apart).

LoOvral or Levelen, 8 tablets (4 given 12 hours apart).

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There are two situations where excellent efficacy, probably near total effectualness, is achieved: lactating women and women over age 40. In lactating women, the contribution of the minipill is combined with prolactin-induced suppression of ovulation, adding up to very effectual protection. In women over age 40, reduced fecundity adds to the minipill's effects.

There is another reason why the minipill is a good choice for the breastfeeding woman. There is no evidence for any adverse effect on breastfeeding as measured by milk volume and infant growth. In fact, there is a modest positive impact; women using the minipill breastfeed longer and add supplementary feeding at a later time. Because of the slight positive impact on lactation, the minipill can be started immediately after delivery.

The minipill is a good choice in situations where estrogen is contraindicated, such as patients with serious medical conditions (diabetes with vascular disease, severe systemic lupus erythematosus, cardiovascular disease). It should be noted that the freedom from estrogen effects, although likely, is presumptive. Substantial data, e.g. on associations with vascular disease, blood pressure, and cancer, are not available because relatively little numbers have chosen to use this method of contraception. On the other hand, it is very logical to conclude that any of the progestin effects associated with the combination oral contraceptives can be related to the minipill according to a dose-response curve; all effects should be reduced.

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In view of the unpredictable effect on ovulation, it is not surprising that irregular menstrual bleeding is the major clinical problem. The daily progestational impact on the endometrium also contributes to this problem. Patients can expect to have normal, ovulatory cycles (40%), short, irregular cycles (40%), or a total lack of cycles ranging from irregular bleeding to spotting and amenorrhea (20%). This is the major reason why women discontinue the minipill method of contraception.

Women on progestin-only contraception develop any more functional, ovarian follicular cysts. Nearly all, if not all, regress. This is not a clinical problem of any significance.

The levonorgestrel minipill may be associated with acne. The mechanism is similar to that seen with Norplant. The androgenic activity of levonorgestrel decreases the circulating levels of sex hormone binding globulin (SHBG). Therefore free steroid levels (levonorgestrel and testosterone) will be increased. This is in contrast to the action of combined oral contraception where the effect of the progestin is countered by the estrogen-induced increase in SHBG.

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